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Background: Effective disaster preparedness requires coordination across multiple organizations. This article describes a detailed framework developed through the BioNet program to facilitate coordination of bioterrorism preparedness planning among military and civilian decision makers.

Methods: The authors and colleagues conducted a series of semistructured interviews with civilian and military decision makers from public health, emergency management, hazardous material response, law enforcement, and military health in the San Diego area. Decision makers used a software tool that simulated a hypothetical anthrax attack, which allowed them to assess the effects of a variety of response actions (eg, issuing warnings to the public, establishing prophylaxis distribution centers) on performance metrics. From these interviews, the authors characterized the information sources, technologies, plans, and communication channels that would be used for bioterrorism planning and responses. The authors used influence diagram notation to describe the key bioterrorism response decisions, the probabilistic factors affecting these decisions, and the response outcomes.

Results: The authors present an overview of the response framework and provide a detailed assessment of two key phases of the decision-making process:

  1. pre-event planning and investment and
  2. incident characterization and initial responsive measures.

The framework enables planners to articulate current conditions; identify gaps in existing policies, technologies, information resources, and relationships with other response organizations; and explore the implications of potential system enhancements.

Conclusions: Use of this framework could help decision makers execute a locally coordinated response by identifying the critical cues of a potential bioterrorism event, the information needed to make effective response decisions, and the potential effects of various decision alternatives. Key words: bioterrorism, decision making, organization and administration, regional health planning

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American Journal of Disaster Medicine
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This study examined the link between exposure to particulate matter—a form of air pollution in which fine particles are suspended in the air—and adverse health outcomes for the elderly, who are hypothesized to be affected disproportionately.  In order to continue to determine environmental standards for pollution and to design effective public health warnings about pollution, an understanding of the health effects is needed. Such policies are particularly pertinent to the elderly, who might be socially isolated and less able to leave an area during a high-pollution episode.

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Preconception and interconception care respond to the growing body of evidence that many of the most important determinants of birth outcomes may exist before pregnancy occurs. In this sense, the strategy of extending prenatal care into the preconception and interconception periods marks a useful step in reforming the public health approach to improving birth outcomes. However, although helpful in underscoring the continuity of risk that can ultimately find expression in adverse birth outcomes, the concern is that without greater critical attention these relatively new care constructs have the potential to undermine rather than strengthen a comprehensive system of women's health care.

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Women's Health Issues
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Paul H. Wise

Office of Public Health Surveillance & Research
VA Palo Alto Health Care System
3801 Miranda Ave. (132)
Palo Alto, California 94304-5107

holodniy@stanford.edu

(650) 852-3408 (650) 858-3978
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Professor of Medicine, Stanford University School of Medicine
holodniy_mark_9-19-16.jpg MD, FACP, FIDSA

Dr. Holodniy is Professor of Medicine (Infectious Diseases & Geographic Medicine) at Stanford University and has been a full time employee of the Department of Veterans Affairs (VA) for over 25 years. He has been national director of Public Health Surveillance and Research (PHSR) in VA since 1999, which is a national program office based at the VA Palo Alto Health Care System (VAPAHCS). His current VA responsibilities include public health surveillance, conducting outbreak and large-scale lookback investigations within VA, and directing the VA Public Health Reference Laboratory (PHRL). PHRL is a national VA laboratory, aligned with CDC and the Laboratory Response Network (LRN), which supports clinical care and public health investigations utilizing state-of-the-art diagnostic microbiology methods and equipment. He also serves as the hospital epidemiologist and staff infectious disease physician for the VAPAHCS. Previously, he directed pharmacy services at the VAPAHCS from 1996-1999, the HIV clinical program at VAPAHCS from 1991-2011, and was the acting director of the VA Cooperative Studies Program Coordinating Center at VAPAHCS from 2007-2009, where he oversaw a portfolio of several multicenter VA studies and the VA DNA Bank Genomics Program.

His research program focuses on viral evolution, microbial development of drug resistance, clinical trial evaluation of novel diagnostics and antimicrobial compounds, and evaluation of clinical outcomes associated with infectious diseases. In that capacity, Dr. Holodniy has overseen the conduct of over 80 clinical and diagnostic assay trials at VAPAHCS since 1991. He has also mentored many infectious disease fellows, graduate students, and Epidemic Intelligence Service (EIS) officers, in collaboration with CDC.

