Graduate School ETD Form 9 (Revised 12/07)

PURDUE UNIVERSITY
GRADUATE SCHOOL Thesis/Dissertation Acceptance
This is to certify that the thesis/dissertation prepared By Feng Lin Entitled Optimal Control Problems in Public Health

For the degree of Doctor of Philosophy

Is approved by the final examining committee:

Mark Lawley
Chair

Ozan Akkus

Nan Kong

Dulcy Abraham

To the best of my knowledge and as understood by the student in the Research Integrity and Copyright Disclaimer (Graduate School Form 20), this thesis/dissertation adheres to the provisions of Purdue Universitys Policy on Integrity in Research and the use of copyrighted material.

Mark Lawley Approved by Major Professor(s): ____________________________________

Approved by: George R. Wodicka

Head of the Graduate Program

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____________________________________
04/20/2010
Date

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W
Ann Rundell

Graduate School Form 20 (Revised 1/10)

PURDUE UNIVERSITY
GRADUATE SCHOOL Research Integrity and Copyright Disclaimer

Title of Thesis/Dissertation:
Optimal Control Problems in Public Health

I certify that in the preparation of this thesis, I have observed the provisions of Purdue University Teaching, Research, and Outreach Policy on Research Misconduct (VIII.3.1), October 1, 2008.* Further, I certify that this work is free of plagiarism and all materials appearing in this thesis/dissertation have been properly quoted and attributed.

Feng Lin ______________________________________

Printed Name and Signature of Candidate

04/20/2010 ______________________________________
Date (month/day/year)

*Located at http://www.purdue.edu/policies/pages/teach_res_outreach/viii_3_1.html

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I certify that all copyrighted material incorporated into this thesis/dissertation is in compliance with the United States copyright law and that I have received written permission from the copyright owners for my use of their work, which is beyond the scope of the law. I agree to indemnify and save harmless Purdue University from any and all claims that may be asserted or that may arise from any copyright violation.

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Doctor of Philosophy For the degree of ________________________________________________________________

OPTIMAL CONTROL PROBLEMS IN PUBLIC HEALTH

A Dissertation Submitted to the Faculty of Purdue University by

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In Partial Fulllment of the

Requirements for the Degree of

Doctor of Philosophy

Purdue University West Lafayette, Indiana

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Feng Lin May 2010

UMI Number: 3413904

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To my beloved husband and loving parents

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ACKNOWLEDGMENTS First of all, I am grateful to my advisor, Dr. Mark Lawley, for his continuous support in the Ph.D. program. Dr. Lawley has explored tremendous opportunities for me to learn and understand the essential of scientic research. He showed me dierent means to approach a problem and the importance to be persistent. He made me a better researcher. He always had condence in me even when I had doubt of myself. He taught me how to ask questions, how to express my ideas, and how to write academic papers. He was always there to meet and talk about my ideas, to improve my papers and reports, and to ask me good questions to help me think through my problems. Without his encouragement and constant guidance, and the tender loving care for me, I could not have nished this dissertation.

dell for serving on my dissertation committee and providing valuable suggestions and advise on my research. I thank Dr. Kumar Muthuraman for his technical guidance on optimal control theory and sharing his research approach. I also thank Dr. Laura Sands for sharing her perspective of the Americans long-term care system and her insight of the public insurance programs. Special thanks to Prof. Pam Aaltonen for sharing her expertise in public health and her continuous encouragement. She made me believe that engineers could make signicant contribution to public health. I was delighted to have the opportunity of working at Purdues Healthcare Technical Assistance Program (HealthcareTAP) for several years. Many thanks to Dr. David McKinnis and Mary Anne Sloan who allowed me to learn and understand the hospital operations in the real world. I also thank Dr. Patricia Coyle-Rogers for teaching me how nurses see and solve a problem in real world. I was also very fortunate to have the opportunity of working at the Purdue Homeland Security Institute on Pandemic Exercise Preparedness Program. I thank Dave Hankins, Timothy

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I thank Dr. Dulcy Abraham, Dr. Ozan Akkus, Dr. Nan Kong, and Dr. Ann Run-

