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Research Interests: Engineering and Law
Special Issue on COVID-19 & Misinfodemics, Guest-Editors Editorial.
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Objectives. To identify and analyze common challenges from multiple US communities affected by the hepatitis A epidemic beginning in March 2017, and to identify operational lessons to support preparedness for similar future public health... more
Objectives. To identify and analyze common challenges from multiple US communities affected by the hepatitis A epidemic beginning in March 2017, and to identify operational lessons to support preparedness for similar future public health emergencies.Methods. We conducted semistructured interviews with health officials from 9 city or county health departments to collect the firsthand experience of public health responders. We collected data from January to October 2018 via teleconference. Key informants, whom we purposefully sampled, were senior public health officials who were directly involved in outbreak response or in preparing for potential hepatitis A outbreaks in their communities.Results. Several themes emerged during these discussions, including common challenges and solutions pertaining to sanitation and hygiene infrastructure, hepatitis A vaccination, health workforce availability and surge capacity, communication and stigma, and partnerships and coordination with local law enforcement and other stakeholders.Conclusions. By generating key, evidence-based operational lessons, this study can inform response activities in localities currently experiencing outbreaks as well as community preparedness for possible future outbreaks due to the presence of similar at-risk populations.
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Context: Senior health officials of local health departments are uniquely positioned to provide transformational leadership on health disparities and inequities. Objective: This study aimed to understand how senior health officials in... more
Context: Senior health officials of local health departments are uniquely positioned to provide transformational leadership on health disparities and inequities. Objective: This study aimed to understand how senior health officials in large US cities define health equity and its relationship with disparities and characterize these senior health officials' perceptions of using health equity and disparity language in local public health practice. Design: In 2016, we used a general inductive qualitative design and conducted 23 semistructured interviews with leaders of large local health departments. Thematic content analysis was conducted using NVivo 11. Participants: A purposive sample of senior health officials from Big Cities Health Coalition cities. Results: Health equity was conceptualized fairly consistently among senior health officials in big cities. Core elements of these conceptualizations include social and economic conditions, the input and redistribution of resources, equity in practice, values of justice and fairness, and equity as an outcome to be achieved. Senior health officials saw health disparity and health inequity as distinct but related concepts. Relationships between concepts included disparities data to identify and prioritize inequities, inequities creating health disparities, health equity to eliminate disparities, and disparities becoming inequities when their root causes are unjust. Some respondents critiqued health equity terminology for representing a superficial change, being inaccessible, and being politically loaded. Conclusions: Understanding how senior health officials conceptualize health equity and disparities can focus policy priorities, resources, and the scope of work undertaken by local health departments. Having a common language for health equity allows for policy and resource advocacy to promote the health of marginalized populations.
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Mosquito-borne infectious diseases such as dengue, chikungunya, and now Zika, pose a public health threat to the US, particularly Florida, the Gulf Coast states, and Hawaii. Recent autochthonous transmission of dengue and chikungunya in... more
Mosquito-borne infectious diseases such as dengue, chikungunya, and now Zika, pose a public health threat to the US, particularly Florida, the Gulf Coast states, and Hawaii. Recent autochthonous transmission of dengue and chikungunya in Florida, the recent dengue outbreak in Hawaii, and the potential for future local spread of Zika in the US, has led to the consideration of novel approaches to mosquito management. One such novel approach, the release of sterile genetically modified mosquitoes, has been proposed as a possible intervention, and a trial release of GM mosquitoes is being considered in one Florida community. However, this proposal has been controversial. The objective of this research was to increase understanding of community knowledge, attitudes, and beliefs regarding mosquito control and GM mosquitoes. An 18-question self-administered survey was mailed to all households in the identified Key West, Florida neighborhood where a GM mosquito trial has been proposed. This survey was fielded between July 20, 2015 and November 1, 2015. The main outcome variable was opposition to the use of GM mosquitoes. Measures included demographic information and opinions on mosquitoes, mosquito control, and vector-borne diseases. A majority of survey respondents did not support use of GM mosquitoes as a mosquito control method. Reasons for opposition included general fears about possible harmful impacts of this intervention, specific worries about human and animal health impacts from the GM mosquitoes, and environmental concerns about potential negative effects on the ecosystem. Residents were more likely to oppose GM mosquito use if they had a low perception of the potential risks posed by diseases like dengue and chikungunya, if they were female, and if they were less concerned about the need to control mosquitoes in general. These findings suggest a need for new approaches to risk communication, including educational efforts surrounding mosquito control and reciprocal dialogue between residents and public health officials.
