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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

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 PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 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-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25650 Library of Congress Control Number: XXXXXXXXXX Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America 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. PREPUBLICATION COPY: UNCORRECTED PROOFS

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY: UNCORRECTED PROOFS

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 PREPUBLICATION COPY: UNCORRECTED PROOFS v

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 Study Staff 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 Consultants 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 SCHUNEMANN, McMaster University PREPUBLICATION COPY: UNCORRECTED PROOFS vi

Reviewers 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: RICHARD N. ASLIN, Haskins Laboratories, Yale University JEANNE MARIE GUISE, Oregon Health & Science University SHELDON H. JACOBSON, University of Illinois at Urbana-Champaign HARRY B. JEFFRIES, JR., Georgia Department of Public Health (retired) YASMIN KHAN, University of Toronto CHRISTOPHER NELSON, RAND Corporation ALONZO PLOUGH, Robert Wood Johnson Foundation JEFFREY SCHLEGELMILCH, National Center for Disaster Preparedness, The Earth Institute, Columbia University HILARY THOMSON, University of Glasgow W. CRAIG VANDERWAGEN, East West Protection, LLC CHRIS J. WIANT, Caring for Colorado (retired) STEPHANIE ZAZA, American College of Preventive Medicine 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 examination 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. PREPUBLICATION COPY: UNCORRECTED PROOFS vii

Preface 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 (SARS); the federal smallpox vaccination program; monkeypox; 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 emergency 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 PREPUBLICATION COPY: UNCORRECTED PROOFS ix

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 (AARs, 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 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 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). PREPUBLICATION COPY: UNCORRECTED PROOFS x

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 PREPUBLICATION COPY: UNCORRECTED PROOFS xi

Contents ACRONYMS AND ABBREVIATIONS xxv ABSTRACT AB-1 SUMMARY S-1 1 ADVANCING PUBLIC HEALTH EMERGENCY PREPAREDNESS AND RESPONSE SYSTEM CAPABILITIES TO RESPOND TO INCREASING THREATS 1-1 Study Charge, 1-2 Conceptualizing the Complex Public Health Emergency Preparedness and Response System, 1-3 The Building Blocks of the PHEPR System, 1-3 Defining a Public Health Emergency Preparedness and Response Practice, 1-9 Underlying Reasons for the Current State of the Public Health Emergency Preparedness and Response Evidence Base, 1-11 A Rapidly Evolving PHEPR System, 1-12 The Increasing Complexity of Public Health Emergencies and the PHEPR System, 1-14 Methodological Challenges for PHEPR Research, 1-15 A Poorly Organized Approach to PHEPR Research and Implications for the PHEPR Researcher Pipeline, 1-16 A Well-Documented Gap Between PHEPR Research and Practice, 1-17 The Importance of Evidence-Based Practice and Guidelines, 1-17 The Emergence of Evidence-Based Guidelines and Policies to Promote Evidence-Based Practice, 1-18 Moving Beyond the Traditional Evidence Hierarchy for Evaluating the Effectiveness of PHEPR Practices, 1-19 About This Report, 1-20 Study Approach and Scope, 1-20 Report Audiences and Uses, 1-22 Organization of the Report, 1-23 References, 1-25 2 THE LANDSCAPE AND EVOLUTION OF PUBLIC HEALTH EMERGENCY PREPAREDNESS AND RESPONSE RESEARCH IN THE UNITED STATES 2-1 Characterizing the Research on Public Health Emergency Preparedness and Response: A Map of the Evidence, 2-1 Overall Distribution of Articles Within the 15 PHEPR Capabilities, 2-2 Quantitative Impact Studies Within the 15 PHEPR Capabilities, 2-4 Studies Within Specific Practice Areas of the 15 PHEPR Capabilities, 2-7 Implications for Future Research and Evidence Reviews, 2-8 A Look Back at PHEPR Research Programs, 2-10 PREPUBLICATION COPY: UNCORRECTED PROOFS xiii