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iv Collins, and Martha Burns who generously shared their expertise in emergency response and planning. Such experience not only helped me identify my dissertation direction, but it also helped me tremendously in balancing academia pursuits and practical implications. Let me also say thank you to my fellow research colleagues and friends: Dr. Ping Huang, Dr. Ayten Turkcan, Dr. Po-Ching DeLaurentis, Santanu Chakraborty, Ji Lin, Dr. Renata Konrad, Rebeca Sandino, Brian Leonard, and Dr. Arun Chockaling. We had many enjoyable and memorable moments shared over the past few years. Last, but not least, I thank my family: my parents, Xiarong Lin and Liying Zhou, for giving me life in the rst place, for educating me with aspects from both arts

dearest husband, Chenzhou, for his love, encouragement, and never-ceasing faith in

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me.

and sciences, for unconditional love and encouragement to pursue my interests; my

TABLE OF CONTENTS Page LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LIST OF FIGURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER 1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . 1.1 1.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2.1 1.2.2 1.3 1.4 1.5 1.6 Public health achievements . . . . . . . . . . . . . . . . . . . Public health challenges . . . . . . . . . . . . . . . . . . . . viii ix xii xiii 1 1 2 2 4 6 7 8 10 11 12 15 19 21 21 27 29 38 39

CHAPTER 2. AN OPTIMAL CONTROL THEORY APPROACH TO NONPHARMACEUTICAL INTERVENTIONS . . . . . . . . . . . . . . . . . 2.1 2.2 2.3 2.4 Literature review . . . . . . . . . . . . . . . . . . . . . . . . . . . . Optimal control model . . . . . . . . . . . . . . . . . . . . . . . . . Model analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Computational examples . . . . . . . . . . . . . . . . . . . . . . . . 2.4.1 2.4.2 2.4.3 2.4.4 2.5 NPI policies assuming linear NPI implementation cost . . . NPI policies assuming quadratic NPI implementation cost . Sensitivity analysis . . . . . . . . . . . . . . . . . . . . . . . Sensitivity to exponential terminal time assumption . . . . .

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Optimal control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Optimal control and public health . . . . . . . . . . . . . . . . . . . Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Outline of dissertation . . . . . . . . . . . . . . . . . . . . . . . . .

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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vi Page 2.5.1 2.5.2 2.5.3 2.5.4 2.5.5 2.6 Eect of NPI policies on the epidemic . . . . . . . . . . . . . Sensitivity analysis . . . . . . . . . . . . . . . . . . . . . . . Linear v.s. quadratic cost functions . . . . . . . . . . . . . . Exponential vaccine arrival time . . . . . . . . . . . . . . . . Model limitations . . . . . . . . . . . . . . . . . . . . . . . . 39 40 42 43 43 44 46 47 50 52 55 57 58 59 61 62 65 65 67 68 69 70 72 73 76 80 84

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 3. STOCHASTIC CONTROL WITH DEGRADING COMPLIANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 3.2 Literature review . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.2.1 3.2.2 3.3 3.4

Public compliance models . . . . . . . . . . . . . . . . . . . Stochastic optimal control model with public compliance . .

Model analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Computational examples . . . . . . . . . . . . . . . . . . . . . . . .

3.5

3.6

CHAPTER 4. CAPACITY PLANNING OF PUBLICLY FUNDED COMMUNITY BASED LONG-TERM CARE . . . . . . . . . . . . . . . . . . . . 4.1 4.2 Literature review . . . . . . . . . . . . . . . . . . . . . . . . . . . . Problem formulation . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2.1 4.3 Admission rate modeling . . . . . . . . . . . . . . . . . . . .

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3.4.1 3.4.2 3.4.3 3.5.1 3.5.2 3.5.3 3.5.4

State-dependent compliance . . . . . . . . . . . . . . . . . . Time-dependent compliance . . . . . . . . . . . . . . . . . . State- and time-dependent compliance . . . . . . . . . . . .

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Eect of compliance . . . . . . . . . . . . . . . . . . . . . . Practical implication . . . . . . . . . . . . . . . . . . . . . . Parameter estimation . . . . . . . . . . . . . . . . . . . . . . Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . .

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Model analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Mathematical model . . . . . . . . . . . . . . . . . . . . . . . . . .

vii Page 4.4 Computational example . . . . . . . . . . . . . . . . . . . . . . . . 4.4.1 4.4.2 4.5 Application to population with dementia . . . . . . . . . . . Sensitivity analysis . . . . . . . . . . . . . . . . . . . . . . . 91 92 96 100 100 100 101 102 103 107 107

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5.1 4.5.2 4.5.3 4.5.4 Advantages of HCBS . . . . . . . . . . . . . . . . . . . . . . Limited HCBS expansion . . . . . . . . . . . . . . . . . . . . Sensitivity analysis . . . . . . . . . . . . . . . . . . . . . . . Methodology deciency . . . . . . . . . . . . . . . . . . . . .

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Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5.1 5.2 5.3

Optimal NPI implementation during inuenza pandemic . . . . . .

Extensions to other public health problems . . . . . . . . . . . . . .

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Capacity planning of publicly funded community based long-term care 109 111 113 125

LIST OF REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . VITA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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CHAPTER 5. CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . .

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LIST OF TABLES Table 2.1 2.2 2.3 2.4 2.5 2.6 2.7 3.1 4.1 4.2 4.3 4.4 Model notation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comparison of the means of the expected person-days lost per person due to death and control intensity between the linear and quadratic models Design of experiment for parameter eect analysis . . . . . . . . . . . . Parameter ranges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Descriptive statistics from the uncertainty analysis . . . . . . . . . . . Partial rank correlation coecients . . . . . . . . . . . . . . . . . . . . Page 15 29 31 34 34 35 38 51 81 92 96 97

Model notation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model notation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Input parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Design of experiment for sensitivity analysis . . . . . . . . . . . . . . . Partial rank correlation coecients (PRCCs) for the optimal HCBS capacity and the corresponding total expenditure over 1500 experiments .

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Descriptive statistics of percentage dierence in cumulative deaths at exponential and gamma terminal times . . . . . . . . . . . . . . . . . . .

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LIST OF FIGURES Figure 2.1 2.2 2.3 Scheme of Susceptible-Infectious-Recovered Model. Boxes represent compartments and arcs represent ux between compartments. . . . . . . . Scheme of Susceptible-Infectious-Recovered/Death (SIRD) Model. Boxes represent compartments and arcs represent ux between compartments. Optimal NPI policy and optimal isolation policy derived in [103] for an inuenza characterized as = 0.4, = 0.25, = 0.05, c = 0.05, and b = 0.2. (a) Optimal NPI policy for the SIRD model. (b) Optimal isolation policy derived in [103]. . . . . . . . . . . . . . . . . . . . . . . Page 13 17

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Optimal NPI policy and optimal isolation policy derived in [103] for an inuenza characterized as = 0.6, = 0.25, = 0.05, c = 0.05, and b = 0.2. (a) Optimal NPI policy for the SIRD model. (b) Optimal isolation policy derived in [103]. . . . . . . . . . . . . . . . . . . . . . . Epidemic curves of infectious and dead population with and without NPI implementation in a pandemic characterized as = 0.4, = 0.25, = 0.05, c = 0.05, and b = 0.2. (a) Epidemic curves with and without NPIs starting from x0 = (99%, 1%, 0, 0). (b) Epidemic curves with and without NPIs starting from x0 = (67%, 33%, 0, 0) (to be compared with Fig. 2.5(a)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemic curves of infectious and dead population with and without NPI implementation in a pandemic characterized as = 0.6, = 0.25, = 0.05, c = 0.05, and b = 0.2. (a) Epidemic curves with and without NPIs starting from x0 = (99%, 1%, 0, 0). (b) Epidemic curves with and without NPIs starting from x0 = (50%, 50%, 0, 0) (to be compared with Fig. 2.6(a)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Optimal NPI policy obtained under quadratic control cost. (a) Optimal NPI policy assuming quadratic control cost for an inuenza pandemic characterized as = 0.4, = 0.25, = 0.05, c = 0.05, and b = 0.2. (b) Optimal NPI policy assuming quadratic control cost for an inuenza pandemic characterized as = 0.6, = 0.25, = 0.05, c = 0.05, and b = 0.2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interpretation of the eect of parameter values on the size of control space.