 

Stanford Health Policy Associate

700 Welch Road Suite #225
Palo Alto, California 94304

(650) 736-0629 (650) 497-8465
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Professor of Pediatrics, Stanford University School of Medicine
Medical Director at the Center for Quality and Clinical Effectiveness at Lucile Packard Children’s Hospital Stanford
Chief Clinical Patient Safety Officer at Lucile Packard Children’s Hospital Stanford
Sharek_Paul10-08-08.jpg MD, MPH

Paul graduated from Columbia University Medical School in New York, completed residency and chief residency in pediatrics at the University of California, San Francisco, received a Masters of Public Health from University of California, Berkeley and completed a fellowship in health services research at Stanford University.

Paul is presently a Professor of Pediatrics at Stanford University, a pediatric hospitalist, and is the creator and Medical Director of the LPCH Center for Quality and Clinical Effectiveness and Chief Clinical Patient Safety Officer at Lucile Packard Children’s Hospital. Paul is presently the Director of Quality Improvement for the California Perinatal Quality of Care Collaborative (CPQCC), is a founding and current member of the Solutions for Patient Safety Clinical Steering Committee, and is on the Strategic Planning Committee for Quality and Patient Safety for CHA (Children’s Hospital Association). In 2013, Paul was awarded the inaugural Paul V. Miles Fellow in Quality Improvement from the American Board of Pediatrics, an Award bestowed on individuals who have “dedicated themselves to quality improvement and demonstrated accomplishments leading to better healthcare for children”. Paul is presently an investigator or co-investigator on numerous grants focused on pediatric patient safety. Most recently, Paul has dedicated his research and administrative efforts to translating the tenets of high reliability organization theory into healthcare, and is partnering with human factors engineers to translate “design thinking” into the healthcare industry to accelerate patient safety and quality improvement. Paul has given a substantial number of presentations at national and international academic meetings related to quality of care and patient safety and is a faculty member of the Institute for Healthcare Improvement (IHI). Paul has been a visiting professor on quality/patient safety at numerous children’s hospitals across the world including Great Ormond Street Hospital for Children in London, The Hospital for Sick Kids in Toronto, The Children’s Hospital of Eastern Ontario in Ottawa, and several national children’s hospitals including, Children’s National Hospital in Washington DC, Morgan Stanley Children’s Hospital of Columbia University, Children’s Hospital of Los Angeles, Children’s Hospital of Colorado, St Louis Children’s Hospital, Nationwide Children’s Hospital, and St Jude Children’s Research Hospital. Paul has published extensively on the topics of pediatric quality of care and patient safety, including a Nov 2007 study correlating a Rapid Response Team intervention with decreased mortality in JAMA, and a Nov 2010 study on adverse events over time in the New England Journal of Medicine, and is recognized internationally as a thought leader in the area of pediatric quality and patient safety.

Stanford Health Policy Associate
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Encina Commons, Room 220
615 Crothers Way
Stanford, CA 94305-6006

(650) 721-2486 (650) 723-1919
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Professor, Health Policy
jeremy-fisch_profile_compressed.jpg PhD

Jeremy Goldhaber-Fiebert, PhD, is a Professor of Health Policy, a Core Faculty Member at the Center for Health Policy and the Department of Health Policy, and a Faculty Affiliate of the Stanford Center on Longevity and Stanford Center for International Development. His research focuses on complex policy decisions surrounding the prevention and management of increasingly common, chronic diseases and the life course impact of exposure to their risk factors. In the context of both developing and developed countries including the US, India, China, and South Africa, he has examined chronic conditions including type 2 diabetes and cardiovascular diseases, human papillomavirus and cervical cancer, tuberculosis, and hepatitis C and on risk factors including smoking, physical activity, obesity, malnutrition, and other diseases themselves. He combines simulation modeling methods and cost-effectiveness analyses with econometric approaches and behavioral economic studies to address these issues. Dr. Goldhaber-Fiebert graduated magna cum laude from Harvard College in 1997, with an A.B. in the History and Literature of America. After working as a software engineer and consultant, he conducted a year-long public health research program in Costa Rica with his wife in 2001. Winner of the Lee B. Lusted Prize for Outstanding Student Research from the Society for Medical Decision Making in 2006 and in 2008, he completed his PhD in Health Policy concentrating in Decision Science at Harvard University in 2008. He was elected as a Trustee of the Society for Medical Decision Making in 2011.