Centers for Disease Control and Prevention (CDC)-Funded Academic PHEPR Workforce Development and Research Centers, 2-10 Other Federal Disaster Research Programs, 2-12 Specific Efforts to Enhance the Conduct of Research During Public Health Emergencies, 2-14 Limitations of PHEPR Research Programs, 2-15 Misaligned and Unclear Research Priorities, 2-17 Lack of Infrastructure to Support the Conduct of Quality PHEPR Research, 2-17 Lack of Coordination Across Funders and Shortcomings of Research Funding, 2-17 Concluding Remarks, 2-20 References, 2-21 3 AN EVIDENCE REVIEW AND EVALUATION PROCESS TO INFORM PUBLIC HEALTH EMERGENCY PREPAREDNESS AND RESPONSE DECISION MAKING 3-1 Evolving Philosophies for Evaluating Evidence to Inform Evidence-Based Practice: Implications for Public Health Emergency Preparedness and Response, 3-2 Limitations of the Traditional Evidence Hierarchy, 3-2 Evolving Methods for Evaluating Complex Health Interventions in Complex Systems, 3-3 Implications for Evaluating Evidence in the PHEPR System, 3-5 How Do Different Fields Evaluate Evidence?: A Review of Existing Frameworks, 3-7 Applying a Methodology to Review, Synthesize, and Assess the Certainty of the Evidence for Public Health Emergency Preparedness and Response Practices, 3-13 Formulating the Scope of the Reviews and Searching the Literature, 3-14 Synthesizing and Assessing the Certainty of the Evidence, 3-17 Formulating the Practice Recommendations and Implementation Guidance, 3-30 Limitations, Lessons Learned, and Recommendations for the Future, 3-34 Limitations of the Committee’s Evidence Review and Evaluation Methodology, 3-34 Reflections and Lessons Learned from the Mixed-Method Reviews, 3-35 Need for Ongoing PHEPR Evidence Reviews, 3-40 An Infrastructure to Sustain PHEPR Evidence Reviews, 3-41 References, 3-43 4 ENGAGING WITH AND TRAINING COMMUNITY-BASED PARTNERS TO IMPROVE THE OUTCOMES OF AT-RISK POPULATIONS 4-1 Description of the Practice, 4-3 Defining the Practice, 4-3 Scope of the Problem Addressed by the Practice, 4-5 Overview of the Key Review Questions and Analytic Framework, 4-7 Defining the Key Review Questions, 4-7 Analytic Framework, 4-8 Overview of the Evidence Supporting the Practice Recommendation, 4-10 Effectiveness, 4-11 Balance of Benefits and Harms, 4-13 Acceptability and Preferences, 4-14 PREPUBLICATION COPY: UNCORRECTED PROOFS xiv

Feasibility and PHEPR System Considerations, 4-14 Resource and Economic Considerations, 4-14 Equity, 4-15 Ethical Considerations, 4-15 Considerations for Implementation, 4-16 Facilitators for CBP Engagement, 4-16 Facilitators for CBP Training, 4-17 Practice Recommendation, Justification, and Implementation Guidance, 4-17 Evidence Gaps and Future Research Priorities, 4-19 References, 4-21 5 ACTIVATING A PUBLIC HEALTH EMERGENCY OPERATIONS CENTER 5-1 Description of the Practice, 5-3 Defining the Practice, 5-3 Scope of the Problem Addressed by the Practice, 5-4 Overview of the Key Review Questions and Analytic Framework, 5-8 Defining the Key Review Questions, 5-8 Analytic Framework, 5-8 Overview of the Evidence Supporting the Practice Recommendation, 5-11 Effectiveness, 5-11 Balance of Benefits and Harms, 5-12 Acceptability and Preferences, 5-12 Feasibility and PHEPR System Considerations, 5-13 Resource and Economic Considerations, 5-13 Equity, 5-13 Ethical Considerations, 5-14 Considerations for Implementation, 5-14 Factors in Determining When to Activate Public Health Emergency Operations, 5-14 Other Implementation Considerations, 5-16 Practice Recommendation, Justification, and Implementation Guidance, 5-18 Evidence Gaps and Future Research Priorities, 5-20 References, 5-22 6 COMMUNICATING PUBLIC HEALTH ALERTS AND GUIDANCE WITH TECHNICAL AUDIENCES DURING A PUBLIC HEALTH EMERGENCY 6-1 Description of the Practice, 6-3 Defining the Practice, 6-3 Scope of the Problem Addressed by the Practice, 6-5 Overview of the Key Review Questions and Analytic Framework, 6-6 Defining the Key Review Questions, 6-6 Analytic Framework, 6-7 Overview of the Evidence Supporting the Practice Recommendation, 6-9 Effectiveness, 6-10 Balance of Benefits and Harms, 6-11 Acceptability and Preferences, 6-11 Feasibility and PHEPR System Considerations, 6-12 PREPUBLICATION COPY: UNCORRECTED PROOFS xv

