Public health and medical preparedness, emergency response and disaster medicine, and critical infrastructure defense

Emergency response capability and medical preparedness are necessary features of any community or nation. In a world with an ever expanding populous, the number of those affected by natural disasters, terrorist attacks, as well as biological, chemical, or radiological incidents continues to rise. When a disaster strikes, damage to critical infrastructure, availability of needed human and material resources, as well as time limitations are significant challenges. Thus, response capability and preparedness are of paramount importance.

However, emergency response planning is a highly complex task. In addition to the difficult immediate concerns of treating the injured, providing temporary shelters and distributing essential supplies, such events may also necessitate measures to protect a large segment of the population through disease spread risk prediction and containment, mass dispensing of medicines, as well as long term measures to track and provide for displaced citizens. A variety of social and economic consequences must also be addressed.

A significant thrust of our research effort focuses on public health population protection and large-scale response effort for all hazard events, including biological, chemical, and radiological incidents, as well as infectious disease outbreaks. Much of our effort is joined with the Centers for Disease Control and Prevention (CDC), vaccine centers, and thousands of local/state/tribal public health departments and healthcare organizations. We briefly highlight three major topics below:

Strategies for predicting the immunity of vaccines

The effectiveness of vaccination can only be ascertained after vaccinated individuals have been exposed to infection. This is a major challenge. The ability to identify early predictive signatures of vaccine responses and novel and robust correlates of protection from infection will be essential to developing next-generation rationally designed vaccines. This will facilitate both rapid design and evaluation of new and emerging vaccines and the identification of individuals unlikely to be protected by the vaccine. Working closely with vaccinologists and clinicians, we develop machine learning and systems informatics framework to uncover gene signatures that predict vaccine and antibody responses. Some of our recent effort and results are highlighted below.

Medical countermeasures dispensing: strategies for large-scale population protection

Planning for a catastrophe involving a disease outbreak with the potential for mass casualties is a significant challenge for emergency managers. For example, how should we perform rapid rescues and treat the sick? Where and how many distribution centers should we set up for food, shelter, medical supplies, and prophylactic dispensing? How should we staff the sites? How should we control disease spreading when a large affected population visits our sites? The time to respond, and the decisions made as an event unfolds, can spell the difference between life and death.

Since the anthrax attacks in the United States in 2001, over $70 billion has been spent on population protection, particularly on rapid detection of outbreaks and on mass dispensing of prophylactic medical countermeasures to contain biological and pandemic outbreaks. Despite these enormous efforts, we have little actual experience or firsthand knowledge to call upon to plan for these rare but potentially catastrophic events. Their rarity, cost, and complexity, and the added challenge of competing priorities are of great concern to policy makers who are aware of past failures to manage rapidly escalating catastrophes, failures that include ambiguity in communications and the unintended consequences of decisions that have been made at a higher level. Thus, having a powerful, realistic mathematical modeling and real-time decision support system for training, planning, and actual operations is of paramount importance.

We team with public health experts to address important aspects of mass dispensing: medical supply distribution, locations of dispensing facilities, optimal facility staffing and resource allocation, routing of the population, and dispensing methods. A software enterprise suite, RealOpt©, designed for tactical, strategic and operational planning has been developed. RealOpt can sift through massive amounts of data to better optimize decision-making during the event of an emergency scenario – especially in the case of a deadly outbreak. The system utilizes a number of data sets, including population demographics, socioeconomic information, hospital data and scientific literature regarding a range of infectious diseases – such as the flu, smallpox, anthrax, and more. With this information, the software can produce detailed instructions with very little input from the user.

In the event that an infectious pathogen emerges, health officials can input into RealOpt information regarding what disease is spreading, the geographical area in need of service, and the resources at their disposal – and within seconds, the system will provide users with instructions on how to proceed. Social media influencing and human behavior (both the responders and the affected population) are elementary elements within the models.

Currently, there are over 14,000+ RealOpt user sites. RealOpt has been used for seasonal flu vaccination, smallpox and hepatitis vaccine dispensing, H1N1 mass vaccination, fire, flood and hurricane responses (for setting up shelters, food/medical/supply distribution sites, command-control logistics etc), Haiti earthquake emergency response relief, Japan Fukushima radiological response (rapid screening and decontamination, food/shelter, supplies distributions), optimizing Ebola treatment center operations, and predicting Zika disease spread. The system has also been used by numerous hospitals/clinics for optimizing workflow and operations efficiency. The system allows management of multiple resource types simultaneously, for example, labor, equipment, beds, financial investment, medical supplies, and countermeasures.

Contact Dr. Lee at evalee-gatech@pm.me.