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The COVID-19 pandemic has taken many lives in the last two years. Handling high volumes of decedents within and beyond a hospital’s environment has put healthcare- and deathcare-workers at an increased health risk throughout this... more
The COVID-19 pandemic has taken many lives in the last two years. Handling high volumes of decedents within and beyond a hospital’s environment has put healthcare- and deathcare-workers at an increased health risk throughout this pandemic. However, systematic research about manual handling of the dead either at the hospital, morgue, funeral home, or in situations of mass fatalities is still in infancy. This session aims to educate ergonomics and safety professionals on the importance of understanding the risk factors associated with handling the decedents, design issues of body bags, effects of PPE, routine versus mass fatality handling of the decedents, and participatory ergonomics. This session will also examine the feasibility of translating the past and current research on the handling of live patients to the handling of patients postmortem. Finally, psychosocial risks due to handling the deceased within the pandemic environment that might influence these workers’ risk of muscul...
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Background: In fall 2009, the New York City Department of Health and Mental Hygiene (DOHMH) launched one of the nation's largest efforts including a school-located campaign and a community-based Point of Dispensing (POD) campaign to... more
Background: In fall 2009, the New York City Department of Health and Mental Hygiene (DOHMH) launched one of the nation's largest efforts including a school-located campaign and a community-based Point of Dispensing (POD) campaign to deliver influenza A (H1N1) 2009 monovalent vaccine. The objective of this study was to estimate and compare total campaign costs and costs per dose. Methods: Expenses including personnel, supplies/equipment, logistics and overhead were calculated in 2009-2010 U.S. dollars from DOHMH's perspective. Costs were obtained from invoices or estimates of expended resources. Vaccination data were obtained from the Citywide Immunization Registry and POD reports. Maximum capacity was estimated by applying the number of doses administered at high performing sites to all schools and PODs. Results: The school-located campaign delivered an estimated 240,205 vaccines at a cost of $17.6 million and cost per dose of $73. PODs delivered 49,986 vaccines at a cost of...
Background: There is growing evidence that children are a key link in the chain of influenza transmission, and vaccinating children can decrease morbidity and mortality in the community as a whole. To vaccinate children during the 2009... more
Background: There is growing evidence that children are a key link in the chain of influenza transmission, and vaccinating children can decrease morbidity and mortality in the community as a whole. To vaccinate children during the 2009 H1N1 influenza pandemic, the New York City (NYC) Department of Health and Mental Hygiene used three strategies: school-located vaccination, community-based mass vaccination through Points of Dispensing' (PODs), and medical provider-based vaccination. Objective: To determine the number of children reached by each strategy and the percent of children that received influenza vaccination for the first time in each strategy. Methods: Data on the number and source of vaccinations given were obtained from NYC's Citywide Immunization Registry (CIR), an electronic system for tracking immunizations of individual children. Children aged 4-10 with a H1N1 vaccine recorded in CIR and were included in the analysis. Results: Approximately 112,000 children wer...
Increasingly frequent and costly disasters in the US have prompted the need for greater collaboration at the local level among healthcare facilities, public health agencies, emergency medical services, and emergency management agencies.... more
Increasingly frequent and costly disasters in the US have prompted the need for greater collaboration at the local level among healthcare facilities, public health agencies, emergency medical services, and emergency management agencies. We conducted a multiphase, mixed-method, qualitative study to uncover the extent and quality of existing collaborations, identify what factors impede or facilitate the integration of the preparedness community, and propose measures to strengthen collaboration. Our study involved a comprehensive literature review, 55 semistructured key-informant interviews, and a working group meeting. Using thematic analysis, we identified 6 key findings that will inform the development of tools to help coalitions better assess and improve their own preparedness community integration.