Resource and Economic Considerations, 6-12 Equity, 6-12 Ethical Considerations, 6-12 Considerations for Implementation, 6-13 Engaging Technical Audiences in the Development of Communication Plans, Protocols, and Channels, 6-13 Considerations for Selection of Communication Channels, 6-14 Facilitating Communication with Technical Audiences During a Public Health Emergency, 6-15 Practice Recommendation, Justification, and Implementation Guidance, 6-17 Evidence Gaps and Future Research Priorities, 6-18 References, 6-20 7 IMPLEMENTING QUARANTINE TO REDUCE OR STOP THE SPREAD OF A CONTAGIOUS DISEASE 7-1 Description of the Practice, 7-3 Defining the Practice, 7-3 Scope of the Problem Addressed by the Practice, 7-5 Overview of the Key Review Questions and Analytic Framework, 7-6 Defining the Key Review Questions, 7-6 Analytic Framework, 7-7 Overview of the Evidence Supporting the Practice Recommendation, 7-10 Effectiveness, 7-11 Findings from a Synthesis of Modeling Studies: Quarantine Is More Effective Under Certain Circumstances, 7-12 Balance of Benefits and Harms, 7-14 Acceptability and Preferences, 7-14 Feasibility and PHEPR System Considerations, 7-14 Resource and Economic Considerations, 7-15 Equity, 7-15 Ethical Considerations, 7-16 Considerations for Implementation, 7-16 Facilitating Adherence to and Minimizing Harms from Quarantine Measures, 7-17 Other Implementation Considerations, 7-18 Practice Recommendation, Justification, and Implementation Guidance, 7-20 Evidence Gaps and Future Research Priorities, 7-22 Quarantine and the COVID-19 Pandemic, 7-24 References, 7-25 8 IMPROVING AND EXPANDING THE EVIDENCE BASE FOR PUBLIC HEALTH EMERGENCY PREPAREDNESS AND RESPONSE 8-1 A National Public Health Emergency Preparedness and Response Science Framework, 8-3 Key Components of a National PHEPR Science Framework, 8-3 Ensuring Adequate Infrastructure and Supporting Mechanisms to Facilitate the Conduct of PHEPR Research, 8-9 Conclusion and Recommendations, 8-13 PREPUBLICATION COPY: UNCORRECTED PROOFS xvi