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2.5

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2.6

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2.8

x Figure 2.9 Interpretation of the eect of parameter values on the size of control space. Page 32

2.10 Empirical CDFs for the proportion of control area, , and mean cumulative death, dT , obtained from the 1000 LHS scenarios. (a) Empirical CDF for the proportion of control area . (b) Empirical CDF for the mean cumulative death dT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11 Partial rank scatterplots of the ranks for and each of the ve sampled input parameter values. . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 3.2 3.3 3.4 3.5 Scheme of Susceptible-Infectious-Recovered/Death (SIRD) Model. Boxes represent compartments and arrows represent ux between compartments. State-dependent compliance model . . . . . . . . . . . . . . . . . . . . Time-dependent compliance model . . . . . . . . . . . . . . . . . . . . State- and time-dependent compliance model . . . . . . . . . . . . . . Optimal NPI policy derived for an inuenza pandemic characterized as = 0.6, = 0.15, = 0.05, and b = 0.2 under the assumption of state-dependent compliance. (a) Optimal NPI policy under linear cost assumption. (b) Optimal NPI policy under quadratic cost assumption.

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Optimal NPI policy derived under compliance and linear control cost. (b) Optimal NPI policy at Week 3. (d) Optimal NPI policy at Week 7.

the assumptions of time-dependent (a) Optimal NPI policy at Week 1. (c) Optimal NPI policy at Week 5. . . . . . . . . . . . . . . . . . . . .

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3.7

Optimal NPI policy derived under the assumptions of time-dependent compliance and quadratic control cost. (a) Optimal NPI policy at Week 1. (b) Optimal NPI policy at Week 3. (c) Optimal NPI policy at Week 5. (d) Optimal NPI policy at Week 9. . . . . . . . . . . . . . . . . . . . . Optimal NPI policy derived under the assumptions of state- and timedependent compliance and linear control cost. (a) Optimal NPI policy at Week 1. (b) Optimal NPI policy at Week 3. (c) Optimal NPI policy at Week 5. (d) Optimal NPI policy at Week 7. . . . . . . . . . . . . . . . Optimal NPI policy derived under the assumptions of state- and timedependent compliance and quadratic control cost. (a) Optimal NPI policy at Week 1. (b) Optimal NPI policy at Week 3. (c) Optimal NPI policy at Week 5. (d) Optimal NPI policy at Week 9. . . . . . . . . . . . . . . .

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3.10 Time line and milestones of 2009 H1N1 outbreak and public health responses in the State of Indiana. . . . . . . . . . . . . . . . . . . . . . .

xi Figure 4.1 The compartmental model for HCBS capacity planning. Boxes represent compartments and arrows represent ow between compartments. H HCBS; N - institutional care; E - without LTC; D - death. . . . Admission rates into nursing home and HCBS program vs. capacity of HCBS program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Annual spending on the studied population vs. capacity of HCBS program using dynamic admission rates H (S, x(t)) and N (S, x(t)). . . . . . . . Annual spending on the studied population vs. capacity of HCBS program using relaxed admission rates H (S, x(0)) and N (S, x(0)). . . . . . . . Optimal HCBS capacity S against C H and C N under two HCBS infrastructure costs (C S = 5000 and 10000) when the proportion of people to be admitted to receiving LTC is 20% ( = 20%). (a) Optimal HCBS capacity S against C H and C N under C S = 5000 and = 20%. (b) Optimal HCBS capacity against C H and C N under C S = 10000 and = 20%. . Page

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4.2 4.3 4.4 4.5

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Optimal HCBS capacity S against C H and C N under two HCBS infrastructure costs (C S = 5000 and 10000) when the proportion of people to be admitted to receiving LTC is 30% ( = 30%). (a) Optimal HCBS capacity S against C H and C N under C S = 5000 and = 30%. (b) Optimal HCBS capacity against C H and C N under C S = 10000 and = 30%. . Optimal HCBS capacity S against C H and C N under two HCBS infrastructure costs (C S = 5000 and 10000) when the proportion of people to be admitted to receiving LTC is 40% ( = 40%). (a) Optimal HCBS capacity S against C H and C N under C S = 5000 and = 40%. (b) Optimal HCBS capacity against C H and C N under C S = 10000 and = 40%. .

