key: cord-0751910-24mi9y46 authors: Hall, Matthew T; Matthews, Karen; Shyy, Jiunwei; Do, Tai A title: Navy Public Health Emergency Officers and the COVID-19 Pandemic date: 2021-02-02 journal: Mil Med DOI: 10.1093/milmed/usab023 sha: 6eea3179cde183ce17c72e563167b7d1b17e606f doc_id: 751910 cord_uid: 24mi9y46 nan clinical and experiential expertise that has direct implications for thousands of personnel. Their actions are critical to the preservation of health and warfighting readiness. Considering this, efforts should be made to increase both the number of individuals trained as PHEOs and the specialties that contribute to their manning pool and provide them appropriate assistance in the performance of their duties. Public health emergencies within the DoD are declared and managed by commanders who oversee military installations. Installations often have a number of tenant commands with varying roles such as aviation (with airfields), special warfare, and ships. Installation commanders (ICOs) have a breadth of legal and military authority to make decisions for the safety of those who live and work on the installation they oversee. During pandemics such as the one caused by Severe Acute Respiratory Syndrome Coronavirus-2 (COVID-19), ICOs may declare PHEs to focus efforts and expand legal authority specifically on disease response. 1 During COVID-19, PHEOs have become a critical component to this response and substantial efforts will likely need to be taken to ensure that this specialty is expanded to support the increased demand for their service in the future. Public health emergency officers and their alternate public health emergency officers (APHEOs) serve as the public health subject matter expert advisors to the ICOs. Public health emergency officers are required to be clinicians, while APHEOs are not required to be clinicians. Fully qualified PHEOs and APHEOs (PHEOs/APHEOs) also must have earned a Master of Public Health or possess 4 years of experience in public health, preventive medicine, or environmental health. In addition, PHEOs/APHEOs are required to complete the DoD's public health emergency management (PHEM) course. This training prepares PHEOs/APHEOs in both epidemiologic and public health science (e.g., Master of Public Health) and the practical experience of managing emergencies (e.g., PHEM course and clinician experience) to advise on the response to a pandemic, which includes being the medical liaison between the ICO, the supporting medical treatment facilities, and local community public health officials. Individuals may serve in the PHEO/APHEO role up to 1 year while they complete the training requirements. While there are a wide range of skill types that can fill the APHEO role, the PHEO role is often filled by physicians. The PHEO role is considered a collateral duty for a physician and constitutes 50% of their clinical time. Before the COVID-19 pandemic, PHEOs were often underutilized and primarily consulted during emergency preparedness training exercise involving pandemic influenza. In rare situations, PHEOs would be involved with the occasional emerging threats, such as the cases of Ebola in the United States in 2014. The onset of COVID-19 has increased the demand for PHEOs and expanded their role beyond what is described in DoD instructions. In an attempt to quantify the responsibilities of the PHEO/APHEO roles in the context of the COVID-19 pandemic within the Department of the Navy, a needs assessment survey of a convenience sample of PHEO/APHEO was completed. Public Health and Safety staff at the Bureau of Navy Medicine and Surgery conducted a survey using a contact list of 132 PHEOs/APHEOs to identify duties, responsibilities, and characteristics of the community and anticipate future needs in planning. The anonymous survey was conducted using the Max.gov survey instrument and completed over a 5-day period in July 2020 and included 47 questions; divided into 3 sections: demographics, responsibilities, and contact tracing. Fifty-nine people responded to the survey ( Table I) . The brief inquiry made into the PHEO/APHEO community found that among the respondents, most were PHEOs (61%, n = 36) and physicians (68%, n = 40) and most were mid-career and commander or lieutenant commander (42% and 31%, respectively) in rank and had an average time in service of 16.1 years (range: 2-33). A similar situation was noted for APHEOs who primarily held the rank of lieutenant commander or lieutenant (30% and 39%, respectively) and had an average time in service of 12.9 years (range: 2-25). Public health emergency officers reported practicing nine different specialties but were primarily practicing preventive medicine (33%, n = 12), occupational medicine (28%, n = 10), or family medicine (14%, n = 5). Additionally, 39% of PHEOs reported having a secondary specialty with family medicine and occupational medicine being the most prevalent (both 14%, n = 5). Most PHEOs completed the PHEM course (86%, n = 31) and were designated in writing by the ICO (86%, n = 31). The survey did not ask whether or not the individual was in the 1-year interval period between being assigned the role and needing to be fully qualified (i.e., awaiting PHEM training or completing the public health training experience). Public health emergency officers reported being in their current role for an average of 1.6 years (range: 0-9) and plan to change duty stations within an average of 311.4 days (range: −18.2 to 782.4). Most PHEOs do not have an identified replacement after their departure (67%, n = 24). Unlike most physicians, the responsibility of PHEOs extends beyond just the clinical encounter. Respondents reported being responsible for an average of five installations (range: 0-50) each with an average estimated population size of 16,215 (range: 0-100,000). Many (38%, n = 23) reported to and advised the senior most Navy leaders (O7-O10, RDML-ADM, respectively) regarding COVID-19 health protection measures. Before the COVID-19 pandemic, the PHEOs reported that they spent an average of only 7% of their time on PHEO work (range: 0-50) and an average of 3 hours per week (range: 0-20). Before the COVID-19 pandemic, most had never served as an PHEO/APHEO during a simulated pandemic (51%, n = 30) or during an actual pandemic (53%, n = 31). During the pandemic, the time allocated toward PHEO responsibilities increased to an average of 41% of their time (range: 0-100) and 43 hours per week (range: 8-80), many required to balance their time between contact tracing, clinic, health protection condition assessments, attending meetings, and notably a large amount of time answering emails (averaged 6 hours per day). Among PHEOs only, 83.3% (n = 30) had clinical responsibilities before COVID-19 and 47.2% (n = 17) were required to continue clinical responsibilities during the pandemic. Fortunately, 69% (n = 41) of respondents were assigned additional untrained personnel to assist them in these responsibilities, but most (63%, n = 37) reported wanting additional assistance. The assigned assistance was for contact tracing (51%, n = 30), non-PHEO duties (41%, n = 24), outbreak information gathering (37%, n = 22), and coordinating with stakeholders (34%, n = 20). In wanting additional assistance with the performing of their PHEO duties, 44% (n = 19) of respondents preferred to have someone take over their non-PHEO duties so that 100% of their time could be dedicated to PHEO work, this was followed by having PHEO "extenders" to assist (30%, n = 16), and having additional PHEOs/APHEOs (26%, n = 11). Before the pandemic, approximately a third of the respondents (36%, n = 27) had conducted contact tracing and during the pandemic this rose to over half (58%, n = 34). Similarly, before the pandemic respondents reported conducting an average of 2.9 contact investigations per week (range: 0-80) and during the pandemic an average of 33.3 investigations per week (range: 0-1,000). One PHEO reported 1,000 investigations per week, which was likely part of a single major outbreak. In the performance of contact tracing, respondents prioritized more personnel (55%, n = 23) over better software for tracing (36%, n = 15) and other electronic enhancements (10%, n = 4). While this was only a brief assessment of PHEO/APHEO activities and responsibilities in the context of the COVID-19 pandemic, it nonetheless provided significant insight into the community and important considerations that should be made in planning for future pandemic response. It was clear from this report that before the pandemic, the roles were not given due appropriate consideration or importance. Despite the role permitting 50% allocation of employment time to PHE planning and coordination, survey respondents reported spending less than 10% of their time allocated to the PHEO role. Furthermore, less than a third had ever been involved in a simulated or real pandemic response. These findings suggest that PHEOs did not have an active role with installation emergency preparedness outside of pandemic influenza exercises before the COVID-19 pandemic. Unfortunately, this lack of attention on the PHEO/APHEO roles before the pandemic may have contributed to delayed or inadequate responses. Much of the demand on PHEOs appears to not require clinical experience because nearly half of activities involved administrative work such as responding to emails, attending meetings, and coordinating with stakeholders. While clinical experience does not appear to be needed in most activities, the