Supporting Methodological Improvements for Public Health Emergency Preparedness and Response Research, 8-14 Common Evidence Guidelines, 8-15 Standards for Reporting of Study Information, 8-22 Conclusion and Recommendation, 8-22 Improving Systems to Generate High-Quality Experiential Evidence for Public Health Emergency Preparedness and Response, 8-23 Limitations of AARs as a Source of Experiential Evidence for Mixed-Method Evidence Reviews, 8-24 Strengthening Methodological Approaches, 8-26 Establishing Mechanisms for Analysis and Dissemination of Lessons Learned from AARs, 8-29 Fostering a Culture of Quality Improvement, 8-30 Conclusions and Recommendation, 8-30 Workforce Capacity Development for Researchers and Practitioners in Public Health Emergency Preparedness and Response, 8-31 Researchers, 8-32 Practitioners, 8-32 Conclusion and Recommendation, 8-33 Translation, Dissemination, and Implementation of Public Health Emergency Preparedness and Response Research to Practice, 8-34 Building Implementation Capacity, 8-36 Conclusion and Recommendation, 8-38 Annex 8-1 Genres of Research to Inform Public Health Emergency Preparedness and Response Practices, 8-39 References, 8-43 APPENDIXES A DETAILED DESCRIPTION OF THE COMMITTEE’S METHODS FOR FORMULATING THE SCOPE OF THE REVIEWS AND CAPTURING THE EVIDENCE A-1 B MIXED-METHOD REVIEWS OF SELECTED TOPICS B-1 B-1 MIXED-METHOD REVIEW OF STRATEGIES FOR ENGAGING WITH AND TRAINING COMMUNITY-BASED PARTNERS TO IMPROVE THE OUTCOMES OF AT-RISK POPULATIONS B1-1 B-2 MIXED-METHOD REVIEW OF ACTIVATING A PUBLIC HEALTH EMERGENCY OPERATIONS CENTER B2-1 B-3 MIXED-METHOD REVIEW OF CHANNELS FOR COMMUNICATING PUBLIC HEALTH ALERTS AND GUIDANCE WITH TECHNICAL AUDIENCES DURING A PUBLIC HEALTH EMERGENCY B3-1 B-4 MIXED-METHOD REVIEW OF IMPLEMENTING QUARANTINE TO REDUCE OR STOP THE SPREAD OF A CONTAGIOUS DISEASE B4-1 PREPUBLICATION COPY: UNCORRECTED PROOFS xvii

C COMMISSIONED REPORTS THAT INFORMED THE FOUR MIXED-METHOD REVIEWS C-1 D COMMISSIONED SCOPING REVIEW AND SERIES OF EVIDENCE MAPS D-1 E PUBLIC COMMITTEE MEETING AGENDAS AND PROCEEDINGS OF A WORKSHOP—IN BRIEF E-1 F COMMITTEE MEMBER BIOSKETCHES F-1 PREPUBLICATION COPY: UNCORRECTED PROOFS xviii

Boxes, Figures, and Tables BOXES 1-1 Statement of Task, 1-2 1-2 Public Health Emergency Preparedness and Response (PHEPR) Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health, 1-4 1-3 Common System Characteristics, 1-8 1-4 Core Terms Used Throughout the Report, 1-21 2-1 National Biodefense Science Board’s Recommendations to Mount a Comprehensive and Rapid Mobilization of Scientific Resources in the Investigative Response to Disasters That Threaten Public Health, 2-14 3-1 Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence Evaluation Domains and Evidence to Decision Framework Criteria, 3-12 3-2 Steps in the Committee’s PHEPR Evidence Review and Evaluation Methodology, 3- 13 3-3 Steps for the Synthesis of Findings from Qualitative Studies, 3-23 3-4 General Ethical Principles to Guide Public Health Emergency Preparedness and Response (PHEPR), 3-31 3-5 Priority Topics for Future PHEPR Evidence Reviews, 3-40 4-1 Defining At-Risk Populations, 4-3 4-2 How Engaging with and Training Community-Based Partners (CBPs) to Improve the Outcomes of At-Risk Populations Relates to the Centers for Disease Control and Prevention’s (CDC’s) PHEPR Capabilities, 4-5 4-3 Key Review Questions, 4-7 5-1 How Public Health Emergency Operations Relates to the Centers for Disease Control and Prevention’s (CDC’s) PHEPR Capabilities, 5-4 5-2 Activating an Emergency Operations Center (EOC), 5-7 5-3 Key Review Questions, 5-8 6-1 How Communicating Public Health Alerts and Guidance with Technical Audiences During a Public Health Emergency Relates to the Centers for Disease Control and Prevention’s (CDC’s) PHEPR Capabilities, 6-3 6-2 Key Review Questions, 6-7 PREPUBLICATION COPY: UNCORRECTED PROOFS xix

