Issue Report Ready or Not? 2011 Protecting The Public’s Health From Diseases, Disasters, And Bioterrorism December 2011 Preventing Epidemics. Protecting People. ACKNOWLEDGEMENTS Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to improving the quality of the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful, and timely change. For more than 35 years, the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. For more information, visit www.rwjf.org. TFAH BOARD OF DIRECTORS REPORT AUTHORS PEER REVIEWERS TFAH thanks the reviewers for their time, exper- Gail Christopher, DN Jeffrey Levi, PhD. tise, and insights. The opinionsexpressed in the President of the Board, TFAH Executive Director report do not necessarily represent the views of Vice President for Health Trust for America’s Health and the individuals or the organization with which WK Kellogg Foundation Professor in the Department of Health Policy they are associated. The George Washington University School Cynthia M. Harris, PhD, DABT of Public Health and Health Services Gerrit Bakker Vice President of the Board, TFAH Senior Director, Preparedness Planning and Director and Professor Laura M. Segal, MA Response Institute of Public Health, Florida Director of Public Affairs Association of State and Territorial Health A&M University Trust for America’s Health Officials Theodore Spencer Dara Alpert Lieberman, MPP James S. Blumenstock Secretary of the Board, TFAH Senior Government Relations Manager Chief Program Officer, Public Health Practice Senior Advocate, Climate Center Trust for America’s Health Association of State and Territorial Health Natural Resources Defense Council Rebecca St. Laurent, JD Officials Robert T. Harris, MD Health Policy Research Manager Leah McCall Devlin, DDS, MPH Treasurer of the Board, TFAH Trust for America’s Health Gillings Visiting Professor Former Chief Medical Officer and Senior University of North Carolina Gillings Vice President for Healthcare School of Global Public Health BlueCross BlueShield of North Carolina Jonathan Fielding, MD, MPH David Fleming, MD Director and Chief Health Officer Director of Public Health Los Angeles County Department of Public Seattle King County, Washington Health Arthur Garson, Jr., MD, MPH Chris Mangal, MPH Director, Center for Health Policy, University Pro- Director of Public Health Preparedness and fessor, and Professor of Public Health Sciences Response University of Virginia Association of Public Health Laboratories John Gates, JD Irwin Redlener, MD Founder, Operator and Manager Clinical Professor of Population and Family Health Nashoba Brook Bakery Columbia University, Mailman School of Alonzo Plough, MA, MPH, PhD Public Health and Director, Emergency Preparedness and Response Director Program National Center for Disaster Preparedness Los Angeles County Department of Senior Staff Public Health Center for Biosecurity Eduardo Sanchez, MD, MPH University of Pittsburgh Medical Center Chief Medical Officer Blue Cross Blue Shield of Texas This report is supported by a grant from the Robert Wood Johnson Foundation. The opinions ex- Jane Silver, MPH pressed in this report are those of the authors and President do not necessary reflect the views of the foundation. Irene Diamond Fund Introduction F or the past decade, since the September 11, 2001 and anthrax events, the United States has grappled with how to best prepare for public health emergencies. These tragedies marked the first time public health was n n the past year, 40 states and Washington, D.C. I considered central to the nation’s emergency prepared- have cut funds to public health, 30 states cut their ness — marking the beginning of a significant transfor- budgets for the second year in a row and 15 of mation. However, the system had been underfunded those have cut their budget three years in a row; for years, and while officials responded to the attacks as n ince 2008, 49,310 state and local public health S best as they could, they often did not have the technol- department jobs have been lost to layoff and at- ogy, resources, workforce or training needed. A series trition — 14,910 in state health agency central of expert assessments after September 11 and the an- offices and 34,400 in local health departments;4 thrax events concluded that the public health system was “structurally weak in almost every area.”1,2,3 n ixty percent of state health agencies have cut en- S tire programs since 2008, while half of all local Since then, the field of public health has faced the public health departments reported cutting at least challenge of rebuilding basic capabilities in all 50 one program altogether in the last year alone;5 and states and territories while also determining how to prioritize and plan for the greatest risks — with n ederal funds for state and local preparedness de- F limited resources. clined by 38 percent from fiscal year (FY) 2005 to 2012 (adjusted for inflation) — and additional cuts There are two key aspects of preparedness. One is to are expected under budget sequestration.6 support the basic functions of a public health system — such as trained epidemiologists, laboratories and This year’s Ready or Not? report examines: surveillance systems. The second is to have the spe- n Section 1: Examples of specific programs and cialized training, procedures, leadership and coordi- capabilities at-risk for major cuts or elimination; nated plans in place so first responders and experts have clear roles and responsibilities and know what capa- n ection 2: State and local public health S bilities exist and how to use them during a crisis. This budget cuts; requires ongoing planning and coordination, exercises s ommentary: Select Agents and Toxins — Impact C and drills, systems for providing care to large numbers of Proposed Regulatory Changes on Public Health of patients when needed, including the ability to rapidly Laboratories — By Chris N. Mangal, MPH, distribute vaccines and medications, and a system to Director of Public Health Preparedness and Re- detect, manage the response and communicate emer- sponse, Association of Public Health Laboratories gencies as soon as they arise. Preparedness requires programs and funds dedicated specifically to building s ommentary: Components of a System Put to the C core capabilities and understanding what is necessary Test: A Look at North Dakota’s Public Health to respond to any hazard or crisis the country faces. Preparedness System — By Tim Wiedrich, Sec- tion Chief Emergency Preparedness and Response For nine years, the Trust for America’s Health Section, North Dakota Department of Health (TFAH) has issued the Ready or Not? report to provide an independent analysis of progress and n ection 3: A review of 10 years of progress S vulnerabilities in public health preparedness. The and gaps in preparedness, a timeline of major reports have found that while a significant invest- public health preparedness events, and a re- ment has led to a major upgrade in the nation’s view of special topics; ability to prevent, diagnose and respond to health s ommentary: Meta-Leadership Empowers Com- C emergencies, the resources have not been sufficient munity Leaders to Act Together in Times of for filling many major gaps. Crisis — By Charles Stokes, president and chief Despite these serious ongoing gaps, the Ready or Not? executive officer of the CDC Foundation reports documented how preparedness had been on an s ommentary: Preparedness and Public Health Sys- C upward trajectory until the economic crisis hit. Since tems and Services Research — By F. Douglas Scutch- then, local, state and federal cuts to public health bud- field, MD, principal investigator of the Center for gets and staff are starting to erode a decade’s worth of Public Health Systems and Services Research at the progress. Health departments are increasingly spread University of Kentucky College of Public Health thin and programs and core capabilities are being cut. 3 s ommentary: Public Health Legal Prepared- C s ommentary: Surveillance: Essential for Public C ness in the United States — Q&A with James G. Health Preparedness and Response, By, Jeffrey Hodge, Jr., JD, LLM, Lincoln Professor of Health Engel, M.D., State Health Director, Division of Law and Ethics and director of the Public Health Public Health, North Carolina Department of Law and Policy Program and director of the Net- Health and Human Services work for Public Health Law-Western Division at l mproving research, development and I the ASU Sandra Day O’Connor College of Law availability of vaccines and medications; s ommentary: Disaster Preparedness for Mass Casual- C ties from Explosive Devices — the Role of Injury Pre- l ncreasing the ability of the public health I vention and Control — By Richard W. Sattin, MD, and health care systems to provide mass FACP, president-elect of the Society for the Advance- care during emergencies; ment of Violence and Injury Research and professor l orking with communities to cope with W and research director at the Department of Emergency and recover from emergencies; Medicine at the Georgia Health Sciences University s ommentary: Vulnerability, Resilience and C n ection 4: An examination of areas with major S Mental Health Considerations in Disaster Plan- gaps in federal policies and recommendations ning and Response: Do Resources Match the for improving all-hazards preparedness — Rhetoric? By David Abramson, PhD, MD and particularly in the context of a reauthorized Irwin Redlener, MD, Columbia University Mail- Pandemic and All-Hazards Preparedness Act man School of Public Health (PAHPA), including: l oordinating public health preparedness C l edicated funding for preparedness and for D with strategic implementation of the U.S. strengthening public health infrastructure; Food and Drug Administration (FDA) s ommentary: A Decade of Public Health Pre- C Food Safety Modernization Act of 2011 paredness: A Focus on Oregon — By Melvin s ommentary: Food Safety: New Law Takes a Big C Kohn, M.D., MPH, State Health Officer and Bite Out of the Problem, but Leaves Much on Public Health Director, Oregon Health Authority the Plate, By By Erik D. Olson, Director of Food s ommentary: Improving Collaboration between C Programs at The Pew Charitable Trusts Federal, State and Local agencies in Planning Overall, the report concludes that while it is for a Worst Case Scenario: A Broad Aerosolized impossible to be prepared for every potential Dispersal of Weaponized Anthrax in a Major threat, it is possible and essential to maintain a Metropolitan Area, By Alonzo Plough, PhD, basic, core level of preparedness and response MPH, Director of Emergency Preparedness and capabilities. Being prepared means the coun- Response of the Los Angeles County Department try must have enough resources and vigilance to of Public Health and Member of the Board of prevent what we can and respond when we have Directors, Trust for America’s Health to. In an era of scarce resources, it is more im- l odernizing biosurveillance to rapidly and M portant than ever to think strategically to ensure accurately detect outbreaks and threats; Americans are not left unnecessarily vulnerable. KEY FINDINGS n ifty-one cities — located in 40 states — are at risk for elimi- F n Potential cuts to the National Center for Environmental Health nation of Cities Readiness Initiative funds, which support the (NCEH) mean the ability for the U.S. Centers for Disease Con- ability to rapidly distribute and administer vaccinations and trol and Prevention (CDC) to mount a comprehensive response medications during emergencies. to nuclear detonation, radiological attacks, chemical attacks and natural disasters is at risk. n All 10 state labs with “Level 1” chemical threat testing status are at risk for losing top level capabilities, which n Forty states and Washington, D.C. cut their state public could leave the U.S. Centers for Disease Control (CDC) health budgets — 29 states cut their budgets for a second with the only public health lab in the country with full year in a row, 15 for three years in a row. chemical testing capabilities. n orty-one states had cuts in state and local preparedness F n Twenty-four states are at risk of losing expert epidemiology sup- support through the Public Health Emergency and Pre- port, which has supplemented state and local gaps in the past. paredness (PHEP) grants from FY 2010 to FY 2011. n Academic preparedness research and training centers are at n All 50 states and Washington, D.C. had cuts in the Hospital risk due to budget cuts. Preparedness Program (HPP) from FY 2010 to FY 2011. 4 Examples of Key Programs at Risk For Major Federal Funding Cuts 1 Section S ince the terrorist attacks of September 11, 2001, CDC has provided more than $7 billion in preparedness funding to states and some major cities. Federal funds for state and local preparedness A number of these programs receive support as declined by 38 percent from fiscal year (FY) 2005 part of the PHEP cooperative agreement (Cities to 2012 (adjusted for inflation) — and additional Readiness Initiative, the chemical laboratory pro- cuts are expected under budget sequestration. gram, and the Career Epidemiology Field Offi- cer Program (CEFO)) and others are part of the From FY2010 to FY2012, there will be a $72 mil- CDC’s operational budget for providing expertise lion reduction to PHEP grants from state, local, and support during national or local crises (sup- territorial, and tribal funds, a $22 million cut port for environmental health emergencies at the to the Academic Centers for Public Health Pre- National Center on Environmental Health). paredness and $5 million from the Advanced Practice Centers. TFAH has identified the following CDC pro- grams as under particular threat as a result of These programs are also at risk based on FY 2012 proposed additional cuts to preparedness fund- and FY 2013 sequestration budget scenarios. ing.  This analysis is based in part on a review This section highlights a number of programs of Administration and Congressional budget that are at risk due to the continued funding cuts documents as well as expert assessments of the to preparedness and response activities at CDC. potential impact of cuts.  FEDERAL, STATE AND LOCAL PUBLIC HEALTH JURISDICTIONS The federal role: Includes setting national policies, State and local roles: Under U.S. law, state funding programs, overseeing national disease pre- governments have primary responsibility for the vention efforts, collecting and disseminating health health of their citizens. Constitutional “police information, building capacity, and directly managing powers” give states the ability to set local some services, and supporting biomedical research policies and enact laws and issue regulations and production capability.7 Some public health to protect, preserve and promote the health, capabilities, such as the Strategic National Stockpile safety and welfare of their residents. In most (SNS), are federal assets managed by federal agen- states, state laws charge local governments with cies that are available to supplement a state’s and responsibility for the health of their citizens. community’s response to a public health emergency State and local health departments and first that overwhelms or may overwhelm their capabili- responders are the front line in any public ties. Public health functions are widely diffused health emergency. across eight federal agencies and two offices. 5 KEY PROGRAMS AT RISK FOR MAJOR FUNDING CUTS Level One Chemical Cities Readiness Initiative At Risk for Losing Career At Risk for Losing Preparedness and Emergency Response Learning Labs At Risk for Cities At Risk for Epidemiology Field Center Support Elimination Elimination Officer Program Support STATE City Alabama Birmingham 3 University of Alabama at Birmingham School of Public Health Alaska Anchorage Arizona 3 University of Arizona College of Public Health Arkansas Little Rock California 3 Riverside, Sacramento Fresno, San Jose 3 Colorado Connecticut New Haven, Hartford Delaware Dover D.C. Florida 3 Orlando, Tampa 3 University of South Florida College of Public Health Georgia Hawaii Honolulu Idaho Boise 3 Illinois Peoria University of Illinois at Chicago School of Public Health Indiana Indianapolis Iowa Des Moines University of Iowa College of Public Health Kansas Wtchita Kentucky Louisville 3 Louisiana Baton Rouge, New Orleans Maine Portland 3 Maryland Baltimore Johns Hopkins University Bloomberg School of Public Health Massachusetts 3 Harvard University School of Public Health Michigan 3 3 Minnesota 3 3 University of Minnesota School of Public Health Mississippi Jackson 3 Missouri Kansas City Montana Billings 3 Nebraska Omaha 3 Nevada 3 New Hampshire Manchester New Jersey Trenton New Mexico 3 Albuquerque New York 3 Albany, Buffalo 3 Columbia Universtiy Mailman School of Public Health; University of Albany SUNY School of Public Health North Carolina Charlotte 3 University of North Carolina Gillings School of Global Public Health North Dakota Fargo 3 Ohio Cincinnati, Columbus Oklahoma Oklahoma City University of Oklahoma College of Public Health Oregon Portland Pennsylvania 3 Rhode Island Providence South Carolina 3 Columbia South Dakota Sioux Falls 3 Tennessee Memphis, Nashville 3 Texas San Antonio 3 Texas A&M School of Rural Public Health Utah Salt Lake City Vermont Burlington 3 Virginia 3 Richmond, Virginia Beach 3 Washington University of Washington School of Public Health West Virginia Charleston 3 Wisconsin 3 Milwaukee Wyoming Cheyenne 3 Total 10 40 24 13 *2011 budget totals adjusted for inflation 6 AND CURRENT FUNDING CUTS At Risk of Losing Prevention and Emergency At Risk for Losing Cuts to PHEP Cuts to State Cuts Response Research Center Support Environmental Funding Public Health to HPP Threat Support Budget* Funding Alabama 3 3 3 3 Alaska 3 3 Arizona 3 3 3 3 Arkansas 3 3 3 California University of California at Berkeley and Los Angeles 3 3 3 3 Colorado 3 3 3 3 Connecticut 3 3 3 3 Delaware 3 3 3 D.C. 3 3 3 Florida 3 3 3 Georgia Emory University 3 3 3 3 Hawaii 3 3 3 Idaho 3 3 3 3 Illinois 3 3 3 3 Indiana 3 3 3 Iowa 3 3 3 3 Kansas 3 3 3 3 Kentucky 3 3 3 3 Louisiana 3 3 3 Maine 3 3 3 3 Maryland Johns Hopkins University Bloomberg School of Public Health 3 3 3 3 Massachusetts Harvard School of Public Health 3 3 3 3 Michigan 3 3 3 Minnesota University of Minnesota 3 3 3 3 Mississippi 3 3 3 3 Missouri 3 3 3 3 Montana 3 3 3 Nebraska 3 3 3 3 Nevada 3 3 3 3 New Hampshire 3 3 3 New Jersey 3 3 3 3 New Mexico 3 3 3 3 New York 3 3 3 3 North Carolina University of North Carolina 3 3 3 3 North Dakota 3 3 Ohio 3 3 3 Oklahoma 3 3 3 3 Oregon 3 3 3 3 Pennsylvania University of Pittsburgh 3 3 3 3 Rhode Island 3 3 3 South Carolina 3 3 3 3 South Dakota 3 3 3 Tennessee 3 3 3 Texas 3 3 3 3 Utah 3 3 3 3 Vermont 3 3 3 3 Virginia 3 3 3 3 Washington University of Washington 3 3 3 3 West Virginia 3 3 3 3 Wisconsin 3 3 3 Wyoming 3 3 3 8 50 + D.C. 41 40 + D.C. 50 + D.C. 7 A. ties Readiness Initiative: 51 Cities At Risk to Be Cut Ci From the Program More than half of the country’s population lives strain on the public PODs. Some of distribu- in urban areas. Many experts believe that be- tion plans depend on school buses, public em- cause of their density, cities are more likely to ployees or postal workers to get medicine to the be the target of a bioterror attack. population.10 In 2004, CDC created the Cities Readiness Ini- In addition to creating plans for the delivery of tiative (CRI), a program that helps cities and medicine, CRI helps participating areas inte- large metropolitan areas prepare to dispense grate emergency plans, so that fire, police and medicine quickly, on a large scale. CRI is funded public health departments, as well as hospitals through PHEP. and local governments, are all working together. From 2004 to 2010, CRI expanded from 21 ini- Every year, CDC tests participating cities to tial cities and metropolitan areas to include 72 gauge their readiness. In a report released cities and metropolitan areas — at least one in in September 2011, Public Health Preparedness: every state.8 2011 State-by-State Update on Laboratory Capabili- ties and Response Readiness Planning, the agency The program focuses primarily on helping these found that the national average for the cities’ cities improve their ability to deliver antibiotics readiness scores increased from 68 out of 100 to the entire population in that area within 48 in 2007-08 to 88 in 2009-10.  According to the hours of an attack, which is the time window for report, cities improved most on training, exer- possible effective treatment. In each metropol- cise and evaluation, as well as on communicat- itan area, health departments have developed ing information to the public.11 their own plans. The primary dispensing model for each plan is through Points of Dispensing The program received $54 million in FY 2011, (PODs). PODs are large public clinics, set up down from $62 million in FY 2010.12 Further to deliver medicine to thousands of people, up proposed cuts to PHEP cooperative agreement to 500 per hour.9 In some places, officials have in FY 2012, could result in 51 cities being cut developed plans for “closed PODs,” which act from the program — reducing the number of as public sector clinics at places such as large CRI cities from 72 back to the initial 21 cities.13 companies, which can distribute medicines to employees and their families, to help relieve the 8 Initial 21 CRI Areas as of 15 CRI Areas (Added in 36 CRI Areas (Added 2004 — Expected to Be 2005) At Risk for Elimination in 2006) At Risk for Funded in FY 2012 in FY 2012 Elimination in FY 2012 Atlanta, GA Baltimore, MD Albany, NY Boston, MA Cincinnati, OH Albuquerque, NM Chicago, IL Columbus, OH Anchorage, AK Cleveland, OH Indianapolis, IN Baton Rouge, LA Dallas, TX Kansas City, MO Billings, MT Denver, CO Milwaukee, WI Birmingham, AL Detroit, MI Orlando, FL Boise, ID District of Columbia Portland, OR Buffalo, NY Houston, TX Providence, RI Burlington, VT Las Vegas, NV Riverside, CA Charleston, WV Los Angeles, CA Sacramento, CA Charlotte, NC Miami, FL San Antonio, TX Cheyenne, WY Minneapolis, MN San Jose, CA Columbia, SC New York City, NY Tampa, FL Des Moines, IA Philadelphia, PA Virginia Beach, VA Dover, DE Phoenix, AZ Fargo, ND Pittsburgh, PA Fresno, CA San Diego, CA Hartford, CT San Francisco, CA Honolulu, HI Seattle, WA Jackson, MS St. Louis, MO Little Rock, AR Louisville, KY Manchester, NH Memphis, TN Nashville, TN New Haven, CT New Orleans, LA Oklahoma City, OK Omaha, NE Peoria, IL Portland, ME Richmond, VA Salt Lake City, UT Sioux Falls, SD Trenton, NJ Wichita, KS Source: http://www.rand.org/pubs/technical_reports/2009/RAND_TR640.pdf, p. 55-56 9 B. ublic Health Laboratory Response Network: P Chemical Threat Testing At Risk in All 10 State Labs with Adequate Chemical Capabilities and Capacities Public health labs have shown dramatic progress date on Laboratory Capabilities and Response Readi- in the past decade. In 2010, every lab except ness Planning, found the most advanced, “Level one increased or maintained their capability to 1” LRN-c labs increased their capabilities by respond to chemical threats. increasing the number of methods they use to rapidly detect chemical agents, from an average In addition, the laboratories created an effective of 6.7 in 2009 to an average of 8.9 in 2010.15 and efficient network, the Laboratory Response Network (LRN-c) to respond chemical threats.14 Over the last two years, funding for Level 1 The LRN-c includes: chemical labs has been decreased significantly. It is unlikely that states will continue to operate n ine Level 3 laboratories, which perform the N their Level 1 chemical labs without sustained basic functions that all of the LRN labs have funding from CDC and cuts to the PHEP coop- — working with hospitals and other first re- erative agreement threaten that funding. sponders within their jurisdiction to maintain competency in clinical specimen collection, The 10 chemical labs currently at Level 1 status, storage, and shipment; and which are at risk if further funding cuts are en- acted include: n hirty-four Level 2 laboratories have chemists T who are trained to detect exposure to a num- n California ber of toxic chemical agents (analysis of cya- n Florida nide, nerve agents, and toxic metals in human samples are examples of Level 2 activities); and n Massachusetts n en Level 1 laboratories provide surge ca- T n Michigan pacity to CDC and can detect exposure to n Minnesota an expanded number of chemical agents, including mustard agents, nerve agents and n New Mexico other toxic industrial chemicals. These labs n New York expand CDC’s ability to analyze large num- bers of patient samples when responding to n South Carolina large-scale exposure incidents. n Virginia Above the Level 1 labs are those at CDC and the n Wisconsin Department of Defense (DOD), which test the most complex and dangerous samples. If the chemical testing capabilities are cut from these 10 labs, CDC would be the only remaining A report released in September 2011 by CDC, public health lab in the country with this ability. Public Health Preparedness: 2011 State-by-State Up- Laboratory Response Network for Biological Threats In addition to responding to chemical threat, the agent activity and handling highly infectious laboratories created an effective and efficient biological agents; network, the Laboratory Response Network n Reference laboratories are responsible for inves- (LRN-bio) to respond biological threats.16 The tigation and/or referral of specimens. They are LRN-bio includes labs with a hierarchy of different made up of more than 100 state and local public capabilities, wherein labs with increased capabili- health, military, international, veterinary, agricul- ties provide support for other labs, consisting of: ture, food and water testing laboratories; and n National laboratories - including those oper- n Sentinel laboratories, which provide routine ated by CDC, U.S. Army Medical Research diagnostic services, rule-out and referral steps Institute for Infectious Diseases (USAMRIID), in the identification process. While these and the Naval Medical Research Center laboratories may not be equipped to perform (NMRC) — are responsible for specialized the same tests as LRN reference laboratories, strain characterizations, bioforensics, select they can test samples. 