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ABBREVIATIONS SIR SIRD NPI LHS LTC HCBS IP ER ADL IADL Susceptible-infectious-recovered model Susceptible-infectious-recovered/death model Non-pharmaceutical interventions Latin hypercube sampling Long-term care

Inpatient hospitalization care

Ambulatory care or emergency visit Activities of daily living

Instrumental activities of daily living

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Home and community based services

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ABSTRACT Lin, Feng. Ph.D., Purdue University, May 2010. Optimal Control Problems in Public Health. Major Professor: Mark Lawley. The health care delivery system in the United States is poorly planned to meet the growing needs of its population. This research establishes the foundations of developing decision-support tools in the emerging eld of health care engineering,

engineering methods, especially optimal control theory, to facilitate decision making

health are studied: 1) how to optimally implement non-pharmaceutical interventions to mitigate an inuenza pandemic; and 2) how to allocate limited long-term care budget eectively.

1. Pandemic planning: Optimal implementation of non-pharmaceutical interventions during inuenza pandemic Non-pharmaceutical interventions (NPIs) are the rst line of defense against pandemic inuenza. These interventions dampen virus spread by reducing contact between infected and susceptible persons. Because they curtail essential societal activities, NPIs must be applied judiciously. Their eectiveness also depends on the degree of public compliance, as NPIs require people to change their daily behaviors. The public buy-in depends on their awareness and perception of the severity of the outbreak. It is also likely to degrade as time evolves due to compliance fatigue. In this work, we use an epidemiologic compartmental model to develop optimal triggers for NPI implementation. The objective is to minimize the expected persondays lost from inuenza related deaths and NPI implementation. In the rst part of

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in the complex health care delivery systems. Two compelling problems of public

with special emphasis on public health. It demonstrates the potential of applying

xiv this work, optimal policies for a deterministic control model are derived. A multivariate sensitivity analysis is performed to study the eects of input parameters on the optimal control policy. Additional studies investigate the eects of departures from the modeling assumptions, including exponential terminal time and linear NPI implementation cost. Next, a stochastic control model is developed from the deterministic model to investigate the eect of public compliance and uncertainties of system dynamics on the NPI policies. The public compliance is modeled as functions of time and incidence of infection. Diusion terms are introduced to capture the uncertainties in the dynamic of the system. Optimal NPI policies are derived for dierent compliance functions

Numerical results for interpreting policy characteristics are presented along with

timely surveillance and eective risk communications during pandemic outbreak. The application of optimal control theory can provide valuable insight to develop eective control strategies for pandemic.

2. Long-term care planning: Capacity planning of publicly funded community based care

Long-term care (LTC) provides medical and non-medical services to people with chronic disease or disability, many of whom are older adults eligible for receiving care through public funding sources. At present, the annual spending on LTC in the U.S. is over $200 billion and this number is increasing rapidly. The federal and state governments paying for LTC are under increasing nancial pressure. Although nursing home care has been a viable option, it often provides expensive and more than necessary care. Home and community based services (HCBS) oers a exible alternative by providing care at home and in the community. However, little is known on how much infrastructure is needed for providing community-based care.

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guidelines for practical implementation. Our ndings highlight the importance of

and diusion terms.

xv This research formulates an optimal control problem to determine the optimal infrastructure capacity of HCBS program from a societal expenditure viewpoint. A compartmental model is established to describe the population dynamics in the publicly funded LTC system. Two models are considered in determining whether to provide LTC in the community or in a nursing home. The objective of the optimal control problem is to minimize the overall expenditure, including spending on longterm and acute care services, over a given time period. We consider two alternative models when determining whether to provide LTC in the community or in a nursing home. Analytical properties are presented along with computational examples for dementia patients based on published data. A full-factorial sensitivity analysis is

The compartmental model is validated against the published data, which indicates

total expenditure suggested by the model indicates that future development of the LTC system should increase HCBS capacity, but unrestricted HCBS expansion is not desirable. Also, HCBS cost should not exceed a certain proportion of nursing home cost for the HCBS program to remain economic.