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The Council on Education for Public Health (CEPH) accredits graduate schools of public health. One critical CEPH accreditation requirement is that all graduate professional public health degree students demonstrate application of basic... more
The Council on Education for Public Health (CEPH) accredits graduate schools of public health. One critical CEPH accreditation requirement is that all graduate professional public health degree students demonstrate application of basic public health concepts through a practice experience. A major challenge for and responsibility of schools of public health is ensuring that this practice experience contributes to the development of knowledge, skills and abilities that graduates will need upon entering the workforce. A competency-based approach was utilized for planning and selecting practicum experiences to maximize the ability of said experiences to contribute to the development of skills graduates need to successfully deliver essential public health services. In 2013, incoming Master of Public Health (MPH) students at the Johns Hopkins Bloomberg School of Public Health were enrolled in Tools of Public Health Practice and Decision Making, a course designed to introduce students to t...
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Evacuation and shelter-in-place decision making for hospitals is complex, and existing literature contains little information about how these decisions are made in practice. To describe decision-making processes and identify determinants... more
Evacuation and shelter-in-place decision making for hospitals is complex, and existing literature contains little information about how these decisions are made in practice. To describe decision-making processes and identify determinants of acute care hospital evacuation and shelter-in-place during Hurricane Sandy. Semistructured interviews were conducted from March 2014 to February 2015 with key informants who had authority and responsibility for evacuation and shelter-in-place decisions for hospitals during Hurricane Sandy in 2012. Interviews were recorded, transcribed, and thematically analyzed. Interviewees included hospital executives and state and local public health, emergency management, and emergency medical service officials from Delaware, Maryland, New Jersey, and New York. Interviewees identified decision processes and determinants of acute care hospital evacuation and shelter-in-place during Hurricane Sandy. We interviewed 42 individuals from 32 organizations. Decisions...
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Objective: To identify essential knowledge, skills, and abilities (KSAs) for and characterize gaps in KSAs of professionals working in large, urban health departments. Design: A survey was disseminated to potentially eligible supervisors... more
Objective: To identify essential knowledge, skills, and abilities (KSAs) for and characterize gaps in KSAs of professionals working in large, urban health departments. Design: A survey was disseminated to potentially eligible supervisors within 26 of 28 health departments in the largest, most urban jurisdictions in the country. A supervisor was eligible to participate if he or she supervised at least 1 staff member whose highest level of education was a master's degree. Setting and Participants: A total of 645 eligible supervisors participated in the workforce survey for a response rate of 27.1% and cooperation rate of 55.2%. Main Outcome Measure(s): Supervisors were asked to rate the importance of KSAs to their masters-level staffs' work and indicate their staffs' proficiency. Results: Fifty-eight percent of supervisors reported supervising staff with a master of public health/master of science in public health degree. More than 30% of supervisors indicated that all of ...
Research Interests: Psychology and Medicine
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Objectives: The Council of State and Territorial Epidemiologists (CSTE) has periodically assessed the epidemiological capacity of states since 2001, but the data do not reflect the total US epidemiology capacity. CSTE partnered with the... more
Objectives: The Council of State and Territorial Epidemiologists (CSTE) has periodically assessed the epidemiological capacity of states since 2001, but the data do not reflect the total US epidemiology capacity. CSTE partnered with the Big Cities Health Coalition (BCHC) in 2017 to assess epidemiology capacity in large urban health departments. We described the epidemiology workforce capacity of large urban health departments in the United States and determined gaps in capacity among BCHC health departments. Methods: BCHC, in partnership with CSTE, modified the 2017 State Epidemiology Capacity Assessment for its 30 member departments. Topics in the assessment included epidemiology leadership, staffing, funding, capacity to perform 4 epidemiology-related Essential Public Health Services, salary ranges, hiring requirements, use of competencies, training needs, and job vacancies. Results: The 27 (90%) BCHC-member health departments that completed the assessment employed 1091 full-time ...