Past and current research topics:

  1. Type 2 diabetes and cardiovascular risk factors: Randomized and observational studies in Costa Rica examining the impact of community-based lifestyle interventions and the relationship of gender, risk factors, and care utilization.
  2. Cervical cancer: Model-based cost-effectiveness analyses and costing methods studies that examine policy issues relating to cervical cancer screening and human papillomavirus vaccination in countries including the United States, Brazil, India, Kenya, Peru, South Africa, Tanzania, and Thailand.
  3. Measles, haemophilus influenzae type b, and other childhood infectious diseases: Longitudinal regression analyses of country-level data from middle and upper income countries that examine the link between vaccination, sustained reductions in mortality, and evidence of herd immunity.
  4. Patient adherence: Studies in both developing and developed countries of the costs and effectiveness of measures to increase successful adherence. Adherence to cervical cancer screening as well as to disease management programs targeting depression and obesity is examined from both a decision-analytic and a behavioral economics perspective.
  5. Simulation modeling methods: Research examining model calibration and validation, the appropriate representation of uncertainty in projected outcomes, the use of models to examine plausible counterfactuals at the biological and epidemiological level, and the reflection of population and spatial heterogeneity.
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PRIMARY AIM: Examine the effectiveness of extended cognitive behavior therapy (CBT) in promoting longer-term smoking abstinence.

DESIGN: Open-label treatment phase followed by extended treatment phase. Randomization conducted prior to entry into open-label treatment phase; analysis based on intention-to-treat to avoid threat of selection bias.

SETTING: Community smoking cessation clinic.

PARTICIPANTS: A total of 304 adult smokers (> or = 18 years of age; > or = 10 cigarettes/day). INTERVENTION: Open-label (8 weeks): all participants received bupropion SR, nicotine patch, CBT. Extended treatment (12 weeks): participants received either CBT + voicemail monitoring and telephone counseling or telephone-based general support.

MEASUREMENTS: Seven-day point prevalence abstinence, expired-air carbon monoxide. RESULTS: At week 20 follow-up, CBT produced a higher 7-day point prevalence abstinence rate: 45% versus 29%, P = 0.006; at 52 weeks the difference in abstinence rates (31% versus 27%) was not significant. History of depression was a moderator of treatment. Those with a positive history had a better treatment response at 20 weeks when assigned to the less intensive telephone support therapy (P < 0.05).

CONCLUSION: The superiority of CBT to 20 weeks suggests that continued emphasis on the development of cognitive and behavioral strategies for maintaining non-smoking during an extended treatment phase may help smokers to maintain abstinence in the longer term. At present, the minimum duration of therapy is unknown.

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Addiction
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OBJECTIVE: To examine the quantity (density) and location (proximity) of tobacco outlets and retail cigarette advertising in high school neighborhoods and their association with school smoking prevalence.

METHODS: Data from the 135 high schools that participated in the 2005-2006 California Student Tobacco Survey were combined with retailer licensing data about the location of tobacco outlets within walking distance (1/2 mi or 805 m) of the schools and with observations about the quantity of cigarette advertising in a random sample of those stores (n=384). Multiple regressions, adjusting for school and neighborhood demographics, tested the associations of high school smoking prevalence with the density of tobacco outlets and retail cigarette advertising and with the proximity of tobacco outlets to schools.

RESULTS: The prevalence of current smoking was 3.2 percentage points higher at schools in neighborhoods with the highest tobacco outlet density (>5 outlets) than in neighborhoods without any tobacco outlets. The density of retail cigarette advertising in school neighborhoods was similarly associated with high school smoking prevalence. However, neither the presence of a tobacco outlet within 1000 ft of a high school nor the distance to the nearest tobacco outlet from school was associated with smoking prevalence.

CONCLUSIONS: Policy efforts to reduce adolescent smoking should aim to reduce the density of tobacco outlets and retail cigarette advertising in school neighborhoods. This may be achieved through local zoning ordinances, including limiting the proximity of tobacco outlets to schools.

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Preventative Medicine
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