10 2011 Survey by the Association of Public Health Laboratories According to a survey conducted by the American Cuts to Chemical Threat Activities Public Health Laboratory Association (APHL) in Thirty percent of state public health reported the fall of 2011 about capabilities from August 10, that budget cuts meant they would be unable 2010 to August 9, 2011, funding cuts are nega- to renew service or maintenance contracts for tively impacting the capabilities of many state pub- some instruments, 29 percent report being un- lic health laboratories. able to expand capabilities for new assays or tests, 27 percent report being unable to hire Cuts to Biological Terrorism staff due to lack of funds, 25 percent report Preparedness Activities being unable to purchase critical equipment and Forty-four percent of state public health labs 23 percent report being unable to attend train- report being unable to renew service or mainte- ings and conferences. nance contracts for instrumentation, 40 percent report losing a full-time staff position and 40 *48 out of 50 states responded to the survey. percent report being unable to attend trainings. Sentinel Laboratory Partnerships and Outreach One of the key components of public health pre- In addition to routine communications with paredness and response is the ability for labora- their sentinel clinical partners, public health tories to quickly and accurately detect and report laboratories provide training on rule-out testing, public health threats. To ensure that a robust sys- biosafety, packaging and shipping to thousands tem is in place, state and local public health labora- of laboratorians across the US. However, this tories that receive CDC Public PHEP cooperative outreach and training is in jeopardy as declining agreement funding must build strong partnerships funds threaten to reduce personnel, supply and with clinical laboratories. These relationships as- travel budgets. sure that specimens are quickly referred into the APHL has established a Sentinel Laboratory public health system. The APHL supports strong Partnerships and Outreach group, comprised and effective communication and collaboration of representatives from state and local public between the public health reference laboratories health laboratories, clinical partners such as the and the sentinel clinical laboratories of the national American Society for Microbiology (ASM) and Laboratory Response Network (LRN). These the American Society for Clinical Pathology, and public-private partnerships are the foundation for a the CDC, to address the status of sentinel and successful system poised to detect the next threat. public health laboratory relationships to enhance In fall 2011, APHL conducted a survey of the overall preparedness and response to emerg- 50 state and Washington, D.C. public health ing threats. In the coming year, the group will laboratories. Forty-eight (94 percent) of labo- review and make recommendations to adopt ratories responded to this survey and provided a definition of sentinel clinical laboratories, de- the following information on sentinel laboratory velop a list of common database elements that preparedness and outreach: PHEP funded state and local public health LRN reference laboratories could use to contact n orty-eight state public health laboratories F sentinel laboratories in their jurisdiction and maintained a list of more than 4,000 active further articulate the broad role of public health sentinel clinical laboratories in their jurisdiction. laboratories in support of the sentinel clinical Forty-one of these laboratories utilized a rapid laboratories. The more standardized definition method, such as the Health Alert Network and contact databases will help public health (HAN), blast-email or fax, to send messages to laboratories to perform more targeted outreach sentinel clinical laboratories. Public health labo- to sentinel clinical partners. ratories also utilized the same tools to send rou- tine updates and information on training events and drills to these clinical laboratories. 11 EXPERT COMMENTARY Select Agents and Toxins — Impact of Proposed Regulatory Changes on Public Health Laboratories By Chris N. Mangal, MPH, Director of Public Health Preparedness and Response, APHL T he events of September 11, 2001 reinforced the need to enhance public health prepared- ness and response across the United States. Recog- about the need for optimized security and for risk management.”18 The executive order directed the Secretaries the Department of Health and Human nizing this gap, Congress passed the Public Health Services (HHS) and the USDA to designate a sub- Security and Bioterrorism Preparedness and Re- set of the select agents and toxins list (Tier 1) that sponse Act of 2002 (“the Bioterrorism Response presents the greatest risk of deliberate misuse with Act” or “the act”) (PL107-188)17, which President the most significant potential for mass casualties or George W. Bush signed into law on June 12, 2002. devastating effects to the economy, critical infra- In addition to bolstering laboratory preparedness structure; or public confidence; explore options for and response capability at CDC and in public health graded protection for these Tier 1 agents and toxins laboratories across the United States, the Act also to permit tailored risk management practices based addressed the need to enhance controls on danger- upon relevant contextual factors; and consider reduc- ous biological select agents and toxins (BSAT) agents ing the overall number of agents and toxins on the by establishing a BSAT list; regulating the possession, select agents and toxins list. Further, the order es- transfer and use of BSAT; maintaining databases of tablished the Federal Experts Security Advisory Panel and inspecting facilities that possessed the agents; and (FESAP) to provide advice to the Secretaries on the screening personnel with access to such agents. The Select Agent Program security including: act culminated with the implementation of the final n The composition and potential reduction of the Select Agents Regulations (SAR) (42 CFR Part 73, 7 Biological Select Agents and Toxins (BSAT) list, CFR Part 331 and 9 CFR Part 121) in April 2005. including the development of “Tier 1 agents,” Since the implementation of the SAR, CDC and the which pose the greatest risk for intentional misuse  US Department of Agriculture (USDA) have main- n Measures to enhance reliability of personnel tained the National Select Agent Registry (NSAR) with access to Tier 1 BSAT  and have routinely inspected facilities which possess BSAT. Public health laboratories which possess lim- n Standards for physical and cyber security for ited quantities of biological select agents and toxins facilities possessing Tier 1 BSAT  for quality assurance and control purposes are typi- n Emerging policy issues relevant to the security cally regulated by the CDC Select Agent Program of BSAT (SAP). Further, these laboratories are also regulated under Occupational Safety and Hazard Administra- The concept of a tiered approach to regulating se- tion (OSHA), National Environmental Laboratory lect agents and toxins assumes that more optimized Accreditation Commission (NELAC), Clinical Labo- security measures can be implemented for agents ratory Improvement Amendments (CLIA), and the that pose a higher risk to public health and safety. College of American Pathologists (CAP). However, the proposed changes articulated in the October 2011 Federal Register Notice, Possession, In July 2010, President Barack Obama signed Execu- Use and Transfer of Select Agents and Toxins; Bien- tive Order 13546, Optimizing the Security of Biological nial Review; Proposed Rule, per the Federal Register Select Agents and Toxins in the United States, noting volume 76, No. 191, October 3, 2011,19 does not that the “absence of clearly defined, risk-based se- take into account the unique role public health labo- curity measures in the SAR/SAP has raised concern 12 ratories play in the Laboratory Response Network n epresentation of local and state public health R (LRN), a national asset in place to ensure a rapid re- laboratories during the development of codifying sponse to public health and emerging threats. The changes and guidance documents; and LRN, formed in 1999 through a partnership between n Removal of Bacillus anthracis Pasteur Strain, bot- CDC, the Federal Bureau of Investigation (FBI) and ulinum neurotoxin, and toxin-producing strains APHL, is the nation’s premier laboratory network of Clostridium botulinum from Tier 1 designation. serving as a model for all other networks, respond- ing to actual events on a daily basis and continually Further, APHL also noted: proving its utility during events such as Amerithrax, n Additional costs to comply with the proposed the H1N1 pandemic, disease outbreaks and natural changes to the rule would adversely impact disasters. The true value of the LRN is demonstrated other critical public health programs that are through the communications and relationships built supported by state and local public health labora- with clinicians, hospitals, law enforcement, first re- tories, many of which have had to take significant sponder and epidemiology communities. These well budget reductions during the past three years. established partnerships are the cornerstone that al- lows the LRN to effectively respond to all threats. n Public health laboratories already foster an environment of biosafety and biosecurity to The proposed changes would adversely impact protect against physical and cyber attacks and the public health laboratories, which comprise 70 insider threats. percent of the LRN, by jeopardizing the ability of these laboratories to respond to biological threats. n Promoting continued exemplary practices of en- In September 201020 and again in July 201121, APHL gaging leadership, encouraging teamwork, build- participated in meetings of the FESAP to provide ing relationships with employees and providing input on the final recommendations issued in their ethics training has greater value than the use of a report, Recommendations Concerning the Select “spot in time” personnel reliability program. Agent Program released on June 12, 2011.22 APHL n Additional requirements for select agents may informed the panel of existing biosecurity practices result in some laboratories abandoning the within state and local public health laboratories that LRN, resulting in a weakened capability for comprise the LRN and the impact of changes to the national response. select agent regulations on these laboratories.  n Modifying occupational health programs or add- APHL has publicly commented on the proposed ing personnel reliability program requirements rule, calling for: will put further strain, including legal ramifica- n Exemption of all LRN reference laboratories from tions for request for health information, on the proposed Tier 1 requirements. APHL encour- laboratories already facing worker shortages. aged the Select Agent Program to consider the n ncreased biosecurity requirements will be I recommendation from the FESAP, where they damaging to public health laboratories storing noted: The FESAP recognizes that there are unique limited quantities of BSAT used during response facilities such as diagnostic, public health, animal to public health emergencies and would com- health, and environmental laboratories, such as the promise lab preparedness and the ability of the laboratories of the Laboratory Response Network, US to detect and respond to threats. which perform a vital national security function and may require different methods of implementation of APHL continues to monitor changes to the Select the recommended standards. In these instances, the Agent Regulations, providing feedback to federal FESAP encourages the Select Agent Program, through officials to ensure that public health laboratories are their authority in Section 4 of E.O. 13546, to “ex- not adversely affected and that robust biosecurity plore options for graded protection of Tier 1 agents and biosafety practices implemented within pub- and toxins… to permit tailored risk management lic health laboratories remain in place to protect practices based upon relevant contextual factors.” against public health threats. 13 C. areer Epidemiology Field Officer Program: 24 States C At Risk to Lose Epidemiology Support In 2002, CDC developed a program to help As of November 2011, the program had 32 state, territorial, and local health departments epidemiologists working in 24 states.25 The strengthen their epidemiologic capability for program is supported as part of the PHEP co- public health preparedness and response. The operative agreement. Under the FY2012 cuts to Career Epidemiology Field Officer (CEFO) Pro- state and local preparedness programs at CDC, gram assigns CDC epidemiologists at the request states that currently have CEFOs could lose the of state, territorial or local health departments. support, including: The program has filled a critical gap by establish- n Alabama ing a system to assign well-trained, highly capa- ble epidemiology staff to provide direct support n Arizona and assistance to health departments.23 n California All CEFOs have completed CDC’s Epidemic In- n Florida telligence Service (EIS) training or comparable training. Once assigned to a location, CEFOs n Idaho take on a range of roles: n Kentucky n eveloping and strengthening state and local D n Maine surveillance systems; n Michigan n nvestigating major health problems; I n Minnesota n raining local staff; T n Mississippi n elping develop local public health emer- H gency plans and disaster-response exercises; n Montana n oordinating local response to disasters and out- C n North Carolina breaks with CDC and other federal agencies; and n North Dakota n ostering cooperation between emergency F n Nebraska responders, health care providers and other agencies involved in disaster response. n Nevada Over the past decade, CEFOs have played es- n New York sential roles in a wide range of incidents. For n Pennsylvania example, a CEFO assigned in New York City helped the city respond in the early stages of the n South Dakota H1N1 flu epidemic, tracking cases among high n Tennessee school students who had returned from spring break in Mexico.24 A CEFO in Kentucky orga- n Texas nized and led the emergency needs assessments n Virginia for over 7,000 persons in temporary shelters fol- lowing the 2009 ice storm. The CEFO in North n Vermont Dakota served as Planning Chief for the state’s n West Virginia public health emergency response to the 2010 Red River flooding. The CEFO in Mississippi es- n Wyoming tablished surveillance to monitor health effects in coastal residents following the Gulf oil spill. 14 D. eparedness and Emergency Response Learning Pr Centers: 14 Universities At Risk to Lose Funds from Cuts to the Training Program In 2010, 14 universities around the country In FY 2011, $13 million in grants were awarded received funding to create Preparedness to the 14 institutions listed below, with the and Emergency Response Learning Centers grants totaling approximately $940,000 each.32 (PERLCs) to help train and educate public The federal funds for these programs will be health workers on disaster preparedness significantly cut in 2012: and response. PERLCs are designed to help n olumbia University Mailman School of Pub- C integrate federal and local disaster response lic Health, New York, NY by educating workers and officials on federal standards and strategies.26 n arvard University School of Public Health, H Boston, MA A number of local public health officials have said these programs help fill a crucial gap. n ohns Hopkins University Bloomberg School J “Many people in critical public health roles of Public Health, Baltimore, MD don’t come through with formal training,” said n exas A&M School of Rural Public Health, T then New York State Health Commissioner Dr. College Station, TX Richard F. Daines. “They… desperately need the support of academic training.”27 n niversity at Albany SUNY School of Public U Health, Albany, NY Some PERLCs are expanding on schools’ exist- ing work. For instance, at Harvard, the PERLC n niversity of Alabama at Birmingham School U replaces the Harvard Center for Public Health of Public Health, Birmingham, AL Preparedness, which began in 2002. Over the n University of Arizona College of Public last nine years, the center has trained nearly Health, Tuscan, AZ 33,000 students and organized drills and exer- cises involving more than 6,000 public health n niversity of Illinois at Chicago School of U officials.28 Over the past decade, Columbia Uni- Public Health, Chicago, Illinois versity’s PERLC, the Columbia Regional Learn- n niversity of Iowa College of Public Health, U ing Center (CRLC), has trained 100,000 public Iowa City, IA health workers across the country. Because the center uses online training for many of its n niversity of Minnesota School of Public U classes, a significant number of these workers Health, Minneapolis, MN are outside the school’s immediate area.29 n niversity of North Carolina Gillings School U CDC originally announced that the centers would of Global Public Health, Chapel Hill, NC be funded for five years. But in the FY 2011 fed- n niversity of Oklahoma College of Public U eral budget, the PERLC budget was reduced by Health, Oklahoma City, OK 30 percent. The Academic Centers for Public Health Preparedness, which include the PERLCs n niversity of South Florida College of Public U and Preparedness and Emergency Reseponse Re- Health, Tampa, FL search Centers (PERRCs), are scheduled for $10 n niversity of Washington School of Public U million in additional cuts in FY 2012.30, 31 Health, Seattle, WA 15 E. eparedness and Emergency Response Research Pr Centers: Nine Universities At Risk to Lose Funds from Cuts to the Program One of the major ongoing gaps in preparedness ters and emergencies, and then to translate that is understanding ways to measure standards and knowledge into practical guidelines that can be create performance metrics. adopted by public health departments across the country. In 2008 and 2009, CDC awarded $13.6 million to nine schools of public health around the Each center is undertaking three or four re- country to help them form Preparedness and search projects, focusing on a different area of Emergency Response Research Centers (PER- study. The research topics, which have been RCs).33 The goal of these centers is to study key recommended by the Institute of Medicine questions about how best to respond to disas- (IOM), include: School Research Priority Award Emory University (Atlanta, GA) Create and maintain sustainable preparedness and $1,562,676 response systems Harvard University (Boston, MA) Generate criteria and metrics to measure effectiveness $1,717,286 and efficiency Johns Hopkins University Preparedness to address the risks of vulnerable populations $1,495,398 (Baltimore, MD) University of California (Berkeley, CA)* Achieve public health and community readiness for today’s $1,506,306 challenges and future threats University of California* Preparedness and Emergency Response Centers: A public $1,193,365 (Los Angeles, CA) health systems approach University of Minnesota (Minneapolis, Enhance the usefulness of training $1,470,307 MN) University of North Carolina Create and maintain sustainable preparedness and response $1,695,189 (Chapel Hill, NC) systems University of Pittsburgh (Pittsburgh, PA) Create and maintain sustainable preparedness and response $1,701,845 systems and generate criteria and metrics to measure effectiveness and efficiency University of Washington (Seattle, WA) Improve communications in preparedness and response $1,270,632 *Funded FY 2003-2013 Source: http://www.cdc.gov/phpr/documents/science/PERRC_Fact_Sheet.pdf So far, the research has resulted in the budget significantly cuts funding for PERRCs.36 publication of 64 peer-reviewed articles.34 Depending on how CDC allocates cuts to the PERRCs and PERLCS, any of the nine research For FY 2011, CDC cut the overall PERRC budget centers could be eliminated in 2012. by approximately 40 percent.35 The FY 2012 16 F. ational Center on Environmental Health (NCEH) N and Agency for Toxic Substances and Disease Registry (ATSDR) Program: Comprehensive Response Capabilities for Nuclear Detonation, Radiological Attacks, Chemical Attacks and Natural Disasters At Risk The National Center for Environmental Health budget, the agency would need to prioritize and the Agency for Toxic Substances and Disease where internal resources should be targeted. Registry (NCEH/ATSDR) lead CDC in developing CDC officials have indicated that support for national, coordinated, science-based responses to preparedness activities at NCEH/ATSDR, like deal with the health concerns resulting from envi- support for other CDC preparedness programs ronmental threats. Environmental health threats addressing infectious diseases, mass trauma, and comprised eight out of 15 “all-hazard” planning other threats, could be eliminated in order to scenarios that were released in 2005 for use in na- provide sufficient resources to other priorities. tional, federal, state and local homeland security Without these funds, CDC would have limited preparedness activities including: capability to assist all 50 states and Washington, D.C. in the response to natural disasters or with n uclear detonation; N incidents involving toxic substance releases or ra- n adiological attacks or accidents; R diological exposures through contamination as- sessments, field investigations and issuing expert n hemical attacks or accidents, including blis- C guidance on protective actions. ter agents, toxic industrial chemicals, nerve agents and chlorine explosions; and In addition, if the approximately $1.7 million in preparedness funding for poison center (PC) n atural disasters, including major earth- N surveillance was cut, it would mean: quakes and hurricanes.37 n ll national surveillance efforts for chemical A These scenarios were “designed to be the foun- and radiological exposures and illness would dational structure for the development of na- stop (there is currently no alternative system tional preparedness standards from which available which could replace this); homeland security capabilities can be measured because they represent threats or hazards of na- n CEH-CDC would no longer be able to N tional significance with high consequence.”38 honor requests for assistance from other Additionally, natural disasters to date have Departments, including DHS, and Agencies, caused more fatalities and destruction in the FDA, EPA in particular, with regard to poison United States than any others. center data in a public health emergency; In FY 2011, NCEH received around $2.7 mil- n aintenance and support would cease for M lion to support emergency preparedness and re- the web-based National Poison Control Data sponse activities. In addition, in FY 2011, NCEH System (NPDS) services used by state public received $3.5 million in support from CDC’s Of- health departments and BioSense agencies; fice of Public Health Preparedness and Response n aintenance and support of PC upload of M (OPHPR) for activities related to radiological data to NPDS would cease; emergency preparedness and response and $2.3 million from OPHPR for maintaining and en- n CEH-CDC would lose their unrestricted access N hancing CDC radiological laboratory capacity to to the national poison center database; and respond to a radiological or nuclear emergency. n CEH-CDC would no longer be able to per- N NCEH/ATSDR has led CDC’s response to the form customized, incident-specific surveil- public health challenges of diverse environmen- lance for exposures and illness from a public tal emergencies. These include the Deepwater health threats where this has been utilized in Horizon oil spill, the Fukushima nuclear power the past such as carbon monoxide poison- plant disaster, and every hurricane response in- ing from hurricanes, oil exposures from the cluding major disasters such as Katrina (2005) Deepwater Horizon incident, adverse effects and Gustav and Ike (2008). With cuts proposed from medical countermeasures used during to CDC’s preparedness activities in the FY 2012 the 2011 Japan nuclear incident. 