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Life and Liberty: Economic, Political and Ethical Issues Arising from 21st Century Quarantines for Influenza
"Quarantine is a word that elicits fear among many. However, it is also a long-utilized and important policy tool for controlling the spread of infectious diseases. This thesis considers the role of quarantine for influenza outbreaks during the twenty-first century. I thematically review scientific literature on the ethical, social and political, and economic issues that have arisen from or have the potential to arise from quarantines for influenza. After identifying these issues, I make policy recommendations targeted at mitigating them. I then compare these with the World Health Organization's (WHO) Influenza Preparedness and Response Guidance to determine where our recommendations overlap and diverge. I propose a set of five additional recommendations to the WHO Guidance for governments considering implementing quarantines for influenza: develop of a body of experts and stakeholders for policymaking, use least-restrictive policy measures first, establish a duty to treat and its limits, determine who will be prioritized during cases of scarcity, and establish support and compensation mechanisms for quarantined individuals. My research contributes to the discourse around quarantine for influenza by identifying a broad scope of consequences of quarantine for influenza. It also contributes to the existing literature on quarantine design for influenza by proposing policies targeted at addressing the issues I identify. While this research is a start, there is still a great need for further research to prepare for and learn from influenza outbreaks. My recommendations fit well alongside existing influenza pandemic preparedness plans such as the WHO's Pandemic Influenza Preparedness and Response Guidance during an influenza outbreak to develop robust disease control policy for influenza outbreaks."
Duke University
Serat, Simone
2017
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Data Interoperability and Exchange to Support COVID-19 Containment
From the Executive Summary: "The success of COVID-19 [coronavirus disease 2019] containment as the United States reopens will depend on timely sharing of key information related to testing, contact tracing, and detecting and acting on new outbreaks. Containment strategies across the country depend on effective collaboration of public health authorities with health care providers, laboratories, and community-based organizations to conduct testing, support effective contact tracing, quickly discern new patterns in health care use plausibly related to COVID-19, and identify ways to improve all of these activities over time. But public health, health care, and testing organizations have never had to work together with the scale or urgency required for COVID-19 containment. In particular, public health agencies are facing difficulties routinely accessing critical data from these other key participants in the containment effort, despite valiant attempts to cobble together information from many disparate systems."
Duke University
Mostashari, Farzad; McClellan, Mark B.
2020-05-01
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COVID-19 is Not 'Like a Nuclear Attack' but Another Kind of Virus Might Be
From the Article: "A few weeks ago the 'Bulletin of the Atomic Scientists' headlined an interview with novelist and academic Jeffery Lewis claiming it would explain '[h]ow the coronavirus outbreak is like a nuclear attack.' Indeed, Lewis insists the pandemic is, as he describes it, a 'nuclear war in slow motion.' It isn't, but as life under COVID-19 [coronavirus disease 2019] restrictions highlights the nation's and, really, the 'world's' growing dependence on the web and associated cyber technologies, a virulent computer virus just might prove as dangerous as a nuclear war."
Duke University
Dunlap, Charles J., 1950-
2020-04-18
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National COVID-19 Surveillance System: 'Achieving Containment'
From the Document: "This report describes the features and capabilities of a national surveillance system to mitigate the current COVID-19 [coronavirus disease] pandemic wave and to limit and suppress future outbreaks. Developing these capabilities in each state and region will enable the U.S. to move beyond extreme and disruptive physical isolation measures. The proposed COVID-19 surveillance system builds on existing models and principles of public health surveillance, but recognizes that the transmissibility and virulence of COVID-19 require a much more substantial capacity for rapid detection and public health response. Timely and efficient implementation of such a surveillance system will require ongoing coordination between health care providers and state and local public health authorities, with Federal support coordinated through the Centers for Disease Control and Prevention (CDC) to achieve effective implementation throughout the country as soon as possible, and certainly in time for the Fall, when COVID-19 may become a seasonal threat."
Duke University
McClellan, Mark B.; Gottlieb, Scott; Mostashari, Farzad . . .
2020-04-07
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Advancing Treatments to Save Lives and Reduce the Risk of COVID-19
From the Document: "Many potentially beneficial treatments for COVID-19 [coronavirus disease] are in various stages of development. Patients facing the risk of serious complications from the virus and no therapeutic alternatives will understandably want access to them. We need to determine which treatments work best to advance safe and effective products to market efficiently, while providing the best possible care for patients with COVID-19 and enabling access to promising treatments for patients who might benefit from them now. To accomplish these goals, we can support large scale access to different drugs that have shown they may be effective against the coronavirus in a framework that enables us to collect good information to determine which medicines are working best for patients, and ultimately merit full FDA approval. At the same time, we can advance treatments that can help protect people from becoming infected with coronavirus in the first place. We also need more tools for early detection of the virus so we can prevent future outbreaks. Building on approaches taken in prior public health emergencies and on improved capabilities for data collection and analysis, all these things are possible to address the COVID-19 pandemic."