7-1 How Quarantine Relates to the Centers for Disease Control and Prevention’s (CDC’s) PHEPR Capabilities, 7-3 7-2 Key Review Questions, 7-7 8-1 Components of a PHEPR Research Agenda, 8-7 8-2 Eleven-Item Tool for Assessing the Methodological Rigor of After Action Reports, 8-24 8-3 The Committee’s Suggested Elements for a PHEPR After Action Report (AAR) Template, 8-29 A-1 Seminal Literature Sources for the Committee’s Evidence Review Methodology, A-1 A-2 Selection Criteria for Review Topics, A-3 A-3 PICOTS Criteria for Inclusion and Exclusion of Articles, A-9 A-4 Data Extraction Elements for Quantitative Studies, A-12 A-5 Priority Topics for Future PHEPR Evidence Reviews, A-18 B1-1 Key Review Questions, B1-1 B2-1 Key Review Questions, B2-1 B3-1 Key Review Questions, B3-1 B4-1 Key Review Questions, B4-1 FIGURES S-1 Key components of a National PHEPR Science Framework, S-4 S-2 Framework for integrating evidence to inform recommendation and guidance development for PHEPR practices, S-12 1-1 Conceptual framework for an optimal PHEPR system, 1-6 1-2 Levels of PHEPR practices, 1-10 1-3 PHEPR system timeline: Events, policy, and legislation, 1999–2019, 1-12 1-4 Billion-dollar weather and climate disasters, United States, 2019, 1-15 1-5 Evidence-informed decision making, 1-18 1-6 Layered approach to the presentation of evidence from the PHEPR practice reviews, 1-24 2-1 Distribution of evidentiary articles by PHEPR capability (N = 1,106), 2-3 2-2 Type of outcome by PHEPR capability (N = 1,106), 2-4 2-3 Evidence map: Characteristics of U.S. quantitative impact studies across the PHEPR Capabilities (N = 72), 2-6 2-4 Evidence map: Characteristics of studies for the Medical Countermeasure Dispensing and Administration Capability (N = 110), 2-8 2-5 Evidence map: Characteristics of studies for the Emergency Public Information and Warning Capability (N = 66), 2-9 PREPUBLICATION COPY: UNCORRECTED PROOFS xx

2-6 Major categories of challenges to the conduct of PHEPR research and how they can be addressed, 2-16 2-7 Total annual U.S. governmental funding for disaster-related research relevant to the 15 CDC PHEPR Capabilities, 2008–2017, 2-19 3-1 Selection process for the committee’s review topics, 3-16 3-2 Classification and consolidation of studies into methodological streams, 3-19 3-3 Framework for integrating evidence to inform recommendation and guidance development for PHEPR practices, 3-28 3-4 Burden (time and intensity) of the committee’s methodology development and mixed-method review process, 3-39 4-1 Analytic framework for engaging with and training community-based partners to improve the outcomes of at-risk populations, 4-9 5-1 Analytic framework for public health emergency operations, 5-10 6-1 Analytic framework for communicating public health alerts and guidance with technical audiences during a public health emergency, 6-8 7-1 Analytic framework for implementing quarantine during a public health emergency, 7-9 8-1 Distribution of all scoping review articles by study design (N = 1,692), 8-2 8-2 Key components of a National PHEPR Science Framework, 8-4 8-3 Los Angeles County Community Disaster Resilience (LACCDR) mixed-method research study, 8-21 8-4 Root cause analysis: steps and examples, 8-27 B1-1 Analytic framework for engaging with and training community-based partners to improve the outcomes of at-risk populations, B1-3 B1-2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram for the mixed-method review of strategies for engaging with and training community-based partners to improve the outcomes of at-risk populations, B1-5 B2-1 Analytic framework for public health emergency operations, B2-3 B2-2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram for the mixed-method review of activating public health emergency operations, B2-5 B3-1 Analytic framework for communicating public health alerts and guidance with technical audiences during a public health emergency, B3-3 B3-2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram for the mixed-method review of channels for communicating public health alerts and guidance with technical audiences during a public health emergency, B3- 5 PREPUBLICATION COPY: UNCORRECTED PROOFS xxi