17 Officials Voice Concern Over Preparedness Spending Cuts In a September 2011 commentary in the British At the same time, he said, recent funding cuts, medical journal The Lancet, Ali S. Khan, M.D., driven by the economic crisis as well as political M.P.H, director of CDC’s OPHPR, noted that considerations, have threatened these develop- state and local health departments had lost more ments. He noted that a 2009 survey found that than 44,000 jobs between 2008 and 2010. Since 35 percent of state epidemiologists reported then, the number as risen to nearly 50,000. that they did not have substantial-to-full capacity Khan wrote that “(s)tates cannot adequately for an emergency response to a bioterror attack meet everyday needs, let alone increased efforts — a 10 percent increase since federal prepared- for emergency incidents that have potential na- ness funding hit a peak seven years ago.41 tional implications, without reliable, dedicated, or In the same issue of The Lancet, two New York sustained federal funding. Because all responses City Health Department officials authored a are initially local, this limitation is the primary vul- commentary on how their agency has improved nerability to national preparedness.”39 its disaster response abilities.42 Thomas A. Far- Khan argued that in the aftermath of the Sept. ley and Isaac Weisfuse, both of the New York 11, 2001, terrorist attacks and the anthrax at- City Department of Health and Mental Health tacks later that year, the country realized that it (DHMH), write that over the past decade, the wasn’t properly prepared for such events. Since agency has taken several key steps. It has: then, federal, state and local governments have n Created a volunteer Medical Reserve Corps, taken important steps to improve their capacity made up of 9,000 medical professionals, who to respond to attacks and disasters:40 can help the city during emergencies; n In 2006, Congress passed the Pandemic and n Established a formal incident command system, All-Hazards Preparedness Act (PAPHA), which gives all of the agency’s 6,000 workers which created a comprehensive framework specific responsibilities during an emergency; for dealing with threats; n Set up two emergency operations centers at differ- n Increased federal funding helped improve epi- ent sites, in case one is unusable in a disaster; and demiological capacity, as well as the stockpile n eveloped an electronic medical surveillance D of medicines to respond to specific threats, system that includes almost all city hospital including anthrax, smallpox, tularemia, and emergency departments.43 some chemical and nerve agents; The authors single out two areas in which the n CDC funding expanded the network of disaster community must improve: strategies for laboratories that analyze and diagnose cleaning up anthrax from the environment, and bioterrorism agents as well as naturally how to most efficiently distribute medicine to occurring hazardous microbes; and large populations during a disaster or epidemic. n CDC now has a cutting-edge emergency In another September commentary in the Journal operations center; 10 years ago, it had only a of the American Medical Association, Thomas V. makeshift center. Inglesby of the Center for Biosecurity of the Uni- Khan said that these improvements in prepared- versity of Pittsburgh Medical Center agreed that ness have helped public health departments’ disaster preparedness had improved significantly ability to respond to a range of emergencies. over the past decade, largely because the federal He noted that in 2009, CDC and other groups government increased funding.44 He also noted responded effectively to the discovery of the that social media, including Facebook and Twitter, H1N1 flu strain, quickly developing a vaccine. have played a key role in helping both the public and responders share information quickly. He also pointed out that the increased capacity helps in public health departments’ routine opera- At the same time, he wrote, the disaster re- tion. “The US Government is increasingly recog- sponse community must continue to hone its nising [sic] that preparedness and core (routine) strategies and provide adequate funding.45 investments in public health are synergistic,” he “Commitment to a stable level of investment in wrote. “Large-scale and unpredictable natural, ac- disaster preparedness at the federal, state, and cidental, or intentionally caused disease outbreaks local levels is needed,” he wrote. “The gains of and environmental disasters need many of the the last 10 years are now at risk with this de- same routine surveillance, laboratory, risk commu- creased funding and will be further threatened if nication, and other core public health systems.” resources continue to decline.”46 18 EXPERT COMMENTARY Components of a System Put to the Test: A Look at North Dakota’s Public Health Preparedness System By Tim Wiedrich, Section Chief Emergency Preparedness and Response Section, North Dakota Department of Health T o safeguard the public’s health and ensure public safety, North Dakota has built an integrated preparedness system that features six main components. These components are the North Dakota has also built a statewide Health Alert Network Notification System that ensures public health departments and the medical community share information rapidly. result of a strategic approach to preparedness focusing on an Our command and control systems allow responders to take all-hazards approach. action on a common operating picture, which is shared through The investments in public health and preparedness over the the statewide tactical communications, to coordinate operations last decade have helped us develop our preparedness systems among a variety of different responders in different locations. and these components. These investments have been critical Component 3: State Medical Cache for building capabilities and capacity. As the economic situation Much like the Strategic National Stockpile, North Dakota has a continues to worsen, the potential for further funding cuts could state medical cache that includes: put these advancements at significant risk. n arehouse and delivery; W Component 1: Statewide Tactical Communications North Dakota has a secure and redundant wide-area network n Pre-hospital stabilization and staging, which include trailer- that includes a variety of technologies (video conference, data, based kits that feature ten beds that can surge to 20; Voice Over IP, teleconference, web streaming and others) to n State medical shelters for low acuity patients; connect public health, hospitals, long-term care facilities and emergency medical services (EMS). n Ancillary medical equipment; We also have wireless routers in every hospital and trailer-based n Bus conversion kits, which ensure transport for wheelchairs (which includes satellites, VHF public safety, VHF repeaters and and stretchers; and cell phone repeaters) and kit-based (which includes Satellite-Bgan n Tent sheltering. with data and voice, public safety radios with VHF and commer- cial wireless with data and voice) communication systems. Our state’s warehouse and delivery system is a 23,000 square foot facility that houses medical supplies, pharmaceuticals, wrap-around To truly be prepared, responders must be able to communicate supplies and equipment and other public health emergency essen- with each other during public health emergencies. North Dakota tials. The entire cache is standardized, palletized and deliverable by strategically created flexible communications channels that can cargo. Supplies and equipment are ordered by medical and public be utilized during any kind of emergency. Through our statewide health providers through an online ordering process. tactical communications component, everyone involved in public health preparedness shares a common operating picture and can We can quickly transport medicines, materials and people across stay in contact no matter the emergency. the state during an emergency through our state medical cache. Component 2: Command and Control Component 4: Just-in-Time Training The North Dakota Department of Health, like most other state North Dakota has the ability to reach out to the medical com- health departments, has an emergency operations center. Our munity and distribute educational information and rapidly teach operations center houses a trained staff of 50 personnel who them techniques and information they need using our just-in- undergo quarterly training programs. In addition, the depart- time training component. For example, in 2002, the federal gov- ment is committed to the National Incident Management Sys- ernment initiated a smallpox vaccination program to inoculate tem (NIMS), which ensures public health proactively works with key medical and public health responders. Because smallpox other parts of government, nongovernment organizations and vaccination had not been done for several decades, medical the private sector to respond to emergencies. professionals were no longer familiar with the technique. Just- in-time training delivered through a distance learning system Through our statewide situational awareness, each aspect of an provided an effective mechanism to rapidly build this capability. emergency response is integrated and connected; for example, The just-in-time distance learning system includes live and ar- from the vehicle (such as ambulances) and staff staging areas to chived web/video conference capabilities that can be broadcast the sending facility to the receiving facility. Every part of the staff, through dedicated wide area networks, the public internet and patient, transportation and destination is tracked step by step public access television. through command and control. 19 EXPERT COMMENTARY continued North Dakota’s Public Health Preparedness System Component 5: Planning and Response Contracts gate the issues. For example, vaccine distribution relied on our North Dakota has created and entered into planning and re- state tactical communication systems and command and control sponse contracts that determine, in advance, important aspects to distribute the state medical cache. of emergency response. This includes things like medical shel- The flooding in 2009 was labeled as the “500-year flood.” How- ters, pharmaceutical and transportation access, services and ever, our weather patterns in 2010 aligned in the same way many other aspects. as the previous year creating another substantial spring flood The planning contracts have been made with local public health threat. The entire state received heavy snowfall, but an almost departments, the Long Term Care Association and the Hospital perfect spring thaw allowed us to escape serious spring flood- Association. Response contracts also exist with EMS, universi- ing. In 2011, we were not as lucky. Flooding and flood threats ties, bus companies, pharmaceutical distributors and medical occurred on three major river systems. On the east side of the supply and equipment distributors. state, substantial flooding and flood threats were occurring on the Red River. At the same time, there was another flood threat During emergencies, the contracts are activated to obtain the hundreds of miles away on the Missouri River in the central part resources required to respond. of the state near Bismarck. Component 6: Medical Reserve Corps, Emergency Then a third river system, the Souris, was overwhelmed. The System for Advanced Registration of Volunteer Health river, which begins in Canada and goes through Minot and other Professionals (ESAR-VHP) communities, experienced devastating flooding. The hospital In North Dakota, the Medical Reserve Corps and ESAR-VHP are systems were hardened so that evacuation of the hospital was a single statewide system. The system has credentialed more not necessary, but a large long-term care facility and over 11,000 than 800 medical professionals and has the capability of notify- people in Minot needed to evacuate. The flooding river cut the ing all 17,000 licensed medical providers in the state to rapidly city in half and isolated many citizens from medical facilities. The credential and deploy personnel. North Dakota state law estab- local hospital stood up a temporary emergency department and lished a single ESAR-VHP registry operated by the state health clinic on the north side of the city using the state medical cache. department and provides tort protection when medical provid- ers are activated under the auspices of the state response system. During the flood responses for all three river systems, we leaned on transportation agreements to get supplies, people and materi- als to those who in the impacted areas. In total, about 7,000 homes Our Preparedness System, Tested flooded. The health and medical response to these devastating Beginning in 2009, these systems were put to substantial test. floods was successful in large part because of the planning, pro- cesses and systems that have been developed and implemented In 2009, North Dakota experienced extensive flooding along the through the public health and medical preparedness programs. Red River, which impacted Fargo, Valley City and other com- munities in the eastern part of the state. The flooding required public health to create a major evacuation process for thousands Moving Forward of hospital patients, long-term care residents and other vulner- The last three years have validated our preparedness system. It able populations. The evacuation included movement of these has proven to be robust, flexible and effective. However, it is in groups across a three-state area. significant danger of eroding. As we learned in 2011, emergen- The difficulty of the response was exacerbated by an incredible cies can occur simultaneously hundreds of miles apart. spring blizzard that hit the interstate roads and closed down If preparedness funding continues to deteriorate, it is clear that traffic during the evacuation. We relied on our systems to go major portions of our system will be threatened and lost. If I beyond what our initial plan had contemplated to press other look at our six components, there is not one component that types of evacuation processes. We worked with the private sec- can be sacrificed and still maintain an effective system. tor to secure commercial airplanes to transfer people. Delta/ Northwest provided two large commercial aircrafts to do mul- As most states have done over the last decade, North Dakota tiple round trips. has built strong and effective preparedness systems that have been put to the test many times and will continue to be tested Immediately after the flooding subsided, Influenza A (H1N1) was by Mother Nature, pandemics and humans. Preparedness is not spreading across North America. Obviously, this presented a far something you can buy once and put on the shelf, it needs to be different public health emergency. However, at the end of the updated, supported and maintained. day, the same six components were utilized to manage and miti- 20 State and Local Public Health Funding Cuts F orty states decreased their public health budgets from FY 2009-10 to FY 2010-11, 29 states decreased budgets for a second year in a row, and 15 for 2 Section three years in a row. In FY 2010-11, the median state funding for Every state allocates and reports its budget in dif- public health was $30.09 per capita, ranging ferent ways. States also vary widely in the budget from a high of $154.80 in Hawaii to a low of details they provide. This makes comparisons $3.45 in Nevada. across states difficult. TFAH conducts an annual analysis that examines state budgets and appro- From FY 2008 to FY 2011, the median per capita priations bills for the agency, department, or di- state spending decreased from $33.71 to $30.09. vision in charge of public health services, using While most preparedness specific funding a definition as consistent as possible across the comes from the federal level, the federal invest- two years, based on how each state reports data. ment assumes and builds on a core capacity at TFAH defined “public health services” broadly, the state and local level. State budget cuts are including most state-level health funding. undermining core public health capacities. 10 states increased or maintained level funding for 40 states and D.C. DECREASED funding for public public health services from FY 2009-10 to FY 2010-11 health services from FY 2009-10 to FY 2010-11 State and percent increase (adjusted for inflation) State and percent decrease (adjusted for inflation) Alaska (11.2%)2 North Dakota (17.9%)3 Alabama (-0.4%)Nebraska (-3.4%) Arkansas (1.8%)Ohio (7.2%) Arizona (-0.1%)^Nevada (-4.6%)* Florida (3.9%)2 Tennessee (0.2%) California (-5.1%)^New Hampshire (-9.4%)4 Indiana (1.4%) Wisconsin (2.9%) Colorado (-1.3%)*New Jersey (-15.8%)^ Louisiana (1.9%) Connecticut (-8.4%)2, *New Mexico (-11.7%)4, * Michigan (0.4%)3 Delaware (-28.0%)2, *New York (-2.4%)* D.C. (-19.5%)4, *North Carolina (-3.2%)2, ^ Georgia (-15.7%)*Oklahoma (-10.6%)1, * Hawaii (-17.2%)2 Oregon (-18.1%)* Idaho (-1.2%)*Pennsylvania (-6.1%)2, ^ Illinois (-8.9%)* Rhode Island (-2.3%)4, ^ Iowa (-16.2%)4, *South Carolina (-19.2%)^ Kansas (-3.0%)^South Dakota (-4.9%)4 Kentucky (-7.0%)Texas (-1.6%) Maine (-14.2%)2 Utah (-1.6%)4, ^ Maryland (-5.7%)2, 4, ^ Vermont (-10.1%)4, * Massachusetts (-6.2%)^ Virginia (-5.1%)3, ^ Minnesota (-6.5%)2, ^ Washington (-2.1%)3 Mississippi (-13.2%)2, ^ West Virginia (-2.4%) Missouri (-28.5%)* Wyoming (-0.6%)^ Montana (-7.5%) NOTES: were given until November 18, 2011 to confirm or correct the Biennium budgets are bolded. information.  The states that did not reply by that date were 1 May contain some social service programs, but not Medicaid or CHIP. assumed to be in accordance with the findings. 2 General funds only. * Budget decreased for second year in a row 3 Budget data taken from appropriations legislation. ^ Budget decreased for third year in a row 4 State did not respond to the data check TFAH coordinated Source: Research by TFAH of publicly available state budget documents with ASTHO that was sent out October 26, 2011.  States and communications with health and budget officials in the states. 21 The following states’ budgets went down for the second year in a row: Colorado, Connecticut, Delaware, D.C., Georgia, Idaho, Illinois, Iowa, Missouri, Nevada, New Mexico, New York, Okla- homa, Oregon and Vermont. The following states’ budget went down for the third year in a row: Arizona, California, Kansas, Maryland, Massachusetts, Minnesota, Missis- sippi, New Jersey, North Carolina, Pennsylvania, Rhode Island, South Carolina, Utah, Virginia and Wyoming. Public health funding is discretionary spending in most states and, therefore, is at high risk for significant cuts during economic downturns. While few states allocate funds directly for public health preparedness, state and local funding is essential for supporting public health infrastruc- ture and core capacities of health departments. Several states in this analysis that are identified as increasing or maintaining spending may not have actually increased their spending on pub- lic health programs; this can just be a reflection of how that state reports their budget. For in- stance, some states include federal funding in the totals or public health dollars within health care spending totals, such as the state share of Medicaid or mental health expenditures, which makes it very difficult to determine “public health” as a separate item. For additional information on the methodology of the budget analysis, please see Appendix B: Data and Methodology for State Public Health Budgets. Public Health Accreditation In September 2011, the Public Health Accreditation In a time of budget cuts, accreditation can help Board (PHAB) launched the first national accredita- determine when cuts are having an impact on tion program for all public health departments.47 the core standards and capabilities of public health departments. “With shrinking budgets The goal of accreditation is to set standards and and a growing number of health challenges to measures for public health departments, includ- address, there has never been a more important ing in key areas related to preparedness. time for public health departments to focus on According to Kaye Bender, RN, PhD, FAAN, the best and most efficient ways to keep people President and CEO of the Board, “PHAB’s vi- healthy,” according to James Marks, M.D., MPH, sion for accreditation is to create a reliable na- Senior Vice President and Director of the Rob- tional standard for public health. PHAB supports ert Wood Johnson Foundation’s Health Group. health departments in achieving this standard by recognizing the important work they do and by providing support to improve their services.” 22 LOCAL HEALTH DEPARTMENTS CUTS A recent study conducted by the National Association of LHDs continue to struggle with budget cuts. In July, 2011 County and City Health Officials (NACCHO) found significant nearly half of LHDs reported reduced budgets, which is in ad- cuts to programs, workforce and budgets at local health de- dition to 44 percent that reported lower budgets in November partments (LHDs) around the country. 2010.50 In addition, more than 50 percent of LHDs expect cuts to their budgets in the upcoming fiscal year. Since 2008, LHDs have lost a total of 34,400 jobs due to lay- offs and attrition.48 Combined state and local public health job losses total 49,310 since 2008.49 City and County Managers Outline Keys To Disaster Preparedness In September 2011, city and county managers, who oversee Communication: and coordinate jurisdiction-wide responses that encompass a n uring a disaster, frequent communication with the public D range of aspects beyond public health, outlined key aspects of is essential. preparedness from their perspective at the annual conference n t is especially crucial to communicate frequently with I of the International City/Management Association (ICMA).51 the disabled community, as well as with the elderly and Five panelists who represent different types of communities people with children. — Ron Carlee, COO of the ICMA, who, managed Arlington n uring emergencies, Twitter and other social media tools D County, Virginia, during the September 11 attacks; William can help keep the public informed. Fraser, city manager of Montpelier, Vermont; Aden Hogan, city manager of Evans, Colorado,  and former assistant n Especially in smaller communities, disaster response of- city manager of Oklahoma City, Oklahoma during the ficials should be prepared to act as direct communicators 1995 bombing; Elizabeth Kellar, President and CEO of the with the public. Center for State and Local Government Excellence; and Ken n t is important to manage not only those affected directly I Pulskamp, city manager of Santa Clarita, California — identified by the disaster but also the “worried well” who can ei- the following key components to effective disaster response: ther help or hinder a response depending on how they General Planning and Preparation: are supported. n Every disaster is local, and local governments should be What Residents Should Know: prepared to respond in partnership with states. n Authorities may not be able to offer help for 72 hours. n Many communities, especially smaller ones, have difficulty Residents should know that they may have to rely on planning for emergencies. But preparedness is essential. their own resources for that time; they should know their neighbors, be able to turn off water and gas lines, and have n The first few hours after a disaster are crucial. stockpiles of essential supplies such as food, water and bat- n educe disaster responsibilities to checklists. On the day R teries. They should also consider buying a generator. of an emergency no one has time to read pages of text. n The public should know to pay close attention to official n Have a plan, but be flexible. The disaster rarely plays out ex- warnings. Often people don’t take these alerts as seri- actly according to the plan. Be prepared to adjust on the fly. ously as they should. n t is impossible to plan for every contingency. Plan for I n Residents should plan for road closings and major traffic, what is probable. A careful plan that activates resources and should prepare alternate routes to and from home, can be effective in many contexts. work and school. n Have a plan to make use of residents who want to volunteer Challenges: during and after the disaster. This can be a key resource. n Recent federal, state and local budget cuts have put a strain on local preparedness efforts to communicate with n Collaboration between departments, and between neigh- the public in a timely manner to mount the most effective boring jurisdictions, and with state and federal partners, response as well as to engage partners in a coordinated, is critical.  It is very important to practice joint response strategic and as immediate response as possible. strategies with these partners. 23 WMD Commission Report Finds United States Vulnerable to Bioterror A new report, released October 2011, by the n The Department of Health and Human Ser- Bipartisan Weapons of Mass Destruction (WMD) vices (HHS) has not yet developed a set of Terrorism Research Center, headed by former goals for research, product requirements and U.S. Senators Jim Talent (R-MO) and Bob Graham dispensing countermeasures to civilian popu- (D-FL), found the United States is not prepared for lations and is not coordinating these priorities a bioterror attack, particularly a large-scale event.52 with the Department of Defense. Eleven of the nation’s top biodefense experts n hile the government has built up the Stra- W participated in the Bio-Response Report Card tegic National Stockpile (SNS), it has not paid and gave different aspects of the response enough attention to how it will deliver the grades ranging from Bs to Fs. medicines during an attack. The higher grades were awarded to the ability n The usefulness of BioWatch, which is de- to respond to small-scale non-contagious and signed to provide early warning of a bioterror contagious events, but dropped for larger-scale, attack, remains unclear. drug-resistant and global health crises. n The country’s health system is not equipped The lowest grade for capability across all of the to handle the surge of patients that would response scenarios was for “attribution,” which follow a large-scale attack. Current surge is the ability to identify the source of the attack capacity may be as much as 50 times below which is important for determining who is re- what might be needed. sponsible for the attack and how to halt follow- n ery few of the recommendations developed V up attacks if need be. Communication among by the federally appointed National first responders and stakeholders received the Commission on Children and Disasters have highest marks across the types of attacks. been implemented or funded. Children The ability to detect and diagnose biological events, represent one of the largest vulnerable and the availability and ability to distribute vaccines or special needs populations in the U.S.; failure other medicines, and medical management grades to understand and accommodate special were higher for the smaller-scale events and sig- needs becomes a crisis in any major disaster. nificantly lower for larger-scale events. The overall n Most individual citizens are not prepared ability of the country to develop and approve vac- for a bioterror attack and don’t understand cines and drugs received a D. basic medical facts about the most likely Some of the report’s top findings and conclusions bioterror agents. include: n The government has no plan for cleaning n A scientifically and legally validated attribution “ up a large area after an attack with a non- capability [the ability to identify the source of contagious agent such as anthrax. While an attack] does not yet exist for anthrax or vir- small-scale cleanup plans do exist, they are tually any other pathogen or toxin.” not likely to be applicable to a larger area. n The Biomedical Advanced Research and n The federal government has no plan, and Development Authority (BARDA), which en- provides little guidance, on local or regional courages the private sector to develop coun- evacuation following an anthrax attack or termeasures, is significantly underfunded and the detonation of an improvised nuclear is not spurring necessary innovation. device (IND), among other potential large- scale disasters. n The country has adequate doses of smallpox vaccine and antibiotics for anthrax, but it doesn’t have adequate countermeasures for the viral dis- eases known collectively as hemorrhagic fevers. 