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that it is a reasonable abstraction of the LTC system for the elderly. Reduction in

performed to study the sensitivity of various parameters.

Chapter 1. INTRODUCTION
1.1 Background The health care delivery system in the United States is poorly planned to meet the growing needs of its population [1,2]. In 2007, the health care spending consumed over 15% of the U.S. gross domestic product (GDP) [3] and this spending is expected to grow at over 6.7% annually in the future [4, 5]. However, the performance of such expensive service is not competent [6, 7], as the system is riddled with ineciencies, excessive expenses, and poor management [8]. Notably, the average growth in national

growth in GDP [9,10]. The public, government, insurers, and industries are straining

Many of the problems that threaten health care in the U.S. are the result of uninformed, irrational decision making throughout the system, where data driven systems modeling and analysis activities are virtually unknown. Engineering tools, especially mathematical modeling and analysis techniques, are considered as one of the potential means to facilitate and improve decision making in the complex systems [13, 14]. Over the past 30 years, the engineering methods have been successfully applied in the manufacturing, logistics, distribution, and transportation [2, 14, 15]. These methods, properly modied and applied, can provide similar high-level impacts in health care. This dissertation employs engineering methodologies, especially optimal control, to facilitate decision making in health care systems, with special emphasis in public health. Two compelling problems in public health are studied: one focuses on development of response plans for large-scale infectious disease outbreaks, and the other focuses on allocation of limited resources for the long-term care system. This work

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under a serious nancial and societal crisis [11, 12].

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health spending is projected to be 6.2%, which is 2.1% faster than average annual

2 helps showcase the potential of applying engineering approaches, including operations research, systems engineering, and applied mathematics, to improve decision making in health care systems.

1.2

Public health Public health is the science and art of preventing disease, prolonging life, and promoting physical health and eciency through organized community eorts for the sanitation of the environment, the control of community infections, the education of the individual in principles of per-

diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.

The goals of public health focus on proactive, interventional, and collective activities to prevent diseases and maintain the health and well-being of the population. Public health is a combination of science, technologies, and practice to maintain and improve the health of all people. It deals with preventive care at population-level, which diers from clinical medical care that focuses on curative care at individuallevel health issues. While medicine tends to treat a disease when it occurs to a person, public health focus on identifying and implementing interventions to prevent a disease through surveillance of cases and the promotion of healthy behaviors [17].

1.2.1

Public health achievements

Over decades, public health has many successes. In the 20th century, public health in the U.S. made signicant accomplishments in responding to infectious diseases and increasing the lifespan of Americans. The Morbidity and Mortality Weekly Report

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Charles-Edward A. Winslow 1920 [16]

sonal hygiene, the organization of medical and nursing service for the early

3 (MMWR) highlights the ten great public health achievements in the 20th century [18]. These achievements include: Vaccination [19] Motor-vehicle safety [20] Safer workplaces [21] Control of infectious diseases [22] Decline in deaths from coronary heart disease and stroke [23]

Healthier mothers and babies [25] Family planning [26]

Recognition of tobacco use as a health hazard [28]. These achievements indicate that the major health threats in the 20th century were infectious diseases associated with poor hygiene and poor sanitation, diseases associated with poor nutrition, poor maternal and infant health, and diseases or injuries associated with unsafe workplaces or hazardous occupations [29]. They document the established roles of public health in responding to the major causes of morbidity and mortality during that period of time. Nonetheless, they also reect the science and technology advances in public health, which involve a variety of elds, including environmental health, epidemiology, biostatistics, nutrition, behavioral science, health education, and health services administration and management.

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Fluoridation of drinking water [27]

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Safer and healthier foods [24]

4 1.2.2 Public health challenges

Although public health continues to expand its established roles, it is taken for granted and most people are unaware of its critical activities. Government expenditures on health are alarmingly high, but little of the spending is directed towards public health. Meanwhile, new health problems have emerged, such as AIDS/HIV epidemic, environmental pollution, chronic diseases, aging population, and social problems [17, 30]. All these issues have become the major concerns and challenges to public health. An important issue challenging the public health system is emerging infectious diseases, such as severe acute respiratory syndrome (SARS), inuenza, and AIDS/HIV. These diseases have continually threatened the health of populations worldwide. The 2003 SARS outbreak caused severe widespread societal disruption and signicant economic losses, apart from the direct costs of medical care and control measures [3134]. The 2009 H1N1 pandemic has infected over 246,571 humans worldwide, resulting in