B4-1 Analytic framework for implementing quarantine during a public health emergency, B4-3 B4-2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram for the mixed-method review of implementing quarantine to reduce or stop the spread of a contagious disease, B4-5 D-1 Distribution of all articles by study design (N = 1,692), D-2 D-2 Study design by PHEPR Capability (N = 1,184), D-3 D-3 Distribution of evidentiary articles by PHEPR Capability (N = 1,106), D-3 D-4 Distribution of evidentiary articles across PHEPR Capabilities (N = 1,106), D-4 D-5 Type of outcome by PHEPR Capability (N = 1,106), D-4 D-6 Type of disaster by PHEPR Capability (N = 1,106), D-5 D-7 Organization by PHEPR Capability (N = 1,106), D-5 D-8 Setting by PHEPR Capability (N = 1,106), D-6 D-9 Evidence map: Characteristics of U.S. quantitative impact studies across the PHEPR Capabilities (N = 72), D-7 D-10 Evidence map: Characteristics of non-U.S. quantitative impact studies across the PHEPR Capabilities (N = 23), D-8 D-11 Evidence map: Characteristics of studies for Community Preparedness (N = 221), D-9 D-12 Evidence map: Characteristics of studies for Community Recovery (N = 78), D-10 D-13 Evidence map: Characteristics of studies for Emergency Operations Coordination (N = 111), D-11 D-14 Evidence map: Characteristics of studies for Emergency Public Information and Warning (N = 66), D-12 D-15 Evidence map: Characteristics of studies for Fatality Management (N = 15), D-12 D-16 Evidence map: Characteristics of studies for Information Sharing (N = 38), D-13 D-17 Evidence map: Characteristics of studies for Mass Care (N = 30), D-13 D-18 Evidence map: Characteristics of studies for Medical Countermeasure Dispensing and Administration (N = 110), D-14 D-19 Evidence map: Characteristics of studies for Medical Materiel Management and Distribution (N = 36), D-14 D-20 Evidence map: Characteristics of studies for Medical Surge (N = 87), D-15 D-21 Evidence map: Characteristics of studies for Non-Pharmaceutical Interventions (N = 112), D-15 D-22 Evidence map: Characteristics of studies for Public Health Laboratory Testing (N = 15), D-16 D-23 Evidence map: Characteristics of studies for Public Health Surveillance and Epidemiological Investigation (N = 102), D-17 D-24 Evidence map: Characteristics of studies for Responder Safety and Health (N = 51), D-18 D-25 Evidence map: Characteristics of studies for Volunteer Management (N = 55), D- 18 PREPUBLICATION COPY: UNCORRECTED PROOFS xxii