divide is not as clear as the questions would imply. Anecdotally, many meetings require insight into public health and medicine that a non-trained individual would be unable to answer. This interpretation supports the other evidence from this survey in respect to PHEOs desiring administrative assistants or PHEO "extenders" to assist in their work. In fact, most preferred the hiring or assignment of personnel to take over their non-PHEO duties so that they could dedicate 100% of their time to being a PHEO-again, the need expressed is not to reduce their PHEO role but instead allow them to fully integrate into it without distractions. While there is no requirement for seniority or time in service, Navy PHEOs appear to be advanced in both and are trained in a diverse set of specialties. Considering the training and operational requirements for physicians, it is unsurprising that the majority fall within the middle tier of the rank structure and have approximately 15 years of service. This likely allows for PHEOs to apply an experienced clinical perspective to installation pandemic responses. Public health emergency officers are predominantly composed of physicians from preventive medicine, occupational medicine, and family medicine (75%); traditionally, these are specialties with lower financial incentives than other specialties. While it is not known how a specialty incentive would impact the volunteering for PHEO duties, the training and experience developed within these communities have become a critical component to the PHE response within the Department of the Navy and incentivizing individuals to take on this role should be considered. The data from this survey suggest that there are current shortages of PHEOs to support individual ICOs in addition to potential future shortfall in supporting the PHEO role. Public health emergency officers reported being responsible for an average of five installations, which is not ideal during PHEs that usually affect multiple installations simultaneously. Demand for expert consultation during PHEs is high and will strain the ability of PHEO to fully support all ICOs. In addition, new potential requirements for PHEO trained personnel to deploy and support combatant commands and operational deployed forces to manage the effects of the pandemic further stretch already strained resources. Future PHEO shortfalls are anticipated. While nearly 90% had completed the required training to be a PHEO, 56% are set to transfer within a year and 60% of whom have no known replacement. Similarly, military members are typically eligible to retire at 20 years' time in service meaning that 64% of the respondents are within 5 years of possible retirement-leaving a considerable gap in personnel qualified for and experienced in the PHEO role. During the COVID-19 pandemic, PHEOs/APHEOs in the Navy and Marine Corps have taken on a critical role in the response that has been essential in the success of the Department of the Navy and its response to the pandemic. While there were many limitations to the study that was conducted (e.g., convenience sample, small number of respondents, use of a non-validated survey, and short response time), the findings that resulted from it were insightful and should prompt action toward incentivizing people to become and stay A/PHEOs. The PHEOs/APHEOs included in this inquiry reported many responsibilities that range from coordinating with stakeholders to advising some of the most senior levels of leadership within the Navy. Importantly, the clinical and experiential expertise that they provide has direct implications for thousands of service members and their families. Their actions are critical to the preservation of health and warfighting readiness. Notably, the PHEO role is primarily composed of only a few medical specialties and mostly composed of just three: preventive medicine, occupational medicine, and family medicine. These specialties are already in a condition of limited manning and being drawn into roles such as PHEO, which further burdens the medical system. Separately, many of these PHEOs may be transferring or leaving their position, which could potentially result in critical PHEO manning shortfalls. Many PHEOs are responsible for more than one installation, and thousands of personnel and shortfalls could have substantial consequences. Considering this, efforts should be made to increase the number of individuals trained to be A/PHEOs and the specialties that contribute to their manning pool and provide them appropriate assistance in the performance of their duties. Department of Defense: Public Health Emergency Management (PHEM) within the DoD None declared. No funding used to support this work. No conflicts of interest to declare.