Michael A Stoto

Georgetown University | GU · School of Health Systems Administration

Background Heterogeneity in national SARS-CoV-2 infection surveillance capabilities may compromise global enumeration and tracking of COVID-19 cases and deaths and bias analyses of the pandemic’s tolls. Taking account of heterogeneity in data completeness may thus help clarify analyses of the relationship between COVID-19 outcomes and standard prep...

Background Italy implemented various measures, including lockdowns and a mass vaccination campaign, to address the COVID-19 pandemic. This study aims to describe the temporal and regional impact of these measures on mortality between March 2020 and December 2021, partitioning the time series into five periods. Methods We used National Ministry of...

Background Italy responded to COVID-19 with stringent lockdowns and a mass vaccination campaign. We describe the temporal and regional impact of these measures on mortality, along with social-behavioral correlates. Methods The analysis uses National Ministry of Health data on COVID-19 mortality (CM), excess mortality (EM), and vaccine uptake, alon...

In 2021 the “Red Covid,” narrative emerged: states and counties that are predominantly Republican and/or supported Trump experienced widespread vaccine hesitancy and eventually opposed mask and vaccine mandates. Our analysis of excess mortality quantifies this effect. After the first wave, death rates in the South were more than double those in the...

A number of scientific publications and commentaries have suggested that standard preparedness indices such as the Global Health Security Index (GHSI) and Joint External Evaluation (JEE) scores did not predict COVID-19 outcomes. To some, the failure of these metrics to be predictive demonstrates the need for a fundamental reassessment which better...

Background COVID-19 pandemic provides a unique opportunity to learn the challenges encountered by public health emergency preparedness systems, both in terms of problems encountered and adaptations during and after the first wave, as well as successful responses to them. Results This work draws on published literature, interviews with countries an...

Objective: This study aims to comprehensively assess the direct, severe harms of screening colonoscopy in the United States. Whereas other investigators have completed systematic reviews estimating the harms of all types of colonoscopy, this analysis focuses on screening colonoscopies that had adequate follow up to avoid undercounting delayed harm...

A "two Americas" narrative emerged in the summer of 2021: one with high demand for COVID-19 vaccines, and a second with widespread vaccine hesitancy and opposition to mask mandates. But our analysis of excess mortality shows that the U.S. has been a divided nation at least since the start of the pandemic. Through April, 2022, there were 1,335,292 e...

During the summer of 2021, a narrative of "two Americas" emerged: one with high demand for the COVID-19 vaccine and the second with widespread vaccine hesitancy and opposition to masks and vaccines. We analyzed “excess mortality” rates (the difference between total deaths and what would have been expected based on earlier time periods) prepared by...

Background: This study aims to assess the rate at which screening colonoscopy is performed on patients younger or older than the age range specified in national guidelines, or at shorter intervals than recommended. Such non-indicated use of the procedure is considered low-value care, or overuse. This study is the first systematic review of the rat...

During the summer of 2021, a narrative of “two Americas” emerged: one with high demand for the COVID-19 vaccine and the second with widespread vaccine hesitancy and opposition to masks and vaccines. We analyzed “excess mortality” rates (the difference between total deaths and what would have been expected based on earlier time periods) prepared by...

Background: Over the course of the COVID-19 pandemic in Italy, different response measures were taken to contain the spread of the virus. These include a variety of non-pharmaceutical interventions and a mass vaccination campaign. While not definitive, epidemiological measures provide some indication of the impact of such measures on the dynamics o...

Background The COVID-19 pandemic has led to an avalanche of scientific studies, drawing on many different types of data. However, studies addressing the effectiveness of government actions against COVID-19, especially non-pharmaceutical interventions, often exhibit data problems that threaten the validity of their results. This review is thus inten...

Population-based seroprevalence surveys can provide useful estimates of the number of individuals previously infected with SARS-CoV-2 and still susceptible as well as contribute to better estimates of the case fatality rate and other measures of COVID-19 severity. No serological test is 100% accurate, however, and the standard correction that epide...