TABLES S-1 Key Findings and Practice Recommendations from the Committee’s Evidence Review and Evaluation Process, S-16 2-1 Key Federal Stakeholders in Conducting or Supporting Disaster Research, 2-13 3-1 Examples of Evidence Evaluation Frameworks Reviewed by the Committee, 3-7 3-2 Definitions for the Four Levels of Certainty of the Evidence (COE), 3-22 3-3 Matrix with the Generalized Approach by Which the Committee Determined the Certainty of the Evidence (COE), 3-27 4-1 Evidence Types Included in the Mixed-Method Review of Strategies for Engaging with and Training Community-Based Partners to Improve the Outcomes of At-Risk Populations, 4-10 5-1 Evidence Types Included in the Mixed-Method Review of Activating Public Health Emergency Operations, 5-11 6-1 Technical Audiences and Communication Channels Used to Share Public Health Alerts and Guidance, 6-5 6-2 Evidence Types Included in the Mixed-Method Review of Channels for Communicating Public Health Alerts and Guidance with Technical Audiences During a Public Health Emergency, 6-9 6-3 Considerations for Selection of Communication Channels, 6-14 7-1 Evidence Types Included in the Mixed-Method Review of Implementing Quarantine, 7-10 7-2 Summary of Findings on the Effectiveness of Quarantine from 12 Modeling Studies, 7-13 8-1 Key Components of Research Response in the Context of Public Health Emergencies, 8-11 8-2 A Brief Overview of Strengths and Limitations of Study Designs for Quantitative Impact Evaluation for PHEPR, 8-17 8-3 Best Practices for the Translation, Dissemination, and Implementation of Evidence- Based PHEPR Practices, 8-35 Annex Genres of Research to Inform PHEPR Practices: Purpose, Example Research 8-1 Questions, and Appropriate Methods, 8-39 B1-1 Evidence Types Included in the Mixed-Method Review of Strategies for Engaging with and Training Community-Based Partners to Improve the Outcomes of At-Risk Populations, B1-5 B1-2 Effect of Culturally Tailored Preparedness Training Programs on Improved PHEPR Knowledge of CBP Representatives, B1-12 PREPUBLICATION COPY: UNCORRECTED PROOFS xxiii

B1-3 Effect of Culturally Tailored Preparedness Training Programs on Improved Attitudes and Beliefs of CBP Representatives Regarding Their Preparedness to Meet Needs of At-Risk Individuals, B1-14 B1-4 Effect of Culturally Tailored Preparedness Training Programs on CBP Disaster Planning, B1-16 B1-5 Effect of Culturally Tailored Preparedness Training Programs for CBPs and At- Risk Populations They Serve on Improved PHEPR Knowledge of Trained At-Risk Populations, B1-18 B1-6 Effect of Culturally Tailored Preparedness Training Programs for CBPs and At- Risk Populations They Serve on Improved Attitudes and Beliefs of Trained At-Risk Populations Regarding Their Preparedness, B1-21 B1-7 Effect of Culturally Tailored Preparedness Training Programs for CBPs and At- Risk Populations They Serve on Improved Preparedness Behaviors of Trained At- Risk Populations, B1-23 B1-8 Effect of CBP Engagement in Preparedness Outreach Activities Targeting At-Risk Populations on Improved Attitudes and Beliefs of At-Risk Ropulations Toward Preparedness Behaviors, B1-26 B1-9 Effect of Engagement and Training of CBPs in Coalitions Addressing Public Health Preparedness/Resilience, B1-28 B1-10 Evidence to Decision Summary Table for Engaging with and Training Community- Based Partners, B1-38 B2-1 Evidence Types Included in the Mixed-Method Review of Activating Public Health Emergency Operations, B2-6 B2-2 Evidence to Decision Summary Table for Activation of Public Health Emergency Operations, B2-13 B3-1 Evidence Types Included in the Mixed-Method Review of Channels for Communicating Public Health Alerts and Guidance with Technical Audiences During a Public Health Emergency, B3-6 B3-2 Effect of Electronic Messaging System Channels (Email, Text, and Fax) on Improved Technical Audiences’ Awareness of Public Health Alerts and Guidance During a Public Health Emergency, B3-11 B3-3 Effect of Electronic Messaging System Channels (Email, Text, and Fax) on Improved Technical Audiences’ Use of Public Health Guidance During a Public Health Emergency, B3-13 B3-4 Evidence to Decision Summary Table for Channels Used to Communicate Public Health Alerts and Guidance with Technical Audiences During a Public Health Emergency, B3-20 B3-5 Considerations for Selection of Communication Channels, B3-24 B4-1 Evidence Types Included in the Mixed-Method Review of Implementing Quarantine to Reduce or Stop the Spread of a Contagious Disease, B4-6 B4-2 Effect of Quarantine on Reduced Overall Disease Transmission in the Community in Certain Circumstances, B4-10 PREPUBLICATION COPY: UNCORRECTED PROOFS xxiv