AIDS/HIV is a major global health emergency, causing millions of deaths and suffering to millions more worldwide [34, 36, 37]. Although the treatment of AIDS has been improved, it remains the leading infectious cause of adult death and it also fuels reemerging tuberculosis epidemics of global concern [34, 37]. Besides infectious diseases, chronic and degenerative diseases have become leading causes of death and disability [38, 39]. Dierent from acute conditions, the chronic conditions, such as heart disease, stroke, cancer, diabetes, and arthritis, are longlasting and/or recurrent. They require persistent attention and daily assistance for the patients and their families. Nearly 133 million Americans have at least one chronic condition [3941], and these illnesses cause about 70% of deaths in the U.S., accounting for about 75% of the costs each year [39, 40, 42]. As aging population is highly correlated with such conditions, the size of population with chronic conditions is expected to grow signicantly because of longer life spans and aging baby boomers

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at least 12,220 deaths in 2009 [35], and its severity is considered as mild-moderate.

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5 [43]. This number is projected to increase to 171 million by 2030 [40], resulting in 20% increase in the nations health care spending [4446]. Furthermore, people with chronic illnesses are often associated with racial and ethinic diversities. This without doubt places signicant challenges to health care delivery and access. In addition to disease control and prevention, public health is also responsible for emergency preparedness and response, maintenance of healthy environment, and promotion of healthy lifestyle. The tasks of public health have been not only to identify health problems, but also to nd eective interventions to solve these problems within a certain social and political structure. All these issues have placed signicant nancial burden on the federal and state governments, and posed serious threats to

Unfortunately, public health is typically underfunded, yet it is responsible for

accounted for only 3% of total health spending in the U.S., which was much lower than the spending on personal services and even less than the administration cost [4749]. Many vital societal functions that public health is responsible for, including disease control and prevention, environment health, healthy lifestyle promotion, are always carried out under tight budgets and limited resources. These resources are often unevenly distributed, resulting in wide disparities geographically and demographically. In addition, there exists wide variation among communities, as dierent communities are facing distinct health problems and they have dierent demographic, political and social structures. Hence, even the approaches to investigate a similar health problem might dier signicantly in dierent communities. Finally, public health interventions always involve many stakeholders with competing objectives. It is complicated to balance these competing objectives to achieve the best benet for the community as a whole. To summarize, public health agencies are required to make decisions at various scenarios from time to time within various political and societal structures. The decision making is a complicated process that involves the demographic, political,

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critical functions that aect the entire population. In 2004, public health activities

national security.

6 and economic factors, and dierent stakeholders in a given community. It has become increasingly important to help the public health agencies quantify and understand the economic and social impact caused by various threats, as well as to inform the decisions on allocation and management of constrained health care resources.

1.3

Optimal control Optimal control is a mathematical method for nding optimal means to control a

dynamic system. For many problems, a natural question is how to intervene in the system to produce the best possible outcome, as measured by some predetermined

An optimal control problem is composed of two components, the system dynamics and the objective. The system is described by a set of state variables and control variables, which are governed by a set of dierential equations. The cost function measures the performance of the system. Optimal control theory governs strategies for maximizing/minimizing a performance measure as the state of the dynamic system evolves.

Optimal control has been successfully applied to many problems in manufacturing, aerospace and defense, automotive systems, structural and mechanical design, environmental control, and biological and biomedical systems. It has covered a wide range of interdisciplinary and complex problems, in which balancing the benet and the cost of control strategies is important yet nonintuitive. This subject has been enriched rapidly since the early works of Balakrishnan [50], Butkovskii [51], and Fattorini [52]. In the remainder of this section, we review the applications of optimal control theory in economics and management, engineering, and biological systems. Optimal control has also been widely used to nd control mechanisms for automotive, and aerospace and defense systems. For example, Nearly [53] develops throughput control strategies that minimize energy expenditure while satisfying a set of power constraints for wireless networks.

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goals. Optimal control theory is one of the approaches to address such questions.