Duke University
Gottlieb, Scott; McClellan, Mark B.
2020-03-19?
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Achieving Widespread Availability of Timely and Efficient COVID-19 Testing
From the Document: "Efficient, reliable, widely deployed diagnostic tests are critical to our ongoing response to the current COVID-19 [coronavirus disease] epidemic, and our ability to prevent future large outbreaks or epidemic spread of this disease. In the near term, working out large-scale diagnostic testing using polymerase chain reaction (PCR) test capabilities and point-of-care (POC) tests that are beginning to come online is key to the COVID-19 response. While testing capabilities are now scaling up, challenges remain."
Duke University
McClellan, Mark B.; Gottlieb, Scott; Silvis, Lauren
2020-03-26
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Building the Critical Path for COVID-19 Therapeutics
From the Executive Summary: "Hundreds of therapeutics are in preclinical or clinical development for treating COVID-19 [coronavirus disease 2019] patients. But as of May 2020, so far none have demonstrated effectiveness sufficient to warrant approval for general use, although one antiviral drug (remdesivir) has shown sufficient impact in ongoing clinical trials to support an authorization for emergency use. This is a reflection of the complexity, time, costs, and uncertainties associated with developing therapeutics - a process that not only encompasses preclinical evaluation and clinical trials to demonstrate safety and effectiveness, but also manufacturing at pandemic scale, and sufficient payment to enable appropriate and effective access. [...] Policy attention has understandably focused on the development of vaccines as the path to recovery. But even with these unprecedented actions, the widespread availability of effective vaccines remains many months away, if not longer. To reduce the impact of the pandemic in the meantime, intensive effort is also needed to accelerate therapeutics development to help prevent infections, reduce their severity, and mitigate or prevent further outbreak waves."
Duke University
McClellan, Mark B.; Gottlieb, Scott; Allen, Jeff . . .
2020-05-20
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Health Care Payment to Support COVID-19 Detection and Containment
From the Executive Summary: " CMS [Centers for Medicare & Medicaid Services] recently announced new COVID-19 [coronavirus disease payments to reimburse a broader range of state-authorized health professionals that order diagnostic tests, and to pay for specimen collection and test performance in community settings such as pharmacies. This report describes further payment supports for comprehensive and effective health care provider engagement in rapid case detection, management, and containment of the COVID-19 pandemic. Building on recent CMS actions, these payment reforms could be adopted individually or collectively to reinforce and support health care providers in developing the following capabilities to help contain COVID-19: [1] Provider capacity to conduct COVID-19 health monitoring and case detection for their population of patients; [2] Test sample collection or telemedicine supervision of tests done at home; [3] Test performance with rapid reporting, including timely data sharing with public health authorities; [4] Case management at home or in the community for infected individuals; [5] Assistance with contact tracing, quarantine, and follow-up management. These payments could be implemented in different ways, all of which either fall within current CMS authority for provider and laboratory test payment, or within the scope of COVID-19 legislation to assist health care providers."
Duke University
McClellan, Mark B.; Mostashari, Farzad; Barker, Tom
2020-05-01
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Hurdles to Herd Immunity: Distrust of Government and Vaccine Refusal
From the Abstract: "More children have been granted nonmedical exemptions from required vaccinations in recent years in the United States. While the majority of the population quietly benefits from high vaccination rates, there exists a small (but growing) raucous minority of opponents who refuse vaccination and are incredibly vocal in society. Underlying this minority antivaccine ethos is a sense of distrust of the government and in healthcare providers. This distrust influences where parents obtain their vaccine information and further serves as a filter that colors immunization resources from healthcare providers or government agencies with a layer of skepticism and suspicion. Parents who distrust the government or their healthcare providers are less likely to vaccinate their children fully and more likely to seek out complementary/alternative medicine (CAM) practitioners or antivaccine websites for vaccine information. These antivaccinators do not change their decisions about vaccination when confronted with scientific information on vaccine safety and the dangers of vaccine-preventable diseases. New modalities for delivering pro-vaccine messages need to be researched. Innovative techniques to reach this distrustful population could include vaccine negotiation training for healthcare providers, specifically emphasizing the importance of gaining trust. Local initiatives to create parental peer advocate programs for vaccines through school Parent-Teacher Associations, professional groups, or religious groups could better access the antivaccine population. Increased collaboration between public health officials and CAM practitioners may also improve vaccination rates."