B4-3 Effect of Quarantine on Reduced Time from Symptom Onset to Diagnosis in Quarantined Individuals, B4-12 B4-4 Effect of Congregate Quarantine for Influenza and Agents with Similar Transmissibility on Increased Risk of Infection Among Those in the Shared Setting, B4-14 B4-5 Effect of Quarantine on Psychological Harms in Quarantined Individuals, B4-19 B4-6 Effect of Quarantine on Financial Hardship in Quarantined Individuals, B4-22 B4-7 Effect of Health-Promoting Leadership on Reduced Depression and Anxiety Symptoms in Quarantined Individuals, B4-24 B4-8 Effect of Risk Communication and Messaging and Employment Leave on Improved Adherence to Quarantine Measures, B4-27 B4-9 Summary of Findings on the Effectiveness of Quarantine from 12 Modeling Studies, B4-29 B4-10 Evidence to Decision Summary Table for Implementing Quarantine, B4-37 PREPUBLICATION COPY: UNCORRECTED PROOFS xxv

Acronyms and Abbreviations 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 Evidence from Reviews of Qualitative research CESH Center for Evidence Synthesis in Health 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 DOT U.S. Department of Transportation EBM evidence-based medicine EOC emergency operations coordination/center EtD Evidence to Decision (framework) FDA U.S. Food and Drug Administration FEMA Federal Emergency Management Agency GRADE Grading of Recommendations Assessment, Development and Evaluation HPP Hospital Preparedness Program HRSA Health Resources and Services Administration HSDL Homeland Security Digital Library MMWR Morbidity and Mortality Weekly Report NACCHO National Association of County & City Health Officials NIEHS National Institute of Environmental Health Sciences NSF National Science Foundation PREPUBLICATION COPY: UNCORRECTED PROOFS xxvii

PAHPA Pandemic and All Hazards Preparedness Act PERLC Preparedness Emergency Response Learning Center PERRC Preparedness Emergency Response Research Center PHAB Public Health Accreditation Board 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 SLTT state, local, tribal, and territorial TIDieR Template for Intervention Description and Replication USPSTF U.S. Preventive Services Task Force WHO World Health Organization WWC What Works Clearinghouse PREPUBLICATION COPY: UNCORRECTED PROOFS xxviii

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When communities face complex public health emergencies, state local, tribal, and territorial public health agencies must make difficult decisions regarding how to effectively respond. The public health emergency preparedness and response (PHEPR) system, with its multifaceted mission to prevent, protect against, quickly respond to, and recover from public health emergencies, is inherently complex and encompasses policies, organizations, and programs. Since the events of September 11, 2001, the United States has invested billions of dollars and immeasurable amounts of human capital to develop and enhance public health emergency preparedness and infrastructure to respond to a wide range of public health threats, including infectious diseases, natural disasters, and chemical, biological, radiological, and nuclear events. Despite the investments in research and the growing body of empirical literature on a range of preparedness and response capabilities and functions, there has been no national-level, comprehensive review and grading of evidence for public health emergency preparedness and response practices comparable to those utilized in medicine and other public health fields.

Evidence-Based Practice for Public Health Emergency Preparedness and Response reviews the state of the evidence on PHEPR practices and the improvements necessary to move the field forward and to strengthen the PHEPR system. This publication evaluates PHEPR evidence to understand the balance of benefits and harms of PHEPR practices, with a focus on four main areas of PHEPR: engagement with and training of community-based partners to improve the outcomes of at-risk populations after public health emergencies; activation of a public health emergency operations center; communication of public health alerts and guidance to technical audiences during a public health emergency; and implementation of quarantine to reduce the spread of contagious illness.

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