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Mosquito-borne infectious diseases such as dengue, chikungunya, and now Zika, pose a public health threat to the US, particularly Florida, the Gulf Coast states, and Hawaii. Recent autochthonous transmission of dengue and chikungunya in... more
Mosquito-borne infectious diseases such as dengue, chikungunya, and now Zika, pose a public health threat to the US, particularly Florida, the Gulf Coast states, and Hawaii. Recent autochthonous transmission of dengue and chikungunya in Florida, the recent dengue outbreak in Hawaii, and the potential for future local spread of Zika in the US, has led to the consideration of novel approaches to mosquito management. One such novel approach, the release of sterile genetically modified mosquitoes, has been proposed as a possible intervention, and a trial release of GM mosquitoes is being considered in one Florida community. However, this proposal has been controversial. The objective of this research was to increase understanding of community knowledge, attitudes, and beliefs regarding mosquito control and GM mosquitoes. An 18-question self-administered survey was mailed to all households in the identified Key West, Florida neighborhood where a GM mosquito trial has been proposed. This survey was fielded between July 20, 2015 and November 1, 2015. The main outcome variable was opposition to the use of GM mosquitoes. Measures included demographic information and opinions on mosquitoes, mosquito control, and vector-borne diseases. A majority of survey respondents did not support use of GM mosquitoes as a mosquito control method. Reasons for opposition included general fears about possible harmful impacts of this intervention, specific worries about human and animal health impacts from the GM mosquitoes, and environmental concerns about potential negative effects on the ecosystem. Residents were more likely to oppose GM mosquito use if they had a low perception of the potential risks posed by diseases like dengue and chikungunya, if they were female, and if they were less concerned about the need to control mosquitoes in general. These findings suggest a need for new approaches to risk communication, including educational efforts surrounding mosquito control and reciprocal dialogue between residents and public health officials.
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ObjectiveDuring natural disasters, hospital evacuation may be necessary to ensure patient safety and care. We aimed to examine perceptions of stakeholders involved in these decisions throughout the Mid-Atlantic region of the United States... more
ObjectiveDuring natural disasters, hospital evacuation may be necessary to ensure patient safety and care. We aimed to examine perceptions of stakeholders involved in these decisions throughout the Mid-Atlantic region of the United States during Hurricane Sandy in October 2012.MethodsSemistructured interviews were conducted from March 2014 to February 2015 to characterize stakeholders’ perceptions about authority and responsibility for acute care hospital evacuation/shelter-in-place decision-making in Delaware, Maryland, New Jersey, and New York during Hurricane Sandy. Interviews were recorded, transcribed, and thematically analyzed using a framework approach.ResultsWe interviewed 42 individuals from 32 organizations. Hospital executives from all states reported having authority and responsibility for evacuation/shelter-in-place decision-making. In New York and Maryland, government officials stated that they could order hospital evacuation, whereas officials in Delaware and New Jers...
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Hospitals were once thought to be places of refuge during catastrophic hurricanes, but recent disasters such as Hurricanes Katrina and Sandy have demonstrated that some hospitals are unable to ensure the safety of patients and staff and... more
Hospitals were once thought to be places of refuge during catastrophic hurricanes, but recent disasters such as Hurricanes Katrina and Sandy have demonstrated that some hospitals are unable to ensure the safety of patients and staff and the continuity of medical care at key times. The government has a duty to safeguard public health and a responsibility to ensure that appropriate protective action is taken when disasters threaten or impair the ability of hospitals to sustain essential services. The law can enable the government to fulfill this duty by providing necessary authority to order preventive or reactive responses-such as ordering evacuation of or sheltering-in-place in hospitals-when safety is imperiled. We systematically identified and analyzed state emergency preparedness laws that could have affected evacuation of and sheltering-in-place in hospitals in order to characterize the public health legal preparedness of 4 states (Delaware, Maryland, New Jersey, and New York) in the mid-Atlantic region during Hurricane Sandy in 2012. At that time, none of these 4 states had enacted statutes or regulations explicitly granting the government the authority to order hospitals to shelter-in-place. Whereas all 4 states had enacted laws explicitly enabling the government to order evacuation, the nature of this authority and the individuals empowered to execute it varied. We present empirical analyses intended to enhance public health legal preparedness and ensure these states and others are better able to respond to future natural disasters, which are predicted to be more severe and frequent as a result of climate change, as well as other hazards. States can further improve their readiness for catastrophic disasters by ensuring explicit statutory authority to order evacuation and to order sheltering-in-place, particularly of hospitals, where it does not currently exist.