Duke University
Lee, Charlotte
2014-12
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National Decision Point: Effective Testing and Screening for Covid-19
From the Executive Summary: "The best tools for shifting back to some form of normalcy are effective masking and distancing measures to mitigate spread, coupled with sufficient Covid-19 [coronavirus disease 2019] tests paired with sophisticated strategies for their effective use. This report describes how to offer the latter in ways that can be tailored to local circumstances and risk tolerances. The goal is to give schools, businesses, and other critical institutions a pathway toward operating safely even for higher-risk populations and with continuing community spread. There are four basic elements to a testing strategy that can contain outbreaks, inform public health decision-making, and respond to local Covid-19 prevalence rates: [1] Assessments of the risks of infection and death depending on local spread and population characteristics. [2] Meaningful and measurable goals for acceptable infection reduction through screening and surveillance. [3] Calculation of budgetary and administrative constraints. [4] Adequate supplies of sufficiently reliable tests."
Rockefeller Foundation; Duke University
Silcox, Christina; Anderson, David; Zavodszky, Anna . . .
2020-09?
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Decontamination and Reuse of N95 Respirators with Hydrogen Peroxide Vapor to Address Worldwide Personal Protective Equipment Shortages During the SARS‐COV‐2 (COVID‐19) Pandemic
From the Abstract: "The SARS‐CoV‐2 [severe acute respiratory syndrome coronavirus 2] (COVID‐19) pandemic has placed a tremendous amount of strain on resources in the healthcare setting. One of the most pressing issues is the rapid depletion of personal protective equipment (PPE) used in the care of patients. This is a significant concern for healthcare workers' health and safety. Many entities have depleted or soon will exhaust their stockpile of PPE despite adopting PPE sparing practices as the number of COVID‐19 cases in the U.S. increases at an almost exponential rate and manufacturers struggle to keep up with the worldwide demand. This potential shortage is particularly concerning for commonly used N95 respirators and Powered‐Air Purifying Respirators (PAPRs). Recently, the U.S. Occupational Safety and Health Administration (OSHA) even temporarily suspended the requirement to perform annual fit testing of respirators to allow entities to conserve respirators and preserve them for patient care. These measures are unprecedented and highlight the urgent need for entities to develop solutions to proactively address what could be potentially a grave occupational health issue."
Duke University. Occupational and Environmental Safety Office
Schwartz, Antony; Stiegel, Matthew; Greeson, Nicole . . .
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Guest Post: 'Using Digital Surveillance to Combat COVID-19: What the 9/11 Era Can (And Cannot) Teach US'
From the Background: "Much has been written [...] about the use of mobile phones for the purpose of achieving faster and more comprehensive contact tracing. The idea has gained traction following the introduction of such measures in South Korea, Singapore, and elsewhere. [...] We still know relatively little about how this virus operates, and we have yet to employ testing at a scale that would help such tech-based solutions succeed. Nor will a mobile app or similar software eliminate the important, painstaking work of traditional contact tracing and other measures like social distancing. In other words, we need to be sober in our expectations.[...] If we are thinking of adopting some form of surveillance, particularly one that might involve government (whether through the limited collection of anonymized data or through more invasive measures like mandating the use of apps or using electronic surveillance for quarantine enforcement), we are not working from a blank slate. We have been learning in real time for the last two decades."
Duke University. Center on Law, Ethics, and National Security
Dunlap, Charles J., 1950-; Stansbury, Shane
2020-05-09
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Risk Assessment and Testing Considerations for SARS-CoV-2 Transmission in Congregate Care Facilities
From the Objective: "The purposes of this document are to: 1. Help managers and administrators of congregate care facilities (CCFs), such as assisted living facilities (ALFs), memory care units, and federally subsidized senior housing, assess the risk of Covid-19 [coronavirus disease 2019] in their facilities, and 2. Identify key considerations in developing a screening program to regularly test residents and staff for the virus. In addition, because nearly half the states eased visitor restrictions for CCFs at least temporarily by fall of 2020, we offer considerations for testing of visitors."
Duke University. Margolis Center for Health Policy; Rockefeller Foundation
Van Houtven, Courtney H.; Anderson, David; Gill, Mira . . .