Timely and accurate data on COVID-19 cases and COVID-19‒related deaths are essential for making decisions with significant health, economic, and policy implications. A new report from the National Academies of Sciences, Engineering, and Medicine proposes a uniform national framework for data collection to more accurately quantify disaster-related d...

Population-based seroprevalence surveys can provide useful estimates of the number of individuals previously infected with SARS-CoV-2 and still susceptible as well as contribute to better estimates of the case fatality rate and other measures of COVID-19 severity. No serological test is 100% accurate, however, and the standard correction that epide...

Tests for Coronavirus disease 2019 (COVID-19) are intended for a disparate and shifting range of purposes: (1) diagnosing patients who present with symptoms to inform individual treatment decisions; (2) organizational uses such as "cohorting" potentially infected patients and staff to protect others; and (3) contact tracing, surveillance, and other...

In 2019, Clark County experienced a measles outbreak that challenged local and state public health authorities. Clark County Public Health (CCPH) led the response in collaboration with public and private entities. The first public health response included active surveillance and monitoring and to inform the public about where exposure might be taki...

Background and aim: Testing represents one of the main pillars of public health response to SARS-CoV-2/COVID-19 pandemic. This paper shows how accuracy and utility of testing programs depend not just on the type of tests, but on the context as well. Methods: We describe the testing methods that have been developed and the possible testing strate...

Issue Clark County experienced a measles outbreak that challenged public health authorities. Description of the practice: We conducted a formal After Action Review with state and local health officials, school officials, and others to identify lessons for public health practitioners facing future outbreaks. Results Following the early identificati...

: Quality measurement is at the heart of efforts to achieve high-quality surgical and medical care at a lower cost. Without accurate quality measures, it is not possible to appropriately align incentives with quality. The aim of these National Quality Forum (NQF) guidelines is to provide measure developers and other stakeholders with guidance on th...

Background In 2017, under the supervision of the European Centre for Disease Prevention and Control (ECDC), a list of competencies and knowledge and skill statements for EU professionals working in Public Health Emergency Preparedness (PHEP) systems were identified and integrated into a Competency Model. Building on these efforts, a PHEP competency...

Background: After Action Reviews (AARs) provide a means to observe how well preparedness systems perform in real world conditions and can help to identify - and address - gaps in national and global public health emergency preparedness (PHEP) systems. WHO has recently published guidance for voluntary AARs. This analysis builds on this guidance by...

Research objective: Non-profit hospitals are required to work with community organizations to prepare a Community Health Needs Assessment (CHNA) and implementation strategy (IS). In concert with the health care delivery system's transformation from volume to value and efforts to enhance multi-sector collaboration, such community health improvement...

Research objective: Non-profit hospitals are required to work with community organizations to prepare Community Health Needs Assessment (CHNA) and implementation strategy (IS). In concert with the health care delivery system's transformation from volume to value and efforts to enhance multi-sector collaboration, such community health improvement (...

In 2017, the European Centre for Disease Prevention and Control (ECDC) developed a competency model for individuals who work in public health emergency preparedness (PHEP) in European Union (EU) countries. The model serves as the basis for developing competency-based training programmes to support professionals in PHEP efforts at the country level....

Zika virus disease provides the latest example of a critical nexus between public health and clinical practice. Interpreting Zika virus test results is complicated by the absence of a single testing approach with superior validity across contexts and populations. Molecular tests are highly specific, variably sensitive, and have a short window perio...

Zika virus provides an example for which public health surveillance is based primarily on health care provider notifications to health departments of potential cases. This case-based surveillance is commonly used to understand the spread of disease in a population. However, case-based surveillance is often biased—whether testing is done and which t...

To demonstrate how public health systems can use root-cause analysis (RCA) to improve learning from critical incidents, the research team utilized a facilitated look-back meeting to examine the public health systems' response to a Salmonella outbreak in the water supply in Alamosa, Colorado. We worked with public health, emergency management agenci...