24 A Decade of Public Health Preparedness T en years ago, the September 11th and anthrax tragedies clearly demonstrated that the public health system was not prepared for the range of modern 3 Section health threats we face. Since then, significant investments have resulted in the country being much better prepared to respond to public health emergencies ranging from threats of bioterrorism to major infectious disease outbreaks like a pandemic flu to natural disasters like hurricanes, tornadoes and floods. Since 2003, in the annual Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism, TFAH has documented progress and ongoing vulnerabilities in the nation’s ability to respond to health crises. A. Progress in Preparedness since 2001 Since 2001, major investments in improving pre- turing; the SNS; pharmaceutical and medical paredness have led to significant improvements equipment distribution; surveillance; communi- in preparedness planning and coordination; cations; legal and liability protections; increas- public health laboratories; vaccine manufac- ing and upgrading staff; and surge capacity. 25 MAJOR AREAS OF IMPROVEMENTS Planning and n In June 2002, Congress passed the Public Health Security and Bioterrorism Response Act of 2002, which Coordination included cooperative agreement funding support for states around the country. In 2006, Congress reauthorized the legislation as the Pandemic and All-Hazards Preparedness Act (PAHPA). Congress is considering reauthorization of the bill in 2011. n Homeland Security Presidential Directive-21 (HSPD-21) was issued in 2007 setting a National Strategy for Public Health and Medical Preparedness. n Release of the National Health Security Strategy in 2009. n Creation of the IOM Forum on Medical and Public Health Preparedness for Catastrophic Events. n All 50 states and Washington, D.C. completed initial bioterrorism response plans by September 2003. n The federal government created a comprehensive National Strategy for Pandemic Influenza, involving all federal agencies and partners within state and local governments, businesses, and communities around the country. President Bush requested and Congress appropriated more than $6 billion to support the national strategy, and another $7.7 billion was provided to help respond to the H1N1 pandemic flu outbreak. n All 50 states and Washington, D.C. developed pandemic flu plans that were reviewed by HHS before the 2009 outbreak of H1N1. In 2003, only 13 states had pandemic flu plans. n 44 states and Washington, D.C. activated their Emergency Operations Center (EOC) a minimum of two times in a year as of 2008.*** n 44 states and Washington, D.C. reported that pre-identified staff were able to acknowledge notification of emergency exercises or incidents within a target time of 60 minutes at least twice as of 2008.*** n 48 states and Washington, D.C. developed at least two After-Action Reports/Improvement Plans within 60 days of an exercise or actual incident as of 2008.*** n All 50 states and Washington, D.C. reported conducting an emergency preparedness drill or exercise that included both the health department and the National Guard as of 2007. Public Health n 7 states reported having enough staffing capacity to work five, 12-hour days for six to eight weeks in response 4 Laboratories to an infectious disease outbreak, such as novel influenza A H1N1 from August 10, 2009 to August 9, 2010. n 49 states and Washington, D.C. increased or maintained their Laboratory Response Network for Chemi- cal Threats (LRN-C) chemical capacity from August 10, 2009 to August 9, 2010. In 2005, only 10 state public health labs had adequate chemical terrorism response capabilities. n By 2007, 44 states and Washington, D.C. reported sufficient bio-testing capabilities, an increase from 6 in 2003. n In 2007, only one state and Washington, D.C. reported their labs did not have the capability to provide 24/7 coverage to analyze samples. n By 2006, 47 states reported having sufficient numbers of trained scientists to test for possible anthrax and plague, an increase from 10 in 2004. Vaccine n Congress appropriated billions of dollars through Project BioShield and BARDA to invest in vaccine Manufacturing research and development, but there are still limited financial and business incentives for companies to pursue research and development. n BARDA awarded a contract to develop the first cell-based flu vaccine. Strategic National n The SNS has been substantially upgraded to maintain a variety of critical pharmaceuticals and medical Stockpile (SNS) supplies including antibiotics, chemical nerve agent antidotes, antiviral drugs, pain management drugs, vaccines for a number of agents, and radiological countermeasures. The SNS is positioned in undisclosed locations throughout the United States and is configured to provide flexible response strategies. n In advance of the H1N1 outbreak, the SNS contained pandemic flu countermeasures, including 50 million antiviral treatment courses, 105.8 million N95 respirator masks and 51.7 million surgical masks. Pharmaceutical n All 50 states and Washington, D.C. have adequate plans to receive and distribute supplies from the SNS and Medical based on a CDC evaluation of planning and management. In 2003, only two states had adequate plans Equipment according to CDC. Distribution n 47 states and Washington, D.C. increased vaccination rates for seniors against the seasonal flu from 2008 to 2009. In 2006, only 38 states increased rates from the year before. 26 MAJOR AREAS OF IMPROVEMENTS Surveillance n 44 states and Washington, D.C. reported using a disease surveillance system that is compatible with CDC’s National Electronic Disease Surveil- lance System (NEDSS), as of 2009. In 2004, only 18 states had disease surveillance systems that were NEDSS-compatible. n 43 states and Washington, D.C. can send and/or receive electronic health information with health care providers.** n 40 states and Washington, D.C. have an electronic surveillance system that can report and exchange information.** n 29 states were able to rapidly identify disease-causing E.coli O157:H7 and submit the lab results in 90 percent of cases within four days.*** n CDC, in partnership with state and local health agencies, was able to provide real-time summarized daily data for flu surveillance ahead of the second wave of the H1N1 flu outbreak in the fall of 2009. n By working with state health departments, CDC was able to provide weekly surveillance summaries of oil spill-related health complaints from the affected Gulf states following the 2010 Deepwater Horizon oil spill. Communications and n 25 states and Washington, D.C. mandate all licensed child care facilities to Community Resiliency have a multi-hazard written evacuation and relocation plan. n PAHPA, HSPD-21 and the National Health Security Strategy make community resiliency a top priority of preparedness. n The Long-Term Disaster Recovery Group, composed of the Secretaries and Administrators of more than 20 federal departments, agencies and offices, was created in 2009 to strengthen disaster recovery and help communities recover more quickly and effectively after emergencies. Legal and Liability n Every state had adequate statutory authority to implement quarantine in Protections response to a hypothetical bioterrorism attack as of 2005. n By 2009, at least 33 states had liability protection for entities or organizations that provide volunteer assistance during emergencies. Increasing and n All 50 states and Washington, D.C. met three key criteria for the Medical Upgrading Staff and Reserve Corps (MRC) (having a coordinator, a majority of units in the Volunteer Health state meeting incident management guidelines, and the majority of units Responders are part of a registry). The MRC is a national network of community- based groups which engage volunteers to strengthen public health emergency response and community resilience. In 2007, 13 states did not meet a minimum threshold for MRC volunteers for every 100,000 citizens. In 2008, 16 states did not have MRC coordinators. Surge Capacity n n 2002, the National Bioterrorism Hospital Preparedness Program — I renamed the Hospital Preparedness Program (HPP) in 2006 — was created and has provided around $400 million annually to support hospital preparedness and surge capacity development. n In 2009, the IOM published Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report, which included a five- step process for emergency planners to follow when developing crisis standards of care. Source: TFAH’s Ready or Not reports, data from 2003-2010. ** Source: ASTHO Profile Survey, data from 2010. *** Source: CDC’s Strengthening the Nation’s Emergency Response State by State Report, data from 2007-08. 27 B. Ongoing Gaps in Preparedness The United States often takes a band-aid ments. However, it was not at a sufficient level approach to public health preparedness. As to backfill long-standing gaps in infrastructure new emergencies and concerns emerge and or update technologies to meet state-of-the-art attention shifts, resources are often diverted standards to protect the public’s health. from one pressing priority to another, leaving There is a new threat to preparedness and con- other ongoing areas unaddressed. sequently to the public’s health and safety: the After September 11th and the anthrax attacks, current economic climate and budget cuts at the the federal government made an unprece- federal, state and local level mean that the prog- dented investment to quickly shore up areas of ress made over the past decade could be lost. preparedness, which have led to major improve- MAJOR ONGOING GAPS A Funding Gap Historically, funding for emergencies is often substandard until there is an actual emergency, and then there is a call for emergency supplemental support. This dynamic means the country is often unprepared to immediately respond during crises. The current economic difficulties have led to major cuts in federal, state and local support for public health and preparedness, leaving Americans more vulnerable during emergencies. The economic impact of a disaster can also be more significant if the community cannot return to normal after an event. Adequate preparedness allows for a strong and more timely recovery. n tate cuts: 40 states and Washington, D.C. cut funding for public health from S fiscal year (FY) 2009-2010 to 2010-2011, 30 of these states cut funding for a second year in a row. According to the Center on Budget and Policy Priorities (CBPP), states have experienced overall budgetary shortfalls of $425 billion since FY 2009.53 n Local cuts: Since 2008, 34,400 local public health jobs have been lost, and in the past year, close to half of all local public health departments reported reducing or cutting at least one program altogether;54 n ederal cuts: Between FY2005 and 2011, federal support for state and local F public health preparedness, including the PHEP cooperative agreements was also cut by 38 percent. Since FY 2010, the grant program will have sustained a $72 million cut. A Workforce Gap There is already a major shortage of trained public health workers and funded positions. There are not enough workers, particularly experts, to effectively respond during public health emergencies. The United States has 50,000 fewer public health workers than it did 20 years ago, and one-third of public health workers will be eligible to retire within five years.56, 57 As baby boomers begin to retire, there is not a new generation of workers being trained to fill the void. Also, under current policies and, in some cases, public health workers in one area are not allowed to be shifted to help in other areas, even during emergencies. The recent budget cuts are intensifying the problem, with a reduction of 15 percent of the local public health workforce since 2008, and, at the same time, health departments around the country are experiencing furloughs or shortened work weeks. 28 MAJOR ONGOING GAPS A Surge Capacity In the event of a major disease outbreak or attack, the health care system is Gap stretched beyond normal capabilities. Surge capacity, the ability of the medical system to care for a massive influx of patients, remains one of the most serious challenges for emergency preparedness. A large-scale disaster also requires having enough equipment and appropriate space to treat patients. There are numerous ongoing surge capacity issues related to response in primary care settings beyond just hospitals, including crisis standards of care, alternative care sites, coordinating volunteers to help and providing them with adequate liability protection and regional coordination among health care facilities. A Surveillance Gap The United States still lacks an integrated, national approach to biosurveillance — which would dramatically improve response capabilities ranging from a bioterrorism attack to catastrophic disasters to contamination of the food supply. There is not a standardized, interoperable system using up-to- date technology. Currently, there are major differences in states’ ability to collect and report data, which hampers bioterrorism and disease outbreak identification and control efforts. Timeliness in identifying and emerging health threats can prevent disease and save lives. A Gap in Community The ability of public health to work with communities to cope and recover Resiliency Support from a disaster or public health emergency is another major challenge. It is particularly difficult to address the needs of at-risk, special needs and vulnerable populations, such as children, the elderly, people with underlying health conditions and lower-income communities. The gaps in day-to- day public health departments, such as enough staff to engage community members in preparedness and limits in cultural competencies, make it challenging to build and maintain the relationships needed to identify and work with vulnerable Americans who need the most help during emergencies. Gaps in Vaccine Research and development of medical countermeasures — including diagnostics, and Pharmaceutical antiviral medications and vaccines — is outdated in the United States, in large Research, part because it is not a particularly profitable venture for pharmaceutical Development, and investors. Project BioShield and BARDA were developed to spur innovation and Manufacturing investment in medical countermeasures, but, so far, the result of new, effective products has been limited. The investments made in vaccine research and development did help lead to the production of a vaccine for the H1N1 flu strain in record time, but manufacturers were only able to produce limited quantities by the beginning of the flu season because of insufficient capacity and a reliance on an outdated egg-based production strategy. 29 C. Preparedness History Timeline, 2001-2011 The September 11, 2001 and anthrax attacks re- West Nile Virus (WNV) — in 2002, the virus vealed significant deficiencies in the country’s spread to nearly every state while more than disaster preparedness for health emergencies, 4,000 Americans developed West Nile Virus and led to a paradigm shift in how the govern- and 284 died from the illness.60 The WNV ment and public view disaster readiness. The response helped inform future disease track- following timeline highlights many of the major ing and containment approaches. public health emergencies and policy and re- n Fall — Severe acute respiratory syndrome search events from the past decade.  (SARS) first emerged in Foshan City, Guang- dong Province, China.61 Chinese officials 2001 originally withheld information about the Major Public Health Emergencies outbreak. The disease was later identified to n eptember 11 — Al Qaeda terrorists hijacked S be a new coronavirus. There were no exist- four planes and crashed them into the World ing vaccines for the disease and treatments Trade Center, the Pentagon and a field in did not offer a clear benefit. The full impact Shanksville, Pennsylvania, killing nearly 3,000 of SARS would not be recognized until 2003. people. In the aftermath, public health of- n October -– Pilgrim’s Pride recalled over 27 ficials activated a range of responses, includ- million pounds of frozen and prepared poul- ing readying the SNS and providing services, try products after Listeria was found at a pro- including mental health counseling. cessing plant. Eight people died, 53 became n October — A series of anthrax attacks oc- seriously ill and three women had miscar- curred; five people were killed, 17 were riages or stillbirths.62, 63 sickened and thousands were potentially exposed. Public health officials were at the Major Policy and Research Events lead of the anthrax response –diagnosing and n January — HHS announced $1.1 billion in treating victims, running more than a million funding for state public health, hospital and tests on hundreds of thousands of potentially medical preparedness planning for a bioter- life-threatening samples, providing useful rorist event.64 guidance to the public to address their fears n June -– The Public Health Security and Bioter- and supporting efforts to decontaminate rorism Act became law. It provided guidance postal facilities and other properties contami- to public health officials, created the Assistant nated with anthrax spores. Secretary for Public Health Emergency Pre- paredness and the National Disaster Medical Major Policy or Research Events System and provided cooperative agreement n March -– CDC released a new report, Public grant funds to states for public health emer- Health Infrastructure — A Status Report, in the gency preparedness, including: wake of the tragedies, that concluded the U.S. public health infrastructure “is still struc- s The HPP, which is designed to help hospi- turally weak in nearly every area.”58 tals respond more effectively to bioterror attacks and other public health emergen- n September — President George W. Bush ap- cies such as pandemic flu outbreaks. HPP pointed Gov. Tom Ridge as the director of provides money for hospitals to buy medi- the new Office of Homeland Security within cation, medical supplies, communications the White House.59 equipment and other resources that can n October — The USA Patriot Act became law, help during an emergency.65 expanding definitions and discretion of law s PHEP, which provides money to states, ter- enforcement to investigate and prevent do- ritories and urban areas to improve public mestic and international terrorism. health lab testing, health surveillance, train- ing, planning and other aspects of disaster 2002 response. PHEP currently gives out 62 grants Major Public Health Emergencies a year to the 50 states, four large metropoli- tan areas (Chicago, Los Angeles County, New n Spring/Summer — Public health officials York City and Washington, D.C.) and eight around the country developed strategies for U.S. territories and freely associated states.66 responding to the continuing spread of the 30 n November -– The Homeland Security Act be- n December -– The first case of mad cow disease came law, creating the Department of Home- (bovine spongiform encephalopathy (BSE)) was land Security (DHS), which incorporated a discovered in the United States. The United number of existing federal agencies, includ- States Department of Agriculture (USDA) ing the Customs Service, the Coast Guard and began widespread testing. After detecting very the Secret Service.67, 68 few cases, it scaled back testing in 2006.81 n November — The MRC was established to help Major Policy and Research Events communities respond to disasters. Community- based units made up of volunteers now exist n January — CDC launched a national cam- across the country, ready to be activated when paign to vaccinate 500,000 emergency and necessary. As of 2011, there are more than 950 medical workers on a voluntary basis against units, with more than 200,000 volunteers.69 smallpox. The disease was eradicated in the 1970s, but officials were concerned that ter- n November — Then-U.S. Senate Majority rorists could get samples and use them as a Leader Bill Frist, MD, authored an analysis in bioweapon. Fewer than 40,000 medical and Health Affairs that concluded that “over the emergency personnel — less than 10 percent past two decades, the [nation’s public health] of the campaign’s goal — received the shots. infrastructure has greatly deteriorated.”70 According to a GAO report, many health workers were concerned about the health 2003 risks of vaccination.82 Major Public Health Emergencies n March — The previously existing National n March — The World Health Organization Pharmaceutical Stockpile was expanded by (WHO) issued a global alert for SARS and WHO the Homeland Security Act to become the and CDC issued travel alerts for Vietnam, China SNS, a national repository of antibiotics, and Hong Kong.71 In April, CDC issued a travel chemical antidotes and other medicines and alert for Toronto, which was the center of the medical supplies for use during a chemical outbreak in Canada. A week later the agency or biological terror attack, or other public lifted the Toronto alert.72 CDC issued another health emergency.83 travel alert for Toronto in April that was soon n April — A GAO report examining state and lifted. SARS proved to be highly contagious only local preparedness progress found deficien- in hospitals, so the spread of the virus was able to cies in capacity, communication and coor- be controlled by isolation of the sick and other dination elements essential to preparedness public health interventions.73 In July, WHO and response, including workforce shortages, announced that SARS’ chain of transmission inadequacies in disease surveillance and labo- had been broken.74 Overall, more than 8,400 ratories and a lack of regional coordination people were infected with SARS, and more than and compatible communications systems.84 800 died. The disease spread to 29 countries. In the United States, there were 33 confirmed n September — CDC launched BioSense, a cases. None of these patients died.75, 76 nationwide system to detect early signs of a bioterrorism attack or infectious disease out- n June — There were 37 confirmed cases of the break. Initially, BioSense focused solely on monkeypox virus in Midwestern states. There bioterror attacks, but it expanded over time to were no fatalities, but two children were hos- cover a range of threats, such as Dengue fever pitalized, one with encephalitis. The illness is and health problems related to the Gulf Oil in the same family of viruses as smallpox, al- Spill. The network receives information from though its symptoms are generally milder. In- a wide range of sources across the country: vestigators traced the outbreak to pet prairie nearly 2,000 government and private hospitals dogs, which had contracted it from rodents and healthcare facilities, almost 2,800 labora- imported from Africa.77, 78 tories and more than 49,000 pharmacies.85, 86 n October — A Hepatitis A outbreak began, n October — DHS launched BioWatch, a mon- which was linked to contaminated green on- itoring system that tests air samples for bio- ions and caused more than 600 illnesses and logical agents. As of 2011, there are sensors four deaths. The onions were served in salsa in more than 30 cities around the country, and a cheese dip at a Chi-Chi’s restaurant monitoring six major biological threats, in- outside Pittsburgh. Investigators traced the cluding anthrax.87 onions to farms in Mexico.79, 80 31 n November — The IOM published the Fu- n May — A Salmonella outbreak linked to raw ture of the Public’s Health in the 21st Century almonds sickened at least 29 people in 12 report, which found that the public health states, leading to the recall of 13 million system had: “vulnerable and outdated health pounds of the nuts.93, 94 information systems and technologies; an n July — Tomatoes contaminated with Salmo- inadequately trained public health work- nella caused more than 400 illnesses in nine force; antiquated laboratory capacity; a lack states. Investigators traced the problem to of real-time surveillance and epidemiologi- pre-sliced tomatoes served at a chain of con- cal systems; ineffective and fragmented com- venience stores.95, 96 munications networks; incomplete domestic preparedness and emergency response ca- n Fall — A series of powerful hurricanes hit pabilities; and communities without access Florida. In response, the U.S. Public Health to essential public health services.” Overall, Service sent nearly 500 members of the Com- the report concluded that, “[t]hese problems missioned Corps, a uniformed service of leave the nation’s health vulnerable — and 8,500 public health professional who are able not only to exotic germs and bioterrorism.”88 to help during national and international health emergencies and offer aid.97 n December — The White House issued Home- land Security Presidential Directive-8 (HSPD- n October — The United States faced a flu vac- 8), which established new requirements for cine shortage, when the Chiron Corporation an- national preparedness. HSPD-8 assigned nounced it would not be able to meet demand DHS the lion’s share of responsibility for for its flu vaccine after problems at a British organizing the federal preparedness effort. plant halted production of millions of doses.98 The directive also established the National The shortage highlighted gaps in vaccine re- Preparedness Goal, Universal Task List and search and development in the United States. Target Capabilities List (TCL) to serve as n October — the worldwide death toll from baseline capabilities necessary for all aspects H5N1 avian influenza reached 32 in Asia, trig- of preparedness, from prevention to recov- gering concerns of the potential of new pan- ery. HSPD-8 was the first in a series of Home- demic flu outbreak.99 As of 2011, H5N1 still land Security Presidential Directives related poses a potential threat and is being tracked to bioterrorism and public health prepared- by researchers. ness issued between 2002 and 2009.89 n December — For the first time, every state Major Policy and Research Events and Washington, D.C. were recognized for n April — President Bush signed a classified di- having CDC-approved bioterrorism and pub- rective, Biodefense for the 21st Century, to im- lic health emergency plans.90 prove coordination among the government’s bioterrorism programs and initiatives.100 2004 n July — Project BioShield became law. BioShield Major Public Health Emergencies is a $5.6 billion effort to encourage biotech and n February — Ricin, a highly toxic protein made pharmaceutical companies to develop prod- from the castor bean that is poisonous if in- ucts that will help treat or prevent the effects of haled, injected or ingested, was detected in a a chemical or biological terror attack. In 2007, U.S. Senate mailroom serving the office of Ma- BioShield became part of BARDA. jority Leader Bill Frist, MD. No illnesses were reported in the mailroom or in Sen. Frist’s of- n September — CRI was created, to help cit- fice.91 News reports said it was unclear how ies and large metropolitan areas prepare to the ricin was delivered and approximately 16 dispense medicine quickly, on a large scale. people underwent decontamination. An in- From 2004 to 2010, CRI expanded from 21 to vestigation into the incident is still open. 72 cities and metropolitan areas.101 n March — The New York Times reported on a 2005 Pentagon report, Lessons Learned from the An- thrax Attacks: Implications for U.S. Bioterrorism Major Public Health Emergencies Preparedness, which was written in 2002 but n July — Tomatoes contaminated with Salmonella not previously publicly released. The article sickened 29 people in 16 states. Health officials described the report as “a sweeping assessment traced the problem to a pair of Virginia farms.102 [that] identifies weaknesses in ‘almost every as- pect of U.S. biopreparedness and response.’”92 32 n ugust and September — Two powerful hur- A the United States; (2) limiting the domestic ricanes, Katrina and Rita, hit the Gulf Coast. spread of a pandemic, and mitigating dis- The storms killed approximately 1,900 people ease, suffering and death; and (3) sustaining and caused more than $100 billion in dam- infrastructure and mitigating impact to the age.103  In response, the Commissioned Corps economy and the functioning of society.”108 carried out the largest deployment in its his- tory, deploying some 2,119 Corps officers to 2006 the region between August 26 and November Major Public Health Emergencies 7.  