2021-01-25
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State Strategies for Engaging and Leveraging Primary Care Providers as COVID-19 Vaccinators
From the Document: "As supply of the COVID-19 [coronavirus disease 2019] vaccine has eclipsed demand in many areas across the country, states are shifting strategies to increase accessibility and engage communities with low vaccine uptake. With over 80 percent of adults receiving care through a regular medical home [hyperlink], primary care providers (PCPs) are critical to reaching the nine percent of surveyed adults [hyperlink] who have not received the vaccine but expressed keen interest getting it, as well as the 15 percent with additional questions indicating they would like to 'wait and see'. [...] A key strategy in the next phase of pandemic response is to engage PCPs as trusted resources for vaccinations. The National Governors Association (NGA) and Duke-Margolis Center for Health Policy (Duke-Margolis) interviewed a sample of states and conducted targeted research to identify promising practices for Governors to engage and leverage PCPs as COVID-19 vaccinators. This report summarizes these findings, providing Governors and state officials with considerations and examples of strategies for leveraging PCPs to increase COVID-19 vaccine uptake."
National Governors' Association; Duke University. Margolis Center for Health Policy
Williamson, Kirk; Greene, Katie; Tewarson, Hemi . . .
2021-06
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Case Study of the Virginia COVID-19 Equity Leadership Task Force and Health Equity Working Group
From the Document: "The Commonwealth of Virginia has integrated principles of equity and inclusion into the infrastructure of state government--an approach that has been instrumental in the state's response to COVID-19 [coronavirus disease 2019]. This brief summarizes the unique structure of Virginia's equity work, the strategy and actions taken to date, and success factors and lessons learned."
National Governors' Association; Duke University. Margolis Center for Health Policy
Haldar, Sweta; Tewarson, Hemi; Thoumi, Andrea . . .
2021-07
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Case Study of the Michigan Coronavirus Task Force on Racial Disparities
From the Document: "The Michigan Coronavirus Racial Disparities Task Force has paved the way to address COVID-19 [coronavirus disease 2019] related health inequities in the state, resulting in the reduction of COVID-19 related cases and mortality among Black residents. As a result of the work, the average number of new cases for Black residents dropped from 176 per million population per day in March 2020 to 59 per million population per day in October 2020, and disparities in case rates among Hispanic or Latino Michiganders also narrowed. Governor Gretchen Whitmer created the Michigan Task Force through Executive Order 2020-55 in April 2020 to reduce health disparities within communities disproportionately affected by COVID-19. [...] The Michigan Task Force has achieved positive results by investing in key strategies, which include establishing clear objectives with specific metrics, ensuring cross-sector collaboration and diversity within the task force, and allocating dedicated staffing and resources to implement recommendations focused on identifying and addressing systemic inequities. This case study draws its key findings from the Michigan Coronavirus Racial Disparities' Interim Report and other sources to explore Michigan's approach, key features, results to date, and lessons learned."
National Governors' Association. Center for Best Practices; Duke University. Margolis Center for Health Policy
Tchuisseu, Yolande Pokam; Thoumi, Andrea; Tewarson, Hemi . . .
2021-02
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US Emergency Plan for Global COVID-19 Relief: Urgent Action to End the Pandemic Globally and Accelerate US Recovery and Security
From the Background: "We are at an exceedingly perilous and urgent moment in the COVID-19 [coronavirus disease 2019] pandemic. The Delta variant, vastly more dangerous and pernicious than the original SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] virus, has rapidly spread worldwide. It has been driving a deadly summer surge in the US; ripping through Latin America; causing Indonesia to become the next Asian hotspot; and fueling a third wave of the pandemic in Africa, where less than two percent of the population has been fully vaccinated [hyperlink]. [...] Unless vaccine delivery capabilities markedly improve, we are headed for a global supply glut, even as the vast majority of people in many countries remain unvaccinated. To prevent this, urgent action is needed to translate doses into vaccinations. [...] The plan's focus should be on immediate emergency relief, but it should be developed and implemented in a manner that advances long-term health system capacity for providing routine immunizations for children and adults, as well as other essential health services. Indeed, accelerating the response to the current crisis would be one of the most effective health systems strengthening initiatives ever undertaken. The plan would also serve as a catalyst and a model for efforts by other high-income nations to use their excess vaccine supplies and technical capabilities to augment the global response more effectively."
Center for Global Development; Center for Strategic and International Studies (Washington, D.C.); COVID Collaborative . . .
2021-08-03
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Risk Assessment and Testing Protocols for Reducing SARS-CoV-2 Transmission in K-12 Schools
From the Objective: "The purposes of this document are to 1) help school administrators to assess the risk of SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] (the virus that causes Covid-19 [coronavirus disease 2019]) in their schools, and 2) identify key considerations in developing a screening program to regularly test students and staff for the virus to support schools to open in-person more safely."
Duke University. Margolis Center for Health Policy; Rockefeller Foundation; Johns Hopkins Bloomberg School of Public Health. Center for Health Security
Rivers, Caitlin; Silcox, Christina; Potter, Christina . . .
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