RealOpt-POD©

RealOpt-POD© is a real-time planning and operational system that enables emergency coordinators to

• Design customized and efficient clinic/diagnostic/dispensing facility floor plans for regional needs via an automatic graph-drawing tool.

• Determine optimal labor resources required and provide the most-efficient placement of staff at individual stations within the facility. The results maximize the number of people who can be treated, minimize the average time patients spend in the clinic, and equalize utilization/workload across clinic stations.

• Determine the best location for emergency clinics based on population density and road accessibility, the most efficient facility layout, the number of health care professionals needed in certain areas, the number of medical countermeasures and supplies (e.g. vaccinations, antibiotics) needed and the time it will take to treat patients.

• Process data in real time as the emergency event unfolds, and determine dynamic changes when necessary.

• Perform disease propagation analysis, monitoring intra-facility infectivity, and derive dynamic response strategies to mitigate casualties.

• Provide a framework for emergency healthcare managers to assess current resources and determine minimum needs to prepare for readiness in emergency situations for their regional population.

• Allow large-scale virtual drills and performance analysis, and assist in the study, training and enhancement of emergency response, planning and treatment from terrorism, infectious disease outbreaks, and natural disasters.

RealOpt-Regional©

RealOpt-Regional© is an interactive online software enterprise for large-scale regional medical dispensing and emergency preparedness. It features interactive visualization tools to assist with spatial understanding of important landmarks in the region, assess the population densities and demographic makeup of the region, and identify potential facility locations. It also features backend mathematical models for large-scale facility location problems; a backend novel and rapid solution engine for strategic and operational planning and real-time dynamic optimization, and a multi-level end-user secured login web portal.

The multi-level end-user login capability of RealOpt-Regional© allows granting different authorization levels to users. For example, emergency preparedness and response directors have different privileges than individual households and citizens. Specifically, public health emergency preparedness directors are able to:

• Determine a network of optimal dispensing locations and the optimal combination of dispensing modalities (e.g. combinations of drive-through, walk-through, and mobile PODs) for best population coverage for regional preparedness.

• Review demographics at each dispensing site and identify appropriate personnel (e.g. translators, pediatric assistants) needed for effective dispensing.

• Determine in real-time a re-supply schedule for medical countermeasures across the network of dispensing sites through real-time feed of throughputs.

• Determine the closest and feasible traffic routes to transport sick individuals from PODs to hospitals for treatment.

• Identify region-wide budget and labor needs to accommodate an emergency situation, and determine recruitment needs of healthcare workers and volunteers.

• Perform economic model analysis on multi-modality variations for optimal and cost-effective regional response strategies.

• Analyze the adequacy of existing resources over a broad geographic region.

RealOpt-Regional© allows public users to:

• Locate the nearest facilities for acquiring medical countermeasures.

• Determine feasible traffic routes to access these facilities.

• Review relevant information related to the specific medical countermeasures dispensed.

RealOpt-RSS©

RealOpt-RSS© is a software modeling, simulation and optimization tool for the efficient management of the logistics of Receipt, Stage and Storage (RSS) facilities and Regional Distribution Nodes (RDN) for medical countermeasures. RealOpt-RSS© assists in planning quick and efficient strategies for processing medicines and/or equipment from the receiving point of the RSS to RSS vehicles for delivery. The software includes a warehouse design module, and specific computational modules related to the RSS facility, material handling equipment, staffing, and site configuration. Users can draw their specific warehouse layout, and place medical countermeasures into respective locations. Given a picklist, the system returns optimal sorting and paths within the warehouse.

RealOpt-CRC©

RealOpt-CRC© is a software module designed for radiological population monitoring purposes. RealOpt-CRC© couples graphic-drawing tools, large-scale simulation and fast optimization routines into a decision support system for real-time resource allocation for establishment of community reception centers for population monitoring within the context of radiological emergency planning and response. RealOpt-CRC© shares many key components with RealOpt-POD©. It includes added components to deal with radiological screening and decontamination logistics.

A key requirement for population monitoring involves the setting up of community reception centers that run efficiently. Within these centers, individuals will be assessed for presence of contamination on body or clothing, and for intake of radioactive materials. Removal of external and/or internal contamination (decontamination) must be carried out, and radiation dose received and risk of health effects must be assessed. Registration will be performed to facilitate long-term health effects monitoring. The system can also be used to optimize decontamination operations for emergency responders whose radiation exposure level must be monitored. This is critically demonstrated in the 2011 Fukushima Japan disaster where over 3000 emergency workers were involved and inside the nuclear plants to assist with handling of emergency situations.

Some related news articles

• The most interesting person in the (O.R.) world: Interview with Georgia Tech professor Eva Lee, whose applied work on biomedicine, healthcare delivery, pandemics, disaster response and other projects has global implications.