Of these officers, 81 percent served on teams n March — A cow in Alabama tested positive that provided healthcare and other services for mad cow disease.109, 110 The cow was not directly to the affected communities, while 19 linked to a larger outbreak. percent served on emergency response teams or at local operations centers.104, 105 n ummer and Early Fall — Nearly 200 people S became sick and at least three died due to E. n September — A second major Salmonella out- coli contamination in spinach.111, 112, 113 break occurred — more than 80 people were sickened after eating tomatoes at a chain res- n uly to November — Two Salmonella outbreaks J taurant. Investigators identified the source to occurred, both linked to contaminated toma- a farm in Florida. Twenty-six people overall toes. The first one took place in 19 states, while were hospitalized.106 the second occurred in 21 states and Canada. Overall, more than 300 people were sickened. Major Policy and Research Events Investigators found that one outbreak was re- n September — As part of HSPD-8, DHS re- lated to tomatoes consumed in restaurants, but leased 15 National Planning Scenarios to could not determine the source of the contami- help federal, state and local officials and the nation. In the second case, investigators traced private sector develop better responses for a the problem to a single restaurant, which had re- range of emergencies.107 ceived its tomatoes from an Ohio packinghouse that had been supplied by three growers.114 The 15 National Planning n August — Between August 1, 2006 and Febru- Scenarios: ary 16, 2007, Salmonella-tainted peanut butter from the Peter Pan and Great Value brands n Four biological attacks: aerosol anthrax, sickened 425 people in 44 states. After an in- plague, contamination of ground beef at a vestigation, the manufacturer, ConAgra, said factory and Foot and Mouth Disease; moisture from leaks and a faulty sprinkler sys- n Four chemical attacks: a blister agent, the tem likely led to the problem.115, 116, 117 nerve agent sarin, a toxic industrial chemi- n ovember and December — More than 70 N cal release and a chlorine tank explosion; people who ate at Taco Bell restaurants in the n The detonation of a 10-kiloton nuclear bomb; Northeast were infected with E.coli bacteria. Three-quarters of these people were hospital- n A “dirty bomb” that spreads radiation ized and eight developed a type of kidney fail- throughout a city; ure known as hemolytic-uremic syndrome. At n The bombing of a sports arena; first, Taco Bell traced the problem to green onions, but FDA investigators later ruled out n A cyber attack that damages the nation’s that possibility. Officials eventually deter- financial infrastructure; and mined that lettuce was the likely source.118, 119 n Three natural events: an 8.0 earthquake near a n December — Five school-aged children in major city, a Category 5 hurricane that strikes Rhode Island were diagnosed with encephali- a major city and a pandemic flu outbreak. tis, an acute inflammation of the brain. One of the children died. The health department distributed antibiotics to all students, staff, and family members from the affected school. n November — President Bush released a $7.1 In early January of 2007, public health author- billion plan, the National Strategy for Pandemic ities also closed three nearby school districts Influenza, to guide the “nation’s preparedness as a precautionary measure. The Department and response to an influenza pandemic, with of Health was able to rapidly distribute antibi- the intent of (1) stopping, slowing or oth- otics to more than 1,000 people.120, 121 erwise limiting the spread of a pandemic to 33 Major Policy and Research Events Rybak attributed a quick emergency response n July — The Uniform Emergency Volunteer to the city’s investment of some $50 million Health Practitioners Act (UEVHPA) is adopted since 2001 in emergency preparedness, specifi- by the National Conference of Commissioners cally, enhanced communication technology.130  on Uniform State Laws (NCCUSL) to address n October — California saw the largest evacua- the lack of uniformity in state laws that were tion in state history due to a series of wildfires revealed during the major hurricanes in 2005, that caused 10 deaths and 139 injuries and especially focused on the use and efficacy of forced evacuation of approximately 350,000 volunteers and licensing and accreditation, lia- homes. The California Department of Pub- bility protection and workers compensation.122 lic Health deployed 2,000 alternate care site n December — The Pandemic and All-Haz- beds that had been purchased by the state to ards Preparedness Act (PAHPA) became improve the emergency preparedness capabil- law. PAHPA reauthorized several expiring ities. The department also coordinated evacu- programs in the Public Health Security and ations from 23 nursing homes, two acute care Bioterrorism Act, and established some new facilities and a psychiatric hospital.131 authorities.123 It broadened the government’s n September — Concerns about the H5N1 bird focus from bioterrorism to a more compre- flu as a potential pandemic threat continued to hensive, all-hazards approach that included grow as more than 200 cumulative human deaths infectious diseases and natural disasters, had been linked to H5N1 at this time.132, 133 as well as chemical, nuclear, or radiologi- cal terror attack. It also placed HHS as the n eptember — E.coli contamination in frozen S lead agency for the public health and medi- hamburger meat prompted the third largest cal response to a public health emergency hamburger recall in USDA history. Nearly and created BARDA within HHS to distrib- 22 million pounds of meat were recalled; the ute funding for the development of medical product caused 40 illnesses in eight states.134, 135 countermeasures. BARDA has funded about n October — CDC reported that methicillin-re- 100 projects, including anthrax vaccines and sistant Staphylococcus aureus (MRSA), which antitoxins, radiation treatments and vaccines can cause Staph infections, was responsible for smallpox and influenza.124, 125 As part of for more than 94,000 serious infections and PAHPA, Congress also created the Office nearly 19,000 deaths each year. CDC identi- of the Assistant Secretary for Preparedness fied MRSA as “a major public health problem and Response (ASPR), within HHS. ASPR primarily related to health care, but no longer focuses on preparedness planning and re- confined to intensive care units, acute care sponse, federal emergency medical capabil- hospitals, or any health care institution.”136 ity, countermeasures research and improving hospital and health care disaster response.126 Major Policy and Research Events n ctober — The White House updated the Na- O 2007 tional Strategy for Homeland Security for the first time since September 11, 2001 and also issued Major Public Health Emergencies the Homeland Security Presidential Directive n May — CDC announced that a patient with sus- 21 (HSPD 21), which established a National pected extensively drug resistant- Tuberculosis Strategy for Public Health and Medical Prepared- (XDR-TB), which is spread through the air trav- ness.137 The directive was the most recent in eled to Europe and back, prompting an inter- a series of executive orders issued since Sep- national public health scare. The patient did tember 11, 2001 to protect the nation in the not turn out to have the disease, but problems event of terrorist attacks or other catastrophic in the response raised concerns among public health events. The directive included four key health experts about preparedness for manag- parts: biosurveillance, countermeasure distri- ing a real multidrug resistant TB patient.127 bution, mass casualty care and community re- n June — Lead paint was found on a range of silience.138 The strategy included many of the toys made in China, posing a significant pub- requirements set forth in PAHPA and affirms lic health threat. Over several months, mil- the importance of the all-hazards approach lions of products were recalled.128 to public health emergency preparedness. In addition, it established the Public Health n ugust — The Interstate 35W bridge collapsed A and Medical Preparedness Task Force and re- in Minneapolis during the evening rush hour quired the Task Force to submit yearly status on August 1, leaving 13 people dead and more reports on the implementation plan and sug- than 100 injured.129 Minneapolis Mayor R.T. gested changes to HSPD 21. 34 “Indeed, certain non-terrorist events that reach cata- n March — Salmonella in cantaloupes imported strophic levels can have significant implications for from a Honduran grower and packer was homeland security. The resulting national conse- linked to 50 illnesses in 16 states, as well as quences and possible cascading effects from these nine illnesses in Canada.145 events might present potential or perceived vulnerabili- n March — A Salmonella outbreak in Colorado ties that could be exploited, possibly eroding citizens’ was linked to the water supply.146 confidence in our nation’s government and ultimately increasing our vulnerability to attack. This strategy, n arch and June — Heavy rains caused severe M therefore, recognizes that effective preparation for cat- flooding in the Midwest.  In March, 17 people astrophic natural disasters and man-made disasters, died as a result of the flooding, and, by the while not homeland security per se, can nevertheless end of June, storms and flooding across six increase the security of the homeland.”139 states caused 24 deaths, 148 injuries and more than $1.5 billion in damages to Iowa alone.147 n ational Strategy for Homeland Security, October 2007 N n une — Outbreaks of Salmonella Saintpaul J were linked first to tomatoes, and then, n ecember — Congress created the National D months later, to jalapeño and Serrano pep- Commission on Children and Disasters to ad- pers.  CDC identified more than 1,442 peo- dress the unique needs of children during a ple who were sickened by the outbreak in 43 crisis. The Commission issued its final report states, the District of Columbia and Canada.148 in October 2010, which included recommen- dations for a National Strategy on Children n June — Lightning sparked thousands of wild- and Disasters, establishing permanent chil- fires across northern California. More than dren’s and disaster coordination offices, fund- 2,700 individual fires were recorded, causing ing disaster planning for schools and child mandatory evacuations and damaging thou- care facilities and purchasing child-appropri- sands of acres.149 ate supplies for shelters and hospitals.140 n September — Hurricane Gustav caused wide- spread destruction in Louisiana, amounting 2008 to billions of dollars in damages. Two weeks Major Public Health Emergencies after Gustav, Hurricane Ike hit Texas as a Category 2 storm, causing extreme damage n anuary — A measles outbreak occurred in J in the state.  Twenty-seven deaths were attrib- San Diego after a seven-year-old who had uted to the storm, which forced hundreds of never been vaccinated for measles traveled to thousands of residents to evacuate.150 Switzerland and returned with a case of mea- sles. He spread the disease to 11 other chil- n eptember — Melamine-contaminated in- S dren, none of whom had been vaccinated.141 fant formula and related dairy products produced in China were found in countries n anuary to April — The city of Chicago had J across the globe.151 10 cases of Group C meningococcal inva- sive disease, which is best known as a cause n November — Federal health officials began for meningitis — compared with 13 cases tracking cases of Salmonella linked to tainted in all of 2007. The Chicago Department of peanut butter products.152 Over the next four Public Health launched a mass vaccination months, investigators tracked the problem to campaign focused on the at-risk population two peanut butter plants owned by the Pea- — children aged 11 to 18. The city was able nut Corporation of America. The outbreak to vaccinate 7,213 children in two weeks.142 killed eight people and sickened more than 700 in 46 states.153 n February — In the largest beef recall in history, 143 million pounds of beef were deemed unfit Major Policy and Research Events for human consumption. The recall occurred n February — CDC released its first report after the Humane Society of the United States featuring state-by-state information on the released an undercover video showing workers progress states have made using PHEP grant at a California meat company kicking sick cows funding, Public Health Preparedness: Mobilizing and using forklifts to force them to walk.143 State by State.154 Some key areas of progress n ebruary — Vials of ricin were found in a F included increases in the number of epidemi- motel room in Las Vegas, Nevada after a man ologists and labs with bio-testing capabilities suffering from respiratory distress was taken to and improvements in the ability to distribute the hospital.144 According to news reports, the vaccines and antiviral medications. man said he had the ricin for his “self-defense.” 35 n all — The world economic crisis began, F to stakeholders to develop health care pro- which has led to a continuing wave of public tocols when resources are scarce, including health budget cuts and worker layoffs. Be- taking into account ethics, community en- tween 2008 and 2011, LHDs cut about 34,000 gagement, legal authorities, clear indicators jobs — almost a fifth of the entire local public and evidence-based clinical processes.161 health workforce.155 n December — HHS released the National Health Security Strategy to help galvanize ef- 2009 forts to minimize the health consequences Major Public Health Emergencies associated with significant health incidents. n anuary — A severe ice storm struck Kentucky, J The strategy is built on a foundation of com- and more than 85 percent of the state’s coun- munity resilience.162 ties were declared disaster areas. Immedi- ately after the storm, approximately 800,000 2010 residential and commercial units lost power, Major Public Health Emergencies including numerous hospitals and long-term n January and February — More than 1.3 mil- care facilities. At the height of the response, lion pounds of salami tainted with Salmonella more than 200 shelters in 72 counties pro- were recalled after more than 250 people in vided assistance to more than 7,800 people. 44 states became ill. Federal officials said the In the largest statewide call-up ever, over 4,100 problem may have been related to black and National Guard members helped respond.156 red pepper coating the meat.163 n arch — An outbreak of H1N1, a novel flu M n pril — The Deepwater Horizon oil platform A virus, is identified in Veracruz, Mexico. On exploded on the Gulf Coast, resulting in the April 26, officials from CDC and DHS de- deaths of 11 workers and the release of an esti- clared a national public health emergency mated 205 million barrels of oil into the Gulf.164, as cases of H1N1 began to spread across the 165 In response to the oil spill, with funding country. In June, WHO and CDC classified from the Substance Abuse and Mental Health the outbreak as a pandemic. Hundreds of Services Agency, CDC designed the Gulf States schools across the United States closed in Population Survey to collect the data needed to the initial weeks of the H1N1 outbreak. Al- assess the mental and behavioral health needs though it was viewed as a relatively moderate of the affected population. Data collection pandemic, the H1N1 virus had a serious im- began in December 2010 and will conclude in pact on the United States. It infected around December 2011. The complete public health 20 percent of Americans (approximately impact of the explosion, spill, and dispersants 60 million people), leading to approxi- on the safety of seafood, health of recovery mately 274,000 hospitalizations and 12,000 workers, and psychological wellbeing of Gulf deaths.157 About 90 percent of the Ameri- Coast residents remains unknown.166 cans who died were under the age of 65, in- cluding at least 340 children, as confirmed by n May — An outbreak of Salmonella linked to laboratory testing.158 According to CDC, the eggs caused more than 1,900 illnesses. The actual number of deaths in children could be source of the problem was traced to two large between 910 and 1,880.159 egg farms in Iowa. Eventually, more than 500 million eggs were recalled. FDA officials in- Major Policy and Research Events vestigating the farms found a wide range of n une — In response to the H1N1 outbreak, J health violations, including rodents, maggots Congress passed and President Obama and improperly stored manure.167 signed the Supplemental Appropriations n une — California public health officials de- J Act of 2009, appropriating $1.9 billion in clared a Pertussis, also known as whooping emergency supplemental funding and an cough, epidemic in the state. Over the course additional $5.8 billion in contingency fund- of the year, the epidemic caused almost 8,000 ing.160 These funds helped enhance vaccine illnesses and 10 deaths and was the largest epi- production capacity, purchase and distribute demic in the state in half a century.168 Pertussis vaccines, upgrade surveillance capabilities, vaccinations are recommended beginning at support the state and local pandemic re- two months old, but infants are not fully pro- sponse and meet other needs. tected until they reach six months of age and n September — The IOM released Guidance for have received a series of shots. Officials attrib- Establishing Crisis Standards of Care for Use in uted the epidemic to gaps in vaccinations. Disaster Situations, which provided guidance 36 Major Policy and Research Events 1924. Investigators traced the outbreak to a n ugust — The President’s Council of Advisors A Colorado farm. Officials said this was the first on Science and Technology (PCAST) issued: known outbreak of Listeria in cantaloupe.172 Report to the President on Reengineering the In- n ugust — Hurricane Irene lead to 56 deaths, A fluenza Vaccine Production Enterprise to Meet the $10 to $25 billion in damages, including mas- Challenges of Pandemic Influenza. The report sive flooding in Vermont. The storm resulted found that the response to the H1N1 outbreak in nearly six million Americans losing electric- was “impeded by unanticipated delays that arose ity and major transportation shut downs.173 in manufacturing what was supposed to be the most powerful tool for preventing widespread n August — A multistate outbreak of Salmonella morbidity and mortality: a vaccine designed to was traced to ground turkey, sickening more protect against the 2009 H1N1 virus.”169 The than 136 people in 31 states and one death.174 report featured a series of recommendations to n October — A Halloween nor’easter became enhance the nation’s ability to produce influ- the 14th natural multi-billion dollar natural enza vaccine in a timelier manner. disaster in the United States in 2011, causing n August — HHS released a Public Health Emer- at least six deaths and transportation shut gency Medical Countermeasures Review, Pub- downs and millions to lose electricity on the lic Health Emergency Countermeasures Review: East coast.175 Transforming the Enterprise to Meet Long-Range n November — A Salmonella outbreak linked to National Needs, a strategy to modernize the de- boiled chicken livers sickened more than 179 velopment of medical countermeasures across people in six states.176 the federal government, including addressing issues related to bureaucracy and profitability Major Policy and Research Events to help encourage private industry investment n anuary — The FDA Food Safety Modernization J in the development of vaccines and other Act became law, giving the agency expanded medical countermeasures.170  powers to protect the nation’s food supply. The law, which made the first major changes 2011 to the country’s food safety system in 80 years, Major Public Health Emergencies included authorization of $1.4 billion in fund- n arch — On March 11, 2011, northern Japan M ing over five years and a focus on prevention of suffered first a magnitude 9.0 earthquake cen- foodborne illness, rather than response alone. tered 130 miles off the eastern coast and then Among the major changes, for the first time, an ensuing tsunami. At the Fukushima Daiichi FDA could order recalls of contaminated food. nuclear reactor complex, this caused a cascade Previously, the agency had to work with compa- of events including loss of electrical power to es- nies to engineer voluntary recalls.177 sential cooling systems, reactor overheating and n arch — President Obama issued Presiden- M core meltdown, and radionuclide releases caus- tial Policy Directive-8 (PPD-8), the latest in a ing widespread radioactive contamination of series of policy directives since September 11, residential areas, agricultural land, and coastal 2001, which laid out the country’s approach to waters. The Fukushima nuclear emergency preparing for acts of terrorism, cyber attacks, response identified major public health and disease outbreaks and natural disasters.178 As medical challenges in both Japan and in the part of PPD-8, DHS released an updated Na- United States; challenges in the U.S., included tional Preparedness Goal (NPG) in Septem- the need to identify potential contamination ber 2011 to improve both local and national in food, water, and on returning travelers and disaster response. The top level summary of cargo imported from Japan, as well as to protect the goal is “to have a secure and resilient Na- the health of Americans in Japan. tion with the capabilities required across the n ay — A series of tornadoes in Southern and M whole community to prevent, protect against, Central states resulted in more than $7 bil- mitigate, respond to, and recover from the lion in damages and more than 140 deaths in threats and hazards that pose the greatest Joplin, Missouri.171 risk.”179 Additional requirements of the direc- tive include: a National Preparedness System n July — The first cases of illness associated with Description; a series of National Frameworks Listeria-tainted cantaloupes were reported. and Federal Interagency Operational Plans; The outbreak has sickened more than 139 a National Preparedness Report; and a Cam- people in 28 states, killing 30 of them. Mak- paign to Build and Sustain Preparedness. ing it the deadliest foodborne outbreak since 37 n eptember — The Public Health Accredi- S includes strategies to cooperate with state and tation Board launched the first national local emergency management and health accreditation program for public health de- departments, the private sector and interna- partments, initiated and supported by the tional organizations. It also identifies best Robert Wood Johnson Foundation (RWJF) practices for coordination between public and CDC, to protect and improve Americans’ health departments, emergency management health by advancing the quality and perfor- groups and the healthcare system. In addi- mance of all of the nation’s public health de- tion, it proposes methods to strengthen the partments—state, local, territorial and tribal. surveillance of threats; improve epidemiology and laboratory science related to disasters; n eptember — CDC released a new 10-year Na- S generate more ideas for improving training tional Strategic Plan for Public Health Prepared- and efficient use of funds; increase the ways ness and Response.180 The plan builds on the to improve cooperation and coordination experience the agency has had after a decade across the federal government and among of major public health emergencies, includ- federal, state and local agencies; and develop ing the 2001 terrorist attacks, Hurricane Ka- improvements for evaluating progress. trina and the H1N1 flu pandemic. The plan 2011 CDC Strategic Preparedness Plan Eight Overarching Objectives: n Objective 1: Prevent and/or mitigate threats n Objective 5: Increase the application of sci- to the public’s health ence to preparedness and response practice n Objective 2: Integrate public health, the health- n Objective 6: Strengthen public preparedness care system and emergency management and response infrastructure n Objective 3: Promote resilient individuals and n Objective 7: Enhance stewardship of public communities health preparedness funds n Objective 4: Advance surveillance, epidemiol- n Objective 8: Improve the ability of the public ogy and laboratory science and service practice health workforce to respond to health threats “These are challenging economic times. We must sustain existing public health capabilities and in- frastructure while developing solutions to build the public health systems of the future. Looking ahead towards the year 2020, projected pressures on public health include the increase of the U.S. popula- tion from 308 million to 336 million, more diversified age groups (including a 54% increase of citizens over 65, straining the already overburdened health care system), socio-economic tensions, and mass migrations due to adverse weather events. We also know that the advancement and diffusion of scien- tific technologies will pose threats to health security. Improvements in DNA technologies will increase our vulnerability to attacks from groups who have adapted microbes or created entirely new pathogens with the intent to harm the population. We also face the risk of individuals acting on their own, com- bining readily available chemicals and other materials to create improvised weapons. The increasing ease of global mobility means that bio-attacks, pandemics, and other health threats to our citizens can more easily travel across borders. Vigilance and forecasting are necessary to mitigate these sce- narios and can only be done by sustaining and increasing public health capabilities.” 