To demonstrate how public health emergency systems can use health systems tools to analyze and learn from critical incidents, we employed a facilitated look-back approach to review the public response to a chemical spill in Charleston, West Virginia. We reviewed official reports, news articles, and other documents; conducted in-person interviews wi...

The third paper in a series on how learning health systems can use routinely collected electronic health data (EHD) to advance knowledge and support continuous learning, this review describes how analytical methods for individual-level electronic health data EHD, including regression approaches, interrupted time series (ITS) analyses, instrumental...

Learning health systems use routinely collected electronic health data (EHD) to advance knowledge and support continuous learning. Even without randomization, observational studies can play a central role as the nation’s health care system embraces comparative effectiveness research and patient-centered outcomes research. However, neither the bread...

The second paper in a series on how learning health systems can use routinely collected electronic health data (EHD) to advance knowledge and support continuous learning, this review summarizes study design approaches, including choosing appropriate data sources, and methods for design and analysis of natural and quasi-experiments. The primary stre...

The last in a series of four papers on how learning health systems can use routinely collected electronic health data (EHD) to advance knowledge and support continuous learning, this review describes how delivery system science provides a systematic means to answer questions that arise in translating complex interventions to other practice settings...

This technical report aims to take this work a step further by creating a linkage between the capabilities listed in the logic model for PHEP in the EU Member States – which apply at the emergency preparedness system level – with competencies for individuals who work in the system by generating a competency-based model. A subsequent phase, to be co...

Improving preparedness in the European region requires a clear understanding of what European Union (EU) member states should be able to do, whether acting internally or in cooperation with each other or the EU and other multilateral organizations. We have developed a preparedness logic model that specifies the aims and objectives of public health...

On January 9(th) 2014, a faulty storage tank leaked 10,000 gal of an industrial coal processing liquid into the Elk River in West Virginia (WV), contaminating the drinking water of the nine counties collectively known as the Kanawha Valley. The aim of this study was to 1) explore how and when people obtained information about the water contaminatio...

Public health authorities have adopted entry screening and subsequent restrictions on travelers from Ebola-affected West African countries as a strategy to prevent importation of Ebola virus disease (EVD) cases. We analyzed international, federal, and state policies-principally based on the policy documents themselves and media reports-to evaluate...

Whether the focus of population-health improvement efforts, the measurement of health outcomes, risk factors, and interventions to improve them are central to achieving collective impact in the population health perspective. And because of the importance of a shared measurement system, appropriate measures can help to ensure the accountability of a...

Meta-analysis has increasingly been used to identify adverse effects of drugs and vaccines, but the results have often been controversial. In one respect, meta-analysis is an especially appropriate tool in these settings. Efficacy studies are often too small to reliably assess risks that become important when a medication is in widespread use, so m...

The 2009 H1N1 pandemic tested the limits of the public health emergency preparedness systems in the US and abroad. The successes and failures from this pandemic remain relevant, particularly as pathogens like MER-CoV and Ebola continue to proliferate. The Public Health Response to 2009 H1N1: A Systems Perspective draws lessons from the public healt...

As an alternative to standard quality improvement approaches and to commonly used after action report/improvement plans, we developed and tested a peer assessment approach for learning from singular public health emergencies. In this approach, health departments engage peers to analyze critical incidents, with the goal of aiding organizational lear...

This Perspective focuses on the future of the Pandemic Influenza Preparedness (PIP) Framework, which was initially established to promote the fair sharing of public health-related pandemic influenza samples between countries. We examine the changes that need to be made to address the growing likelihood that genetic sequence data might be shared ins...

The biosurveillance capabilities needed to rapidly detect and characterize emerging biological threats are an essential part of the Global Health Security Agenda (GHSA). The analyses of the global public health system's functioning during the 2009 H1N1 pandemic suggest that while capacities such as those identified in the GHSA are essential buildin...

Background: Infectious disease surveillance is a process the product of which reflects both actual disease trends and public awareness of the disease. Decisions made by patients, health care providers, and public health professionals about seeking and providing health care and about reporting cases to health authorities are all influenced by the i...

Health departments use after-action reports to collect data on their experience in responding to actual public health emergencies. To address deficiencies in the use of such reports revealed in the 2009 H1N1 influenza pandemic and to develop an effective approach to learning from actual public health emergencies, we sought to understand how the con...

Infectious disease surveillance is a process, the product of which reflects both real illness and public awareness of the disease. To develop a statistical framework to characterize influenza surveillance systems, Bayesian hierarchical model was applied to estimate the statistical relationships between influenza surveillance data and information en...

Antiviral medications can decrease the severity and duration of influenza, but they are most effective if started within 48 hours of the onset of symptoms. In a severe influenza pandemic, normal channels of obtaining prescriptions and medications could become overwhelmed. To assess public perception of the acceptability and feasibility of alternati...

The 2009 H1N1 vaccination campaign was the largest in US history. State health departments received vaccines from the federal government and sent them to local health departments (LHDs) who were responsible for getting vaccines to the public. Many LHD's used school-based clinics to ensure children were the first to receive limited vaccine supplies,...

Whether one reads Computerworld or Institute of Medicine issue briefs, it’s clear that most now accept the idea that existing electronic clinical data (ECD) and other health records can be used to manage and improve the processes, outcomes, and the quality of health care. Indeed the increasing popularity of the term “learning healthcare system” sig...

Identify lessons about the public health emergency preparedness system from after action report/improvement plans (AAR/IPs) authored by state and local health departments following the 2009 H1N1 influenza pandemic. Potentially generalizable findings were collected during a workshop attended by representatives from the Centers for Disease Control an...

The National Health Security Strategy calls for a systematic quality improvement efforts to improving health security. In addition, since 2001, billions of dollars have been spent on public health emergency preparedness at the federal, state, and local levels. Policy makers must now ask has this investment been effective, and in what way to measure...

: Local health departments (LHDs) were responsible for administering vaccine to the public during the 2009 H1N1 campaign but had relatively little guidance or experience to inform such a large campaign with limited vaccine supply. They used various processes to deliver vaccines to the public. Learning from the LHDs that were successful in their pub...

Objective Our goal is to develop a statistical model for characterizing influenza surveillance systems that will be helpful in interpreting multiple streams of influenza surveillance data in future outbreaks. Introduction Syndromic surveillance has been widely used in influenza surveillance worldwide. However, despite the potential benefits create...

The 2009 H1N1 outbreak provides an opportunity to identify strengths and weaknesses of disease surveillance and notification systems that have been implemented in the past decade. DRAWING ON A SYSTEMATIC REVIEW OF THE SCIENTIFIC LITERATURE, OFFICIAL DOCUMENTS, WEBSITES, AND NEWS REPORTS, WE CONSTRUCTED A TIMELINE DIFFERENTIATING THREE KINDS OF EVEN...

OBJECTIVE:: To analyze key variations in the after action report/improvement plan (AAR/IP) process used by state and local health departments following the 2009 H1N1 pandemic and identify ideas for improving that process. DESIGN:: Workshop participants discussed their AAR findings and the methods used to prepare their reports and implications for i...

The U.S. National Health Security Strategy calls for the development and wide-spread implementation of quality improvement (QI) tools in public health emergency preparedness (PHEP), including the development of “learning collaboratives,” a structured way for organizations with common interests to close the gap between potential and practice by lear...

The 2009 H1N1 pandemic required a concerted community response, involving public health agencies, health care providers, and other components of local public health emergency preparedness systems. This case study of the island of Martha's Vineyard (MV) in Massachusetts is based on a review of local newspapers, interviews with key stakeholders inclu...

The 2009 H1N1 vaccination campaign was the largest such effort in U.S. history. Local health departments (LHDs) were responsible for administering vaccine to the public, but they had little guidance or experience to inform such a large campaign. Under these circumstances, LHDs used various processes to deliver vaccines to the public. As noted in qu...

The 2009 H1N1 outbreak provides an opportunity to learn about the strengths and weaknesses of current U.S. public health surveillance systems and to identify implications for measuring public health emergency preparedness. We adopted a "triangulation" approach in which multiple contemporary data sources, each with different expected biases, are com...

Black women in the District of Columbia (DC) have the highest breast cancer mortality in the US. Local cancer control planners are interested in how to most efficiently reduce this mortality. An established simulation model was adapted to reflect the experiences of Black women in DC and estimate the past and future impact of changes in use of scree...

Influenza activity in the IHE and general populations. Comparison of American College Health Association (ACHA) influenza surveillance attack rate data for the institutions of higher education (IHE) population and CDC Outpatient Influenza-like Illness Surveillance Network (ILINet) influenza-like illness for the general population, by region, United...

Data sources. Detailed description of data sources, including case definitions, collection protocols, and available dates.

Summary surveillance systems. A summary table comparing surveillance systems analysed in terms of case definitions, populations covered, reporter, collection methods, and timeliness.

Syndromic surveillance has been widely adopted as a real-time monitoring tool for timely response to disease outbreaks. During the second wave of the pH1N1 pandemic in Fall 2009, two major universities in Washington, DC collected data that were potentially indicative of influenza-like illness (ILI) cases in students and staff. In this study, our ob...

Objective: To compare healthcare costs associated with initiating treatment on escitalopram or an alternative selective serotonin reuptake inhibitor. Study Design: Retrospective cohort study using administrative claims data. Methods: Patients were included if they had a depression-related diagnosis and 6 months or longer of health plan eligibility...

Bladder pain syndrome/interstitial cystitis is a poorly understood condition that can cause serious disability. We provide the first population based symptom prevalence estimate to our knowledge among United States adult females. We developed and validated 2 case definitions to identify bladder pain syndrome/interstitial cystitis symptoms. Beginnin...

See the original Letter to the Editor, [p. 1046][1] Edwards-Bennett raises an interesting issue about the need to include disparities in utilization of adjuvant breast cancer radiation therapy (RT) in models to explain differences in mortality by race. In our study, we found that differences in

School closure was employed as a non-pharmaceutical intervention against pandemic 2009 H1N1, particularly during the first wave. More than 700 schools in the United States were closed. However, closure decisions reflected significant variation in rationales, decision triggers, and authority for closure. This variability presents the opportunity for...

U.S. Black women have higher breast cancer mortality rates than White women despite lower incidence. The aim of this study is to investigate how much of the mortality disparity can be attributed to racial differences in natural history, uptake of mammography screening, and use of adjuvant therapy. Two simulation models use common national race, and...

Background To provide timely information on the impact of the 2009 H1N1 influenza epidemic from 8/28/2009 to 4/10/2010, Georgetown University developed and implemented a syndromic surveillance system incorporating a variety of data sources. Research Aims Describe the 2009 H1N1 outbreak at an urban university in Fall 2009. Identify the datas...

The MRC is a national network of community-based units created to promote the recruitment, training, and activation of volunteers, especially with medical and public health background, to provide emergency health services. Especially during the 2009-10 national H1N1 vaccination campaign, many MRC units assisted with flu clinics. In this and the pre...

The Harvard School of Public Health Center for Public Health Preparedness exercise program has two aims: ( 1) educating the public health workforce on key public health system emergency preparedness issues, and ( 2) identifying specific systems-level challenges in the public health response to large-scale events. Rigorous evaluation of 38 public he...

The Harvard School of Public Health Center for Public Health Preparedness exercise program has two aims: (1) educating the public health workforce on key public health system emergency preparedness issues, and (2) identifying specific systems-level challenges in the public health response to large-scale events. Rigorous evaluation of 38 public heal...