• Interview of Dr. Lee after her keynote speech on "Saving Lives".

• RealOpt© – Helping Health Care Officials Make Important Decisions Quickly

• Hours to save the world: New software program aims to stop deadly pandemic spread

• AAAS Panel Gives Consideration to Pandemic Emergency Response

• Japan's Tsunami Anniversary, A Year Since Disaster Struck

• Population monitoring and screening for radiological events

• Curbing Catastrophes With Analytics: How the CDC is using BigData and electronic health records for disaster planning

• Public Health Emergency Preparedness and Mass Dispensing Work is profiled in OR/MS Today, Feb 2008

• Software helps to deal with disaster

Some related papers

• EK Lee, FH Pietz, CH Chen, Y Liu. An interactive web-based decision support system for mass dispensing, emergency preparedness, and biosurveillance. Proceedings of the 2017 International Conference on Digital Health, 137-146

• EK Lee, Y Liu, FH Pietz. A computational framework for a digital surveillance and response tool: application to avian influenza. AMIA Annual Symposium Proceedings 2017, 1090-1099.

• EK Lee, Y Liu, FH Pietz. A compartmental model for Zika virus with dynamic human and vector populations. AMIA Annual Symposium Proceedings 2016, 743-752.

• EK Lee, F Pietz, B Benecke, J Mason, G Burel. Advancing public health and medical preparedness with operations research. Interfaces - The Franz Edelman Award Achievement in Operations Research 2013; 43(1): 79-98.

• EK Lee, F Pietz. Real‐Time Information and Decision Support for Radiological Emergency Response. Medical Physics 40 (6Part6), 146-146

• EK Lee, CH Chen, F Pietz, B Benecke. Disease propagation analysis and mitigation strategies for effective mass dispensing. American Medical Informatics Association Annu Symp Proc 2010; 427-431.

• EK Lee, CH Chen, F Pietz, B Benecke. Modeling and optimizing the public health infrastructure for emergency response. Interfaces - The Daniel H. Wagner Prize for Excellence in Operations Research Practice 2009; 39(5): 476-490.

• EK Lee, HK Smalley, Y Zhang, F Pietz, B Benecke. Facility location and multi-modality mass dispensing strategies and emergency response for biodefense and infectious disease outbreaks. International Journal on Risk Assessment and Management - Biosecurity Assurance in a Threatening World: Challenges, Explorations, and Breakthroughs 2009; 12(2/3/4):311-351.

• EK Lee, S Maheshwary, J Mason, W Glisson. Large-scale dispensing for emergency response to bioterrorism and infectious disease outbreak. Interfaces - OR Applications for Homeland Defense 2006; 36(6):591-607.

• EK Lee, S Maheshwary, J Mason, W Glisson. Decision support system for mass dispensing of medications for infectious disease outbreaks and bioterrorist attacks. Annals of Operations Research- Computing and Optimization in Medicine and Life Sciences 2006; 148:25-53.

Disease propagation analysis, risk prediction, containment strategies, policy-making

SARs, bird flu, H1N1, Ebola, and the recent Zika virus outbreak underscore the importance of preparedness and response. Zika poses unique challenges; its potential association to birth defects and lack of prophylactic treatment currently threaten over 60 countries. At times of pandemic, scientists must race to investigate virus mechanisms to facilitate early detection, effective mitigation, and develop both prophylactic and treatment regimens for global health security. Resources and policies for scientific, clinical and technological advances must be aligned to facilitate rapid understanding of viruses and transmission mechanisms, clinical practice protocols, and effective containment and treatment of the ill to minimize human, societal and economic impact.

Health systems resources (labor, physical capitals, consumables, and financial) must be sufficient and appropriately utilized and managed for effective and efficient care delivery. Optimizing resources for timely and quality care is of paramount importance and remains a major objective in resource rich environments such as the United States and OECD member countries. And it is even more essential in resource-constrained environments. Resource constraints in low-resource settings can affect quantity and quality of healthcare system delivery. Beyond regular healthcare services, it becomes daunting when faced with one or more infectious disease outbreaks. Ebola outbreak in W Africa underscores the fragility and challenges of resource-constrained environment in mounting an effective and rapid response.

Our research herein focuses on scientific and policy work in infectious diseases, vaccine immunogenicity, clinical practice, biological-behavioral-operational modeling for public health decision and policy making, and real-time emergency response operations and strategic planning for population protection.

Understanding that it takes time to develop effective medical countermeasures, a major thrust of our research involves in developing a general-purpose computational modeling decision framework that couples disease modeling with intervention strategies to minimize disease propagation and optimize containment strategies. The model covers agent-host transmission across multiple environments and social landscapes and allow for rapid intervention strategic development.