181 — Ali S. Khan, M.D., M.P.H., U.S. Assistant Surgeon General (Ret), Director, Office of Public Health Preparedness and Response, DHHS/CDC from the National Strategy 38 Major CDC and ASPR Public Health Preparedness Programs, 2011 U.S. Centers for Disease Control and The 2011 PHEP cooperative agreement focuses Prevention on 15 key capability areas, including: n Office of Public Health Preparedness and n Community Preparedness Response: Leads the agency’s preparedness n Community Recovery and response activities by providing strategic n Emergency Operations Coordination direction, support, and coordination for activities across CDC as well as with n Emergency Public Information and Warning local, state, tribal, national, territorial and n atality Management F international public health partners.182 n nformation Sharing I s The Public Health Emergency n Mass Care Preparedness (PHEP) cooperative n Medical Countermeasure Dispensing agreement program awards funds to n Medical Material Management and Distribution states, territories and urban areas to build and sustain public health preparedness n Medical Surge capabilities that enhance their ability to n Non-pharmaceutical Interventions respond to public health emergencies. n Public Health Laboratory Testing PHEP awards funds to 62 public health n Public Health Surveillance and Epidemiological departments nationwide, including the Investigation 50 states; four large metropolitan areas, Chicago, Los Angeles County, New York n esponder Safety and Health R City and Washington, D.C.; and eight U.S. n olunteer Management V territories and freely associated states: s CRI is funded through the PHEP cooperative American Samoa, Guam, U.S. Virgin agreement to help cities and large metro- Islands, Northern Mariana Islands, Puerto politan areas prepare to dispense medicine Rico, Federated States of Micronesia, quickly, on a large scale.185 Republic of the Marshall Islands and the s The SNS is a national repository of antibiotics, Republic of Palau.183 The distribution of chemical antidotes and other medicines and PHEP funds is calculated using a formula medical supplies for use during a chemical that includes a base amount for each or biological terror attack, or other public awardee plus population-based funding. health emergency. Started in 1999, SNS is Funding also is awarded for specific managed through OPHPR. The program preparedness activities. The fiscal year focuses on responding quickly to a large-scale 2011 cooperative agreement includes a bioterror attack in a large city or metropolitan new pilot program that provides a year area (where more than half of the country’s of funding to 10 urban areas to develop population lives). The first line of support is assessments of public health and medical “12-hour Push Packages,” which contain over risks, as well as accelerated development 50 tons of medicines, antidotes and medical of risk reduction strategies that mitigate supplies designed to provide rapid immedi- the public health risks associated with ate help, even when the cause of an attack or higher population areas.184 event is uncertain. Push Packages are kept in secure warehouses across the country, ready for rapid deployment to a designated city or site. SNS also has further supplies, designed to arrive within 24 to 26 hours, if necessary.186 Examples of SNS Contents (as of 2009) n Enough smallpox vaccine to protect 300 million people, or every man, woman and child in America; n Over 41 million regimens of countermeasures against anthrax; n Therapeutic anthrax antitoxins to treat symptomatic patients;187 n Ten million anthrax vaccine (AVA) doses; and n Countermeasures to address radiation exposure including 475,000 combined doses of Cal- cium-DTPA (Diethylenetriamine pentaacetate) and Zinc-DTPA.188 39 Office of the Assistant Secretary of Preparedness and Response n Office of Policy and Planning (OPP) advises disaster site to provide a range of services, HHS and ASPR leadership through policy including medical assessments, primary and options and strategic planning initiatives to emergency medical care, provision of medical support domestic and international public equipment and supplies, victim identification health emergency preparedness and response and veterinary services.192 activities. s Emergency System for Advance Registra- n Office of Preparedness and Emergency Op- tion of Volunteer Health Professionals erations oversees a range of operational pro- (ESAR-VHP), a federal program created to grams, three of which include: support states and territories in establishing standardized volunteer registration programs s ospital Preparedness Program, which H for disasters and public health and medical provides leadership and funding through emergencies. The program, administered on grants and cooperative agreements to states, the state level, verifies health professionals’ territories and eligible municipalities to im- identification and credentials so that they can prove surge capacity and enhance community respond more quickly when disaster strikes. and hospital preparedness for public health By registering through ESAR-VHP, volunteers’ emergencies.189 HPP provides support for identities, licenses, credentials, accreditations hospitals to buy medication, medical sup- and hospital privileges are all verified in advance, plies, communications equipment and other saving valuable time in emergency situations.193 resources that can help during an emergency. The program helps hospitals improve decon- n BARDA encourages the development of vac- tamination capabilities and personnel man- cines, medicines and diagnostic tools that agement and hospital evacuation planning. could be used in public health emergencies. It also pays for disaster training and helps Established in 2006 by PAHPA, BARDA local networks of hospitals — as well as local works to speed up the development of medi- businesses and non-profit groups — work cal countermeasures (MCMs) by supporting together to plan for emergencies. advanced research, development and testing, working with manufacturers and regulators, and helping companies devise large-scale A 2009 HHS evaluation found that more manufacturing strategies. BARDA bridges the than three quarters of hospitals participating funding gap between early research and com- in HPP met at least 90 percent of all mea- mercial production. sures for preparedness.190 In 2011, BARDA has more than 100 ongo- ing projects, including potential vaccines for s National Disaster Medical System smallpox, anthrax, influenza and radiation treat- (NDMS), a federally coordinated system that ments.194 In addition, the program is involved in augments the nation’s medical response capa- helping to open the nation’s first cell-based flu bility, which consists of more than 100 teams vaccine factory.195 of trained doctors, nurses and other medical professionals to help respond to major emer- s roject BioShield, a program within BARDA, P gencies, and coordinates patient transport was set up to guarantee a market for newly and hospital care.191 More than 1,000 hospi- developed vaccines and medicines needed for tals participate in NDMS. Based throughout biodefense that would not otherwise have a the country, these teams are brought to the commercial market.196, 197 40 MEMORANDUM OF UNDERSTANDING FOR EMERGENCY PREPAREDNESS GRANT COORDINATION Several federal departments and agencies 2) rant Cycle/Timeline to align the following: G distribute preparedness funds and/or provide pre-award administration efforts; program- technical assistance and national strategies in matic fiscal years; joint application submis- support of various preparedness activities. sions; and application reviews. ASPR, CDC, the Health Resources and Ser- 3) Grant Administration/Management to co- vices Administration (HRSA), the Department ordinate the use of the grant funding for of Homeland Security’s Federal Emergency administration activities such as site visits; Management Agency (FEMA), and the De- information sharing; co-presentation at na- partment of Transportation’s (DOT) National tional conferences/meetings; and coordina- Highway Transportation Safety Administra- tion of programmatic support. tion (NHTSA) recently agreed through a memorandum of understanding (MOU) to 4) rant Reporting Mechanisms and Evaluation G cooperatively assess their current prepared- to develop tools and resources to coordinate ness grant programs and to engage in collab- grant program performance measures.199 orative efforts to improve interagency grant CDC and ASPR have made significant prog- coordination. The MOU establishes a formal ress in grant alignment, including improving framework that supports joint federal plan- coordination between HPP and PHEP co- ning designed to focus investments, measure operative agreements. The HPP-PHEP col- and improve preparedness outcomes, reduce laboration is working to improve capabilities, duplication, report results, and enhance re- evaluation, framework, IT systems, training turn on investment.198 and technical assistance, grants administration According to the agreement, senior leaders and policy and guidance development. Goals from each agency involved will participate in for the HPP-PHEP collaboration are to: the Interagency Grant Coordination Commit- n Have a joint HPP-PHEP funding opportu- tee as well as the Grant Coordination Work- nity announcement in 2012; ing Group. The Committee and Working Group will work to coordinate grants in the n educe awardee burden, including during R following areas: the application process; 1) rant Program Policies to coordinate G n ncrease programmatic impact of state and I policy guidance and documents, including local preparedness programs; and assuring consistency of grant guidance with n mprove federal efficiencies to better sup- I national emergency preparedness strate- port state and local preparedness programs. gies and priorities. 41 ALL-HAZARDS APPROACH TO EMERGENCY PUBLIC HEALTH THREATS The U.S. public health system is responsible for protecting the American people from a range of potential health threats. EXAMPLES OF MAJOR EMERGENCY PUBLIC HEALTH THREATS Agroterrorism: The “…deliberate introduc- health care. Examples include hurricanes, earth- tion of an animal or plant disease with the goal quakes, tornados, mudslides, fires, and tsunamis. of generating fear, causing economic losses, and/ Pandemic flu: A novel, potentially lethal strain or undermining stability.”200 Agroterrorism can of the influenza against which humans have no be considered a subcategory of “bioterrorism” natural immunity. The H1N1 flu was the first and foodborne diseases. pandemic flu of the 21st century. Historically, Bioterrorism: The intentional or deliberate use pandemic flu occurs two to three times every of germs, biotoxins, or other biological agents hundred years or so. In the 20th century the that cause disease or death in people, animals, world experienced the 1918, 1957/58, and 1968 or plants. Examples include anthrax, smallpox, pandemic flu, although the severity of the dis- botulism, Salmonella, and E. coli. ease varied greatly among them. Blast Injuries: Explosions, whether deliberate or Radiological threats: Intentional or accidental accidental, can cause multi-system, life threatening exposure to radiological material. For example, injuries among individuals and within crowds. In a terrorist attack could involve the scattering of addition, blunt and penetrating injuries to multiple radioactive materials through the use of explo- organ systems are likely when an explosion occurs sives (“dirty bomb”), the destruction of a nuclear and unique injuries to the lungs and central ner- facility, the introduction of radioactive material vous system occur during explosions. into a food or water supply, or the explosion of a nuclear device near a population center. Chemical terrorism: The deliberate use of chemical agents, such as poisonous gases, arsenic, Vector-borne diseases: Diseases spread by or pesticides that have toxic effects on people, an- vectors, such as insects. Examples include Rocky imals, or plants in order to cause illness or death. Mountain spotted fever and malaria. Examples include ricin, sarin, and mustard gas. Water-borne diseases: Diseases spread by Chemical incidents and accidents: The contaminated drinking water or recreational non-deliberate exposure of humans to harm- water, such as typhoid fever and cholera. Ac- ful chemical agents, with similar outcomes to cording to CDC, more than 4,100 persons chemical terrorism. become ill from contaminated drinking water and more than 13,000 persons become ill from Foodborne diseases: Food-borne illness is recreational water disease outbreaks annually in caused by harmful bacteria, viruses, parasites or the United States.201, 202 chemicals that are found in food and beverages and enter the body through the gastrointestinal Zoonotic/Animal-borne diseases: Animal tract. CDC estimates there are approximately diseases that can spread to humans and, in some 76 million pathogen-induced cases of food-borne cases, become contagious from human to human. diseases each year in the United States, caus- Examples include Avian flu, West Nile virus, and ing approximately 127,000 hospitalizations and SARS. In 2000, WHO identified more than 200 3,000 deaths. Examples include botulism, Salmo- diseases occurring in humans that were known to nella, E.coli 0157:H7, shigella, and norovirus. be transmitted through animals.203 Experts believe that the increased emergence of zoonotic diseases Natural disasters: Harm can be inflicted during worldwide can be attributed to population dis- and after natural disasters, which can lead to con- placement, urbanization and crowding, deforesta- taminated water, shortages of food and water, tion, and globalization of the food supply. loss of shelter, and the disruption of regular 42 ECONOMICS AND PUBLIC HEALTH PREPAREDNESS In addition to the health toll that diseases, disasters and bioterrorism sector employed approximately 12.5 million workers in can take, they also have major economic implications. For example: 2008, or nearly nine percent of the total U.S. workforce.215 n eptember 11, 2001 Tragedies: The total economic loss S s n 2001, a foot-and-mouth disease outbreak in Britain led I has been estimated at roughly $80 billion, of which $32.5 bil- to an estimated economic loss of $6 billion to $18 billion, lion was insurable.204 The insurance industry paid the $32.5 and led to the destruction of four million animals.216 A billion in insured losses from business interruption, property, 1999 report estimated that an outbreak of foot-and-mouth workers’ compensation, aviation liability and other liability in California would lead to economic losses of $6 billion.217 costs.205 In addition, World Trade Center workers received s Over the last few decades, the United Kingdom has battled a $625 million settlement for their exposure to toxic dust.206 bovine spongiform encephalopathy (BSE), better known as “mad cow disease.” As of March 2005, 149 people who n Anthrax Attacks: According to an article in the Wash- were infected with the disease have died, and nearly four ington Post, the clean up from the 2001 anthrax attacks million cows have been slaughtered.218 If a significant out- exceeded $1 billion.207 A reported $42 million was spent to break of BSE occurred in the United States, FDA estimates decontaminate the Hart Senate Office Building and other that there would be a loss of $15 billion, resulting from a 24 Capitol Hill offices and it cost in excess of $200 million to percent decline in domestic beef sales and an 80 percent decontaminate the postal facilities at Brentwood in Wash- decline in beef and live cattle exports. Slaughter and dis- ington, D.C. and in Hamilton Township, New Jersey.208 posal costs of at-risk cattle could be additional $12 billion.219 This does not include the cost of the public health response and laboratory testing of specimens around the country. s n 1978, the Arab Revolutionary Council engaged in bioter- I rorism, using mercury to poison Israeli oranges. A dozen s According to a report in the New York Times, under a hy- children in Holland and West Germany were hospitalized pothetical scenario developed by DHS involving an anthrax as a result. Ultimately, this act helped sabotage the Israeli attack, if terrorists were to spray aerosolized anthrax from a economy, resulting in a 40 percent reduction in orange ex- van in three cities initially, followed by two more cities shortly ports.220 At the time, oranges accounted for about a tenth afterward, casualties could well exceed 13,000, and result in a of all Israeli exports.221 The United States produces over 20 loss of billions of dollars.209 Other estimates are that anthrax percent of the world’s citrus, or approximately 15.6 million could result in more than 13,000 deaths in a single city. tons in 2004.222 U.S. citrus exports are roughly $1 billion, s According to a study by Towers Perrin Consulting, one anthrax while U.S. consumers spend more than $3 billion on citrus attack in New York City could lead to $90 billion in workers’ products (orange and grapefruit juice and fresh fruit).223 compensation losses, which would be three times greater than the entire $30 billion workers’ compensation industry.210 n ew Infectious Disease Outbreak: In 2003, SARS swept N through Southeast Asia, infecting over 8,000 people and leaving s isk Management Solutions (RMS), a leading risk consult- R 774 dead.224 Its reach demonstrates the tremendous speed in ing firm, believes an attack on downtown New York which disease can spread. Originating in China, the SARS outbreak City could result in 173,000 casualties. In this scenario, eventually infected individuals from 29 nations around the world. anthrax is weaponized and dispersed in aerosol form, Overall, the economic losses, due to deaths, quarantines and lost resulting in inhalation of anthrax by approximately one tourism dollars, may have been $30 to $50 billion, according to million people. RMS estimates economic losses of $91 some estimates.225 In Toronto alone (many thousands of miles billion from workers compensation alone.211 away from the initial outbreak), more than 27,000 people in and n Nuclear, Biologic, or Chemical Attacks and the Insur- around the city were forced into quarantine during two outbreaks, ance Industry: In 2005, the CEO of Allstate Corp, a lead- which led to an estimated economic loss of nearly $1 billion.226 ing insurance company, stated that nuclear, biological or n evere Pandemic Flu Outbreak: A severe pandemic S chemical terrorist attacks “could literally destroy the entire flu similar to the 1918 pandemic could lead to a significant capital base of the insurance industry.”212 In 2003, the capi- drop in the U.S. Gross Domestic Product (GDP).227 tal base for the insurance industry was $347 billion.213 n ulf Coast Oil Spill: There was a loss of an estimated G n oodborne Illness and Agroterrorism: Agriculture F $1.2 billion in economic output and 17,000 jobs in 2010 ac- represents 1.2 percent of the U.S. gross domestic product cording to an analysis from Moody’s Analytics.228 (GDP), or $173 billion a year.214 Agriculture and the food D. SPECIAL TOPICS — A DECADE AFTER 9/11 AND ANTHRAX The following expert commentaries feature a set of forts; defining the research agenda to further pre- topics that are essential components of prepared- paredness systems and services; ensuring that laws ness, including: bringing a range of community are in place to protect the public and health officials leaders together to prepare together for potential during emergencies; and focusing on injuries, which health emergencies through Meta-Leadership ef- is often an overlooked component of preparedness. 43 EXPERT PERSPECTIVE Meta-Leadership Empowers Community Leaders to Act Together in Times of Crisis By Charles Stokes, president and chief executive officer of the CDC Foundation, an independent, nonprofit organization established by Congress to help CDC do more, faster. T he events surrounding 9/11, Hurricane Katrina and H1N1 should be a wakeup call for America. From my perspec- tive, these emergencies underscore the urgent need for leaders Although the final Meta-Leadership Summit took place in Long Island, New York, in June 2011, the initiative is far from over. A CDC post-Summit team reconvenes leaders approximately to act collaboratively across public and private sectors in times six months after each Summit to continue building cross- of crisis. As ongoing public health budget cuts strain the capacity sector connectivity and applying meta-leadership concepts to of CDC and state and local health agencies across the country, it preparedness planning. Through post-Summit activities unique is critical for communities to find ways to close the gaps to keep to each community, CDC casts a wider net, encouraging America healthy, safe and secure. participants to address preparedness gaps identified at the Summit and through evaluation results. To date, more than The Meta-Leadership Summit for Preparedness, a five-year 2,000 leaders have participated in post-Summit presentations initiative funded by the Robert Wood Johnson Foundation and discussions related to cross-sector preparedness. Topics (RWJF), is a model approach for bringing communities together include addressing the needs of vulnerable populations, engaging to respond to crises. Since 2006, the initiative has connected faith-based organizations in preparedness planning, enhancing close to 5,000 business, government and nonprofit leaders in 36 corporate security and leveraging virtual communities. communities representing approximately 139 million Americans. The CDC Foundation partnered with CDC, the Robert Wood Summit participants are also invited to join a Meta-Leadership Johnson Foundation and the National Preparedness Leadership Online Community (www.meta-leadershipcommunity.org) that Initiative-Harvard School of Public Health to host the successful extends their collaboration. With thoughtful cultivation and networking and training events. ongoing support from the Robert Wood Johnson Foundation, the online community continues to thrive. More than 2,800 What makes the Meta-Leadership Summit for Preparedness members have joined to share resources, discuss topics of program unique is its focus on cross-sector collaboration and interest and connect with other Summit participants, locally community action. As Summits took place across the country, and nationally. local host committees were crucial to endorsing the Sum- mit and getting the right leaders in the room. Local sponsors Throughout the initiative, all partners and stakeholders supplemented the Robert Wood Johnson Foundation’s national sought clear evidence of Summit outcomes and continuous support, covering local event expenses so that participants improvement in the program’s design and implementation. could attend at no cost. Frontline meta-leaders from CDC and Cumulative evaluation results are extremely positive: 94 percent other federal agencies joined with Harvard faculty to provide of respondents agreed that attendance at the Summit was a real-world perspectives on leading in emergencies. High profile valuable use of their time, 91 percent rated the overall quality of speakers — including governors, mayors and CEOs — elevated the Summit as “good” or “outstanding” and 91 percent would the profile of the initiative and attracted local media coverage. recommend the Summit to their colleagues. Realistic scenarios, developed by Harvard faculty in collabora- Practical examples of meta-leadership are evident across the tion with local leaders, helped participants envision the serious country. For example, in San Diego, a public-private coalition consequences that could emerge in their own communities fol- established by the San Diego County Office of Emergency lowing a terrorist attack or natural disaster. Services experienced a significant boost in nonprofit and Sometimes connections among Summit participants were not business participation after the Summit. In Boston, Mayor immediately obvious. For example, at the Boston Meta-Lead- Menino held a cross-sector Boston Influenza Preparedness ership Summit, a leader from the Boston Ballet attended the Summit, building on the meta-leadership model. Eight Illinois event. Some wondered what role the arts could possibly play meta-leaders who participated in a University of Illinois at in community preparedness. However, when leaders identified Chicago (UIC) School of Public Health fellowship program gaps in preparedness — and how they might contribute their made the case for the nation’s first Meta-Leadership Institute own resources and capabilities to fill those gaps — the Boston and applied meta-leadership to community issues beyond Ballet offered its space as a shelter for disaster victims. A syn- preparedness, including school violence, flu vaccination and ergy occurs when leaders connect face-to-face to create better faith-based outreach. Following the Gulf oil spill, Southeast prepared, more resilient communities. Louisiana meta-leaders developed a proposal template and 44 process for BP-funded emotional support services that are community — to help FEMA identify and test ways to better essential to long-term community support. Kay Wilkins, CEO, engage with communities, and to integrate preparedness American Red Cross Southeast Louisiana Chapter said, “What into community and civic organizations that serve those the Meta-Leadership Summit did was open avenues to other communities.  people and groups we might not have thought about.” CDC and public health leaders across the nation shoulder As others learn about meta-leadership, interest continues to the considerable and singular duty to protect the nation from build. In September 2011, the CDC Foundation was invited major health threats 24/7, including catastrophic events. In to help the Federal Emergency Management Agency (FEMA) light of the ongoing budget cuts, and at a time when the develop and implement a “Whole Community” approach to United States and the world faces increasing threats from emergency management. The effort includes methods to build nature, technology and human action, helping leaders on the lessons learned through the Meta-Leadership Initiative understand their counterparts’ interests and establishing — from Summits to post-Summit activities to the online connectivity before disaster strikes is imperative. Meta-Leadership Summit for Preparedness Impact Minneapolis Milwaukee Boston Long Cleveland Pittsburgh Island San Francisco Nebraska Illinois Cincinnati New Jersey Denver Columbus Delaware Valley Central Indiana California Kansas Louisville Maryland National St. Louis Lexington Southwest Virginia Capital Region Los Angeles North Carolina New Mexico San Diego Atlanta Phoenix Dallas Columbus Coastal Georgia Lousiana Florida Capital Houston Tampa From 2006-2011, the Meta-Leadership Summit for Preparedness connected close to 5,000 business, government and nonprofit leaders in 36 communities representing approximately 139 million Americans. What is a Meta-Leader? A meta-leader is a leader of leaders, who Being a meta-leader requires a unique mindset and skill set, mobilizes people and organizations to collaborate in times of crisis. which often goes beyond the scope of an individual’s previous experiences. And it requires building strong alliances with a When disaster strikes, meta-leaders reach across organizations diverse array of leaders before an event occurs. and sectors to build cross-cutting strategies to protect the safety of their families, businesses and communities. They exchange The Meta-Leadership Summit for Preparedness cultivates the information, share resources and coordinate systems and critical problem-solving skills and connectivity that leaders need personnel. They use their influence and connections to guide a to be effective meta-leaders during times of crisis. cooperative course of action. 45 EXPERT PERSPECTIVE Preparedness and Public Health Systems and Services Research By F. Douglas Scutchfield, M.D., principal investigator, Center for Public Health Systems and Services Research at the University of Kentucky College of Public Health T he 10th anniversary of 9/11 and the Anthrax scare give us an occasion to pause and con- sider a vital question. We moved, as a nation, to health are scarce, and it will prompt the cycle of build-up, neglect, event, build-up, etc. Following 9/11 we created, in our nation’s schools assure that we were protected from bioterrorism of public health, preparedness centers that were and were prepared for the natural and unnatural responsible for developing training for preparedness disasters that we will likely experience. We have capacity in our nation’s public health system. These had other reminders of the importance of that centers quickly realized that there was information capacity, Hurricane Katrina being a classic ex- that they needed in their training efforts, information ample. One of the key components of our ability that wasn’t available in the lexicon of public health to respond to either of these sorts of events is our and where they needed research and investigation public health system and its backbone, the local to respond to this need. This need prompted Con- health department. gress to establish authority to empower prepared- Unfortunately, as a nation we have a tendency to ness centers, previously created by CDC as the “fight the last war” and to gear up in response to a result of congressional action, to answer some of major event, but as those problems fade into time, the most difficult questions in how best to address we tend to neglect the lessons, and allow those ef- public health preparedness. With this authority, the forts we invested in preparedness to deteriorate CDC created a few select preparedness centers and return to the status quo that existed before the to help find and make this information available to event. Recently, a colleague and I were working on those who are and were training the individuals that a public health book, in which there was a chapter we needed for preparedness. As an example of the on the history of public health. We were both struck work of these research centers, the University of by the history of public health, gearing up to respond North Carolina at Chapel Hill demonstrated that, in to a major public health event and then watching as North Carolina, which has a state public health de- public health gains that were achieved diminish with partment accreditation program, accredited health time and a loss of support and interest. departments were more likely to score higher on their preparedness profiles than health departments Unfortunately, that is the current state of public that were not accredited. With the advent of na- health. We don’t learn our history lessons, so fol- tional public health accreditation, this information is a lowing the build-up of public health in 2001, we powerful tool to encourage and support those health are now allowing the system we established to de- departments seeking and obtaining accreditation, as teriorate — two steps forward, three steps back. there is the assurance that they are more likely to be As certain as the sun will rise in the east, we will prepared for dealing with disasters. These centers, experience another event that will demonstrate Preparedness and Emergency Response Research our inability to cope, as the resources for public 46 Centers, unfortunately lost their funding two years agenda is rich with issues that stand in the way of ago. That left a major hole in the capacity to help our being able to carry out the programs and proj- develop and train the individuals and organizations, ects that include not only preparedness, but also the as critical gaps exist in knowledge that would impact myriad of public health problems that face America, our ability to cope with disasters. from childhood obesity to the increased concerns with chronic diseases, such as cancer and heart This is not an uncommon problem. One of the first disease. Questions from that agenda include issues cuts made in tight budget times is the activities that such as how should state health departments be produce new data and knowledge. Often the as- organized, independent entities or part of a health sumption is made that we can move on programs, and social services umbrella organization? How can including preparedness, without understanding local health departments develop and sustain shar- what’s necessary to develop, implement and evalu- ing agreements across jurisdictional boundaries to ate health or public health programs. The required assure that the capacity for emergency response knowledge and skills come as the result of efforts exists for the communities they serve? How are to examine the questions and find answers that broad categorical areas of public health, including have utility and can be used to deal with whatever preparedness, funded? How do decisions about this the problem is that presents itself. In fact, one of funding impact other areas of public health responsi- the most useful things we can engage in, during bility? Does, for example, an emphasis on prepared- tight budget times, is the questions of efficiency ness detract from the community’s immunization and effectiveness of our programs. We need to use efforts and lead to the increase in whooping cough limited resources as best we can — and research is cases we are experiencing in the U.S.? key to knowing how best to accomplish our goals. These are not trivial questions; in fact the latter As with other public health programs, successful issue has prompted a study by GAO and one in the implementation depends on the infrastructure to Department of Health and Human Services Assis- deliver the program. The workforce, technology, tant Secretary of Planning and Evaluation’s office. finances and organization influence tremendously the capacity of the public health system and its Over the past century, public health has played a units to respond to any eventuality. It is impera- vital role in efforts to address these issues. Strong tive that we have the best knowledge possible on public health programs are a critical component the infrastructure that allows us to be successful to our nation’s ability to thrive, even in trying eco- in our efforts to implement any public health pro- nomic times. In order to have those programs, it gram, including preparedness. is imperative that we have the knowledge that lays the groundwork for that success. Working with Recently, the Robert Wood Johnson Foundation and all segments of the health community in a time CDC led an effort to establish an agenda of the re- of economic instability and tremendous change in search questions we need to know in order to most our health care system, we can and must have the effectively develop and implement public health pro- information and knowledge that allows for suc- grams. The list of research questions that covered cessful public health programs and assures that we workforce, structure, finance and other infrastruc- are prepared for either natural or unnatural disas- ture issues was several pages long, and reflected ters. As Gandhi observed, “It is health that is real the questions and concerns of practitioners, policy- wealth and not pieces of gold and silver.” makers, and public health academicians alike. The 47 EXPERT PERSPECTIVE Public Health Legal Preparedness in the United States An Interview with James G. Hodge, Jr., J.D., LL.M., Lincoln Professor of Health Law and Ethics and director of the Public Health Law & Policy Program and director of the Network for Public Health Law-Western Region at the ASU Sandra Day O’Connor College of Law O n September 27, 2011, the Trust for America’s Health conducted an interview with Professor James G. Hodge, Jr. regarding the nature, scope and challenges of emergency strengthen public health and emergency response efforts by providing essential personnel for overrun medical systems dur- ing a crisis. Thousands of skilled, vetted volunteers streamed to legal preparedness. Edited for content, questions and responses Louisiana and surrounding states post-Katrina in 2005. Their ef- are as follows: forts were greatly facilitated through legal interventions designed to support trained volunteers and encourage their participation. What is the role of law in emergency preparedness from your point of view? Normally, you cannot just bring in out-of-state practitioners Law is an essential component of emergency preparedness. Laws and let them practice medicine in any given state. In non-emer- define what constitutes an emergency, disaster, or public health gencies, state-based licensing laws and other legal liability issues emergency. They authorize (and at times prohibit) specific actions. would stop the deployment and use of out-of-state volunteers. Laws set roles, responsibilities, and liabilities for public and private The emergency legal environment has to evolve quickly to allow sector responders and entities. Ultimately, it is law that helps to skilled volunteers to step in seamlessly and aid in the response. provide guidance for emergency responses, and, when practiced Legal techniques that provide licensure reciprocity and liability appropriately in real-time, laws can contribute to declinations in coverage for volunteers make their contributions possible. Each preventable morbidity and mortality in declared emergencies. of these and many other legal tools have been crafted in the last decade following the terrorist acts of September 11, 2001, and What types of legal challenges do states and other gov- the ensuing anthrax exposures that fall. My ESAR-VHP Legal ernments face in emergency preparedness? and Regulatory Issues Report, prepared for DHHS’ Assistant Legal preparedness challenges across jurisdictions are immense. Secretary for Preparedness and Response, provides some helpful One central challenge of public health legal preparedness relates tables and analyses across the 50 states related to these issues. to meeting surge capacity (i.e., the ability of public health and The report and other helpful documents are available online at medical systems to care for a massive influx of patients during http://www.publichealthlaw.net/Projects/ESAR-VHP.php. public health emergencies). Meeting surge capacity is key to sav- ing lives and preventing the spread of communicable diseases Are there any major gaps in state or local public health in emergencies. Major concerns surrounding surge capacity preparedness laws? include distributing and dispensing antivirals, vaccines, or other Over the last decade, there have been systematic, wholesale changes medicines; increasing health care staffing; and securing adequate to emergency response laws and policies at all levels of government. and safe spaces for the influx of patients. None of these objec- Despite solid models introduced to help policymakers considering tives is possible without real-time legal assistance and support. reforms, many of the legal changes are not uniform across states. While most emergency laws are written broadly enough to allow ex- For example, personnel required in a crisis (including out-of-state tensive and flexible responses, sometimes the breadth of these laws physicians, nurses, and assistants, as well as mental health provid- leads to confusion, debate, and delay in actual emergencies. ers) must be capable of adapting quickly to implementing a crisis standard of care under potentially changing rules regarding scope In addition, there are extensive variances in the legal frameworks of practice. These adaptations necessitate legal changes, as well, related to surge capacity, especially in licensing and reciprocity. inherent in declarations of public health emergency that may typi- Lacking uniform protections concerning common negligence cally precede major jurisdictional shifts in health care personnel. claims, for example, it is empirically shown that volunteers might hesitate to help during a crisis. Volunteers and entities that How can law specifically facilitate health care voluntarism deploy or host them seek strong protections from liability, but during emergencies? sometimes find divergent standards across jurisdictions. There are many legal paths to ensuring adequate and skilled numbers of volunteer health practitioners in declared emergen- What can jurisdictions do to address these gaps? cies. Whether coming through state-based ESAR-VHP pro- Active, advance efforts to assess and address legal preparedness grams, locally-run MRC units, or other routes, civilian volunteers gaps are key. There are several excellent models that provide 48 uniform approaches to key legal preparedness issues. The of CDC. Legally, CDC may be positioned not only to distribute Model State Emergency Health Powers Act, drafted in 2001 by SNS supplies, but also determine the priorities through which the Centers for Law and the Public’s Health at Georgetown and the supplies may be dispensed across states. Johns Hopkins Universities, provides a comprehensive series During the 2009/2010 H1N1 pandemic, CDC dispensed avail- of legislative and regulatory provisions for state and local public able vaccines to states together with its policy outlining who health emergency responses. Nearly every state legislature has should be first in line to receive them. Many state and local considered its provisions in whole or part, and 38 states, as well actors adhered to CDC’s guidance; others did not, however. as the District of Columbia, have passed related bills, according Once these supplies get to points of dispensing, CDC ultimately to the Center’s legislative tracking available at http://www.publi- may lose control over how they are provided to local popula- chealthlaw.net/ModelLaws/MSEHPA.php. tions, although legally it can set a prioritization plan. The Emergency Management Assistance Compact (EMAC), ex- What steps can be taken to improve public health legal ecuted now by all states, provides licensure reciprocity automati- preparedness across all jurisdictions? cally for all “state or local agents” serving across state borders While emergency legal preparedness has improved immensely during declared emergencies. It also provides clear limitations on over the prior decade since 9/11, there are still important gaps liability. Of course, not all volunteers are state or local agents. to be filled at every level of government, but most notably at Private sector volunteers through ESAR-VHP or MRC systems the state level given their prominence in protecting the public’s may garner similar protections under the Uniform Emergency health. States seeking to improve preparedness through law Volunteer Health Practitioners Act of 2007, but only if states might consider actions to: have adopted its provisions. Presently, only 12 states, the District of Columbia, and the Virgin Islands have done so according to 1. Assess critical legal and policy issues that need to be ad- the Uniform Law Commission (available at http://www.nccusl. dressed in advance of the next emergency. Events like Katrina, org/Act.aspx?title=Emergency Volunteer Health Practitioners). the H1N1 pandemic and regional emergencies provide ample il- lustrations of potential gaps in law and policy. So do specific ob- How do federal, state and local preparedness laws differ? servations among emergency and public health responders wary Federal, state and local governments have very different legal of key dilemmas before they arise. Policymakers must routinely authorities. States possess the broadest authority to address study and seek to address these issues affirmatively. public health threats, which they may share in part with local governments depending on the degree of “home rule” that 2. Address the gaps. Identifying gaps is one thing; solving them is assigned to these local governments. This varies consider- is another. Hoping for real-time solutions during an emergency ably across states. Historically, the federal government’s public is counter-productive. Lives may be lost while legal issues are health emergency law responsibilities are more limited to pro- hammered out. This is unacceptable and yet easily corrected. viding significant guidance, resources and expertise, except as Using existing models, practice guidance, or comparisons to pol- related to emergencies implicating national security interests for icy fixes that work in other jurisdictions, states can legislatively which federal jurisdiction is extensive. or via regulation address gaps without waiting for inevitable complications during the next emergency. While the federal government has reorganized itself since 2001 to better handle national response efforts during emergencies, 3. Practice legal preparedness. Like other preparedness skills state and local governments ultimately remain on the frontlines. and capacities, legal preparedness must be practiced to be ef- The federal government defers to state and local agencies in fective. Everyone involved in law and policy responses during many cases, subject to some prominent exceptions. emergencies should work through legal scenarios in “real-time” during training exercises. Practicing what I like to call “legal triage” How can these differences in federal, state, and local powers through actual exercises or education efforts helps to identify and complicate or impede emergency response efforts? remedy gaps — it is an investment that will facilitate future emer- One example concerns the distribution of antivirals, vaccines, gency responses in real-time. CDC and NACCHO have worked and other medicines or supplies. To alleviate the potential for recently with the Network for Public Health Law to develop a national shortages in public health emergencies, Congress has brief public health legal preparedness curriculum of particular value authorized the creation of stockpiles of antivirals and vaccines for state and local officials (which is still under federal review). kept by the SNS, controlled by CDC. These assets are available to supplement state and local response efforts at the discretion 49 EXPERT PERSPECTIVE Disaster Preparedness for Mass Casualties from Explosive Devices—the Role of Injury Prevention and Control By Richard W. Sattin, M.D., F.A.C.P., president-elect, Society for Advancement of Violence and Injury Research and professor and research director at the Department of Emergency Medicine at Georgia Health Sciences University T ornadoes, earthquakes, hurricanes, tsunamis and terrorist bombings have one major health outcome in common— most deaths during these disasters occur due to injury. Drown- those plans and testing alternative strategies are critical to en- sure the care for those injured from explosive devices during a real episode is optimal, especially if a large explosion-related ing, being crushed by a collapsing building or other structure, mass casualty event occurs on our already fragile and overbur- being struck by a moving object, being thrown against a struc- dened response system. The ability to push out key information ture or an object are common outcomes and are predictable. on best practices quickly and efficiently to health professionals Many non-medical types of preparedness exist that reduce inju- who are suddenly faced with a situation with which they are not ries and deaths from natural disasters, including building codes familiar will be essential to optimizing care. (retrofits for earthquakes, construction of safe rooms in tornado During a mass casualty event, health professionals use triage areas, use of hurricane shutters and elevated construction in protocols to identify those persons needing immediate, lifesav- hurricane/typhoon areas), and improved planning and regulation ing care and transport to critical care hospitals while avoiding for land use and building of homes and businesses. Better and overcrowding at those hospitals. Due to the potential extensive more effective preparedness and evacuation plans could lessen nature of a mass casualty event, outcomes are dependent on the impact of these injuries on individuals, families and society. a broad continuum and rapid coordination of multidisciplinary As we remember 10 years later the events of 9/11, it is clear that care together with the availability of hospital resources (e.g., there remain critical issues on how to prevent and lessen the operating theaters, radiology suites, number of intensive-care complications of injuries, including death, disability and emotional beds and respirators, medical specialty care). The number of stress during catastrophic events. Much of the preparedness victims can quickly overwhelm the capacity of the health care for mass casualty events in the United States has focused on the system. Health care providers can expect casualties to arrive threat of biological, chemical, radiation and nuclear incident. within 20 minutes of the bombing, with most of the total victims As events in Oklahoma City, New York City, Madrid, London, presenting for care within two hours. Most current planning for Mumbai, Bali and elsewhere have shown, the use of conventional mass casualty events assumes that the emergency medical re- weapons and explosive devices is a far more likely scenario, sponse will function normally. Auf der Heide provided a review and the resultant injuries present unique triage, diagnostic and of the literature regarding disaster planning (The importance of management challenges to health care providers. Injuries from evidence-based disaster planning Annals of Emergency Medicine explosive materials due to terrorism or other causes are a con- 2006;47, 34–49) indicating, however, that the actual response stant threat that happens worldwide. The remainder of this differs considerably from these planning assumptions; there is commentary will primarily use mass casualties from conventional uncoordinated emergency dispatch, lack of hospital notifica- explosive devices to explain current injury prevention and con- tion and communication, significant bystander involvement and trol principles and ways to strengthen policies and procedures. rescue, absent or ineffective scene triage, self-referral and the transport of many, if not most, patients to the nearest health- Few physicians in the United States, other than those who care facility. What occurs is, therefore, reverse triage, that is, have served in combat areas, have been trained in the care of the least-injured patients arrive at the nearest hospitals before the injured blast victim or have taken care of a patient who the critically injured patients do. The extent of this reverse tri- has sustained injuries from an explosion. Persons injured from age has been shown to correlate directly with the mortality of an explosion often have a much greater number of penetrat- those patients who were critically injured in the event. ing wounds compared with the routine trauma patient. Most hospitals have emergency response plans and do have regular Injury has been described, until recently, as the “neglected dis- exercises, but exercises do not approach the chaos which ac- ease” since it occurs in such great numbers, but has been tacitly companies a mass casualty event. Identifying weak points in accepted as a normal occurrence of living in a modern society. 50 The 1985 report, Injury in America, noted, however, that a public lance data are analyzed to determine the magnitude, scope and health approach similar to that used for other diseases could characteristics of a health problem; to study the factors that lead to significant reduction in injuries. To understand the con- increase the risk of disease, injury, or disability; to determine cepts of injuries from explosions, one must also understand the which risks are potentially modifiable; to assess what can be basic paradigm of injury control. Injury can affect any person’s done to prevent the problem using the information about causes body part, organ, or system and its functioning and can have and risk factors; to design, pilot test and evaluate interventions, both short-term and long-term effects. It is not merely survival and to then implement the most promising interventions on a after an explosion-related injury that is important, but rather the broad scale. Much data during a mass casualty event are perish- ability of the individual to attain maximum physical recovery, to able since there are no active plans to collect these data. This survive financially, and to enable secure, productive lives regard- is unfortunate since determining ways to prevent and improve less of functional status. As with other diseases, injuries can be outcomes from injuries are dependent on understanding what viewed as a relationship between a person (the host), an agent took place and how patients were managed. Standardized mini- and the environment. Unlike other diseases, the underlying mum data collection instruments and definitions are essential agent of injury is not a microbe or carcinogen, but is energy, to generate reliable intra- and inter-country comparisons of most often in the form of mechanical force. The dose of energy injuries from explosions. Data collected through this integrated received, the dose’s distribution, duration and rapidity, and the approach can be used to make the case for the design of safer individual’s response to the transfer of the energy can determine buildings, improve evacuation plans and plan the allocation of if a physical injury occurs or is prevented. For example, a large medical and rescue resources and operations (e.g., ambulances, mechanical energy load quickly transmitted to a hip during a fall blood supply). These enhanced surveillance systems can help involving an older person may lead to a fracture. If that same public health professionals link the findings to the management energy load could be dissipated through use of energy-absorbing decision process and disseminate the data collected to improve flooring or mats or through hip pads or other new technologies, the level of preparedness nation-wide. fewer persons would sustain hip fractures. Similarly, the design Over the last decade, we have made significant strides in caring of safer buildings (e.g., the use of blast-resistant materials such as for the explosion-related victim but further progress in learn- tempered glass and window coverings) dissipates the energy load ing how to maximize care and protect the public is needed. and reduces the numbers of persons injured from an explosion. Further integration of trauma systems and evaluation of that The basic injury paradigm of host, agent and environment also integration with law enforcement, fire prevention, power supply needs to include the effect of the social environment. Victims and other infrastructure issues should take place to improve the of explosions can also experience adverse mental health conse- care of the acutely injured. As communication can be difficult quences including depression, anxiety and low self-esteem, and during the chaos following a mass casualty event, it is important harmful physical health consequences such as suicide attempts, to continue to improve communication systems’ interoperabil- cardiovascular disease and substance abuse. The emotional, ity. Accurate and reliable data systems are critical to determine financial, and psychosocial effects of an acute injury may be how best to prevent injury and care for the injured so identify- even more debilitating than the actual physical injury. An acute ing and improving ways of collecting data, making full use of injury has not just an immediate effect on the injured person, existing data systems and having access to the real-time use of but also a long-term “ripple effect” on that person’s life and the data during an event would be major steps forward. Educa- lives of others in his or her family and community. Temporary tional programs for health care providers are currently available, or permanent loss of income, changes in personal relationships but the exact type and extent of education and the need for and including income responsibilities, and difficulty in care and finan- amount of refresher courses for various providers (pre-hospital cial support for one’s children or parents may be a significant and hospital) to ensure an appropriate level of knowledge and social outcome from the injury. Health care providers may also expertise is not precisely known. Many serious secondary inju- be subject to psychosocial problems resulting from caring for ries occur after a disaster so further coordination between di- so many injured persons in such a short time period. A com- saster preparedness and acute injury care management of these munity’s societal and functional infrastructure may be affected difficult environments and situations is necessary. By integrating extensively during a mass casualty event. further injury prevention and control into disaster preparedness, we will continue to make major strides in preventing injury and An understanding of the epidemiology of explosion-related in providing improved medical, mental health and rehabilitative injuries also requires surveillance data to help identify ways to services to survivors of disaster events. prevent or reduce vulnerability to these types of events. Surveil- 51 Federal Policy Issues and Recommendations I n the coming year, implementation of the reauthorized public health preparedness legislation provides a new opportunity to address ongoing challenges that public 4 Section health preparedness faces while the field considers how to allocate increasingly scarce resources during budget cutbacks. TFAH has identified some top areas of concern, D. Increasing the ability of the public health including: and health care systems to provide mass care during emergencies; A. Assuring dedicated and ongoing funding for emergency preparedness and strengthening the E. Working with communities to cope with core public health infrastructure nationwide; and recover from emergencies, particularly for the more vulnerable members of commu- n ommentary: Improving Collaboration between C nities including children, seniors, people with Federal, State and Local agencies in Planning for a underlying health conditions, racial and ethnic Worst Case Scenario: A Broad Aerosolized Dispersal of minorities and lower-income individuals; Weaponized Anthrax in a Major Metropolitan Area. By Alonzo Plough, PhD, MPH, Director, Emergency n ommentary: Vulnerability, Resilience and Mental C Preparedness and Response of the Los Angeles County Health Considerations in Disaster Planning and Re- Department of Public Health and Member of the sponse: Do Resources Match the Rhetoric? By David Board of Directors of the Trust for America’s Health Abramson, PhD, MPH and Irwin Redlener, MD, Co- lumbia University Mailman School of Public Health B. Modernizing biosurveillance to rapidly and accurately detect outbreaks and threats; F. Coordinating public health preparedness with strategic implementation of the FDA Food C. Improving the research, development and Safety Modernization Act of 2011. availability of vaccines and medications; n ommentary: Food Safety: New Law Takes a Big C n ommentary: Surveillance: Essential for Public Health C Bite Out of the Problem, but Leaves Much on the Preparedness and Response, By, Jeffrey Engel, M.D., Plate. By Erik D. Olson, Director of Food Programs State Health Director, Division of Public Health, North at The Pew Charitable Trusts Carolina Department of Health and Human Services A. ssuring Dedicated Funding and Strengthening A Public Health Preparedness Infrastructure The United States made a significant investment ing a fully-staffed and trained workforce, vac- to improve public health preparedness after the cine and medical countermeasure research and September 11, 2001 and anthrax tragedies. The production, biosurveillance programs, medical main funding streams have included bolstering surge capacity and providing support for com- basic federal capabilities; improving national munities to cope with and respond to crises. vaccine and medication development, stockpil- Historically, the federal approach to prepared- ing and distribution; improving state, local and ness has not provided a stable or sustained level hospital preparedness; and a one-time funding of support for federal, state or localities. The influx to support pandemic flu preparedness. most consistent pattern in U.S. preparedness While the funding has resulted in significant funding is inconsistency. These inconsistencies progress in the past decade, the Ready or Not? make it difficult for states to maintain programs, reports have documented a number of major capabilities and enough employees, particularly gaps that still remain, particularly in maintain- trained scientific experts, for emergencies. 53 Preparedness requires ongoing funding dedi- needed, and 3) any actions they or their fami- cated to ensure that basic capabilities are in lies should take to protect themselves. place and that experts have the training and sys- n ommunication that is able to reach and take C tems to quickly act in the face of emergencies. into consideration at-risk populations. Ten years ago, the nation was caught off-guard n treamlined and effective evacuation of at- S when the public health system was unprepared risk populations with special medical needs. for emergencies. Many core public health func- tions, including epidemiology, laboratories and n An informed and involved public that can pro- outbreak surveillance were lacking. Reviews by vide material and moral support to professional the IOM, CDC, GAO and other experts found responders, and can render aid when necessary the country’s public health “infrastructure had to friends, family, neighbors and associates. greatly deteriorated.”229, 230, 231 On top of that, Dedicated funding is needed to support the little groundwork was in place for hospitals unique capabilities and training required to and public health departments to respond to maintain adequate levels of emergency pre- the massive influx of potential anthrax samples paredness, including: and there was a lack of coordination, training, leadership and communication within the field n eadership, planning and coordination: An L and for public health departments to work with established chain-of-command and well de- other first responders. fined roles and responsibilities for seamless operation across different medical and lo- The United States has learned several lessons gistical functions and among federal, state from the September 11, 2001 and anthrax trag- and local authorities during crisis situations, edies, Hurricane Katrina, the H1N1 pandemic including police, public safety officials and flu and other emergencies, most notably that other first responders. being prepared means having: n ore public health capabilities: Basic public C n unctional core public health systems in place, F health systems and equipment, including lab- including epidemiology, laboratories, commu- oratory testing and communications that keep nication and outbreak surveillance; and pace with advances in science and technology. n mergency-specific training and systems E n n expert and fully-staffed workforce: Highly A across a variety of threats. Similar to military- trained and adequate numbers of public readiness, public health emergency readiness health professionals, including epidemiolo- necessitates ongoing planning, training and gists, lab scientists, public health nurses and upgrading of systems and technology. doctors, and other experts, in addition to Basic preparedness involves: back-up workers for surge capacity needs. n Rapid detection of and response to emer- n odernized technology: State-of-the-art labo- M gency disease threats, including those caused ratory equipment, information collection and by bioterrorism. health tracking systems. n Intensive investigative capabilities to quickly n apid development and ability to manufac- R diagnose an infectious disease outbreak or to ture vaccines and medications: A streamlined, identify the biological or chemical agent used safe, effective system to ensure rapid research in an attack. and production of medical countermeasures to protect people from emerging threats. n Surge capacity for mass events, including adequate facilities, equipment, supplies and n re-planned, safety-first rapid emergency re- P trained health professionals. sponse capabilities and precautions: Tested plans and safety precautions to mitigate po- n Mass containment strategies, including phar- tential harm to communities, public health maceuticals needed for antibiotic or antidote professionals and first responders. administration and isolation and quarantining when necessary. n mmediate, streamlined communications ca- I pabilities: Coordinated, integrated communi- n treamlined and effective communication S cations among all parts of the public health channels so health workers can swiftly and ac- system, frontline responders and the public. curately communicate with each other, other Communications capabilities must include front line workers and the public about 1) the back-up systems in the event of power loss or nature of an emergency or attack, 2) the risk overloaded wireless channels. of exposure and how to seek treatment when 54 It is also essential to consider the costs of re- ties — and trying to build capacity during an sponding to disasters and the toll it takes on emergency response. In these situations, as was health departments — to find mechanisms to evident during the anthrax attacks and H1N1 provide support for rebuilding after an incident outbreak, states and localities have to deal with and response have happened. contracting and bureaucratic restrictions, which often limit the ability to spend funds quickly or The current economic situation is compound- to enter into fast, short-term contracts. Develop- ing the problems created by the historic incon- ing emergency capacity as an event is unfolding sistent funding for emergency preparedness. is particularly challenging when health depart- Combined federal, state and local budget cuts ments do not know how long they will have re- are resulting in the loss of core programs and sources to sustain their capabilities or needs. functions and major staff losses. Even before the recession, federal support for preparedness States and localities have reported it will take began to decline. Federal funds for state and them longer to achieve the 15 national capabili- local preparedness declined by 38 percent from ties for public health preparedness due to lim- fiscal year (FY) 2005 to 2012 (adjusted for infla- ited resources.232 tion) — and additional cuts are expected under Many states and localities have taken creative budget sequestration. approaches to budget and spending restric- A decade of progress in preparedness is at risk due tions, such as making flexible use of their public to the cuts. Federal, state and local health depart- health employees during disasters, to reassign ments will no longer be able to maintain basic individuals to other duties for the time of emer- functions needed to respond to emergencies. gencies. But in some cases, federal grants re- strict this ability if the personnel are funded to For the future, this is likely to mean a reliance support other specific programs, such as mater- on emergency supplemental funding to try to nal and child health. CDC and ASPR are cur- quickly ramp up response efforts after an event rently working with the states and localities to has happened. find ways to be able to make quick use of emer- This puts states and localities in the position gency supplemental funds easier, but emer- of trying to respond without core capabili- gency support cannot fill ongoing gaps. RECOMMENDATIONS In addition to dedicated and sustained support mental funds into existing grant mechanisms for preparedness, TFAH also recommends a se- without additional requirements; ries of actions to ensure preparedness funding n ranting authority to the U.S. Secretary of G is more predictable, to cut down on federal bu- HHS to allow states to also use personnel reaucratic red tape and to ensure flexibility so that are part of other federal programs in re- that when emergencies happen, resources and sponse to a public health emergency; and emergency supplemental support can be used quickly and effectively. This effort requires: n mproving coordination among emergency pre- I paredness grant programs, including PHEP, n stablishing multi-year grant cycles with E HPP, FEMA and CDC grants, through increased greater flexibility in states’ retention and use leadership and direction and by encouraging of carry forward and unexpended funds; uniformity of guidelines and requirements to n reating a mechanism to fast track the award- C maximize efficiency, carrying out the MOU ing and programming of emergency supple- agreements that the agencies have entered into. 55 Overview of Federal Funding for Preparedness Since 2001 In early 2002, HHS announced $1.1 billion in of a potential pandemic flu outbreak made it funding for state public health, hospital and clear that while initial progress had been made medical preparedness planning for a bioterror- to begin to improve federal, state and local ist event.233 In June 2002, Congress passed the public health preparedness, major areas of vul- Public Health Security and Bioterrorism Act and nerability could not be addressed with the level appropriated new federal funds to fill gaps and of resources provided. In 2005, President Bush help modernize the public health system to be announced the National Strategy for Pandemic able to respond to bioterror and health threats. Influenza and in FY 2006, Congress appropri- The funds were devoted to: ated more than $5.6 billion in one-time funds to support pandemic flu preparedness activities, n Improving national capabilities and policies at particularly to support vaccine research, produc- CDC and other areas within HHS; tion and delivery and surveillance, and included n Expanding the SNS, which is a federal reposi- $600 million in grants to state and local health tory of vaccines, medications and other medi- departments. cal equipment for use in emergencies; In 2006, Congress passed PAPHA, reauthoriz- n Creating a medical reserve corps and volun- ing the 2002 bill to expand the focus toward teer networks for support; and more of an “all-hazards” approach to improve readiness for a wider range of potential threats. n Developing two grant new programs, PHEP, The bill created ASPR to better coordinate and which supports state and local public health develop policy at HHS, which included BARDA preparedness, was initially funded just under to provide an integrated, systematic approach to $1 billion annually in FY 2003 — and the the development and purchase of the necessary Hospital Preparedness Program (HPP) was vaccines, drugs, therapies and diagnostic tools funded at around $400 million annually. for public health medical emergencies, which In 2004, Congress passed the BioShield Act includes overseeing Project BioShield, as well as and appropriated $5.6 billion to help fill a major taking over management of the medical reserve gap in the country’s ability to quickly develop corps and volunteer programs, the HPP grants and procure vaccines and other medications and other programs. that could be needed to prevent or respond to When the H1N1 pandemic flu began, Congress health threats. allocated more than $8 billion in one-time funds In 2005 and 2006, following Hurricanes Katrina in FY 2009 to fill immediate needs and gaps to and Rita, national awareness of the implications respond to the outbreak.234, 235 CDC Office of Public Health Preparedness and Response Funding Totals and Select Programs FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 CDC Total $1,747,023,000 $1,533,474,000 $1,507,211,000 $1,622,757,000 $1,631,173,000 $1,472,553,000 $1,479,455,000 $1,514,657,000 $1,522,339,000 $1,415,416,000 $1,306,906,000 State and Local Preparedness $940,174,000 $1,038,858,000 $918,454,000 $919,148,000 $823,099,000 $766,660,000 $746,039,000 $746,596,000 $760,986,000 $664,294,000 $658,850,000 and Response Capability* SNS $645,000,000 $298,050,000 $397,640,000 $466,700,000 $524,339,000 $496,348,000 $551,509,000 $570,307,000 $595,661,000 $591,001,000 $509,486,000 *Includes Public Health Emergency Preparedness (PHEP) cooperative agreements, Centers for Public Health Preparedness, Advanced Practice Centers (FY2004- 09), Cities Readiness Initiative, U.S. Postal Service Costs (FY 2004), All Other State and Local Capacity, and Smallpox Supplement (FY 2003) CDC Funding Source: FY 2002-09: http://www.cdc.gov/phpr/publications/2010/Appendix3.pdf Source: FY 2010-11: U.S. Centers for Disease Control and Prevention. 2011 Operating Plan. http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan_cdc.pdf. Source: FY 2012: http://rules.house.gov/Media/file/PDF_112_1/legislativetext/HR1540crSOM/psConference%20Div%20F%20-%20SOM%20OCR.pdf, p. 26 56 Office of Assistant Secretary for Prepardness and Response Funding Totals and Select Programs FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 ASPR Totals -- -- -- -- $632,000,000 $694,280,000 $632,703,000 $788,191,000 $891,446,000 $913,418,000 $926,724,000 HPP^ $135,000,000 $514,000,000 $515,000,000 $487,000,000 $474,000,000 $474,030,000 $423,399,000 $393,585,000 $425,928,000 $383,858,000 $380,466,000 BARDA -- -- -- $5,000,000 $54,000,000 $103,921,000 $101,544,000 $275,000,000 $304,948,000 $415,000,000 $415,000,000 Bioshield Special -- -- $5,600,000,000* -- -- -- -- -- -- -- -- Reserve Fund * One-time Funding ^HPP moved from HRSA to ASPR in 2007 and includes ESAR-VHP Source: HPP FY 2002: http://archive.hhs.gov/budget/04budget/fy2004bib.pdf, p. 14 Source: HPP FY 2003: http://archive.hhs.gov/budget/05budget/fy2005bibfinal.pdf, p. 16 Source HPP FY 2004:http://archive.hhs.gov/budget/06budget/FY2006BudgetinBrief.pdf, p. 16 Source: HPP FY 2005: http://archive.hhs.gov/budget/07budget/2007BudgetInBrief.pdf, p. 20 Source: BARDA FY 2005-06: http://www.hhs.gov/asrt/ob/docbudget/2010phssef.pdf, p. 45. Source: FY 2006: http://www.hhs.gov/asfr/ob/docbudget/2008budgetinbrief.pdf, p. 109 Source: FY 2007: http://www.hhs.gov/budget/09budget/budgetfy09cj.pdf, p. 288 Source: FY 2008-09: http://www.hhs.gov/asfr/ob/docbudget/2010phssef.pdf, p. 8 Source: FY 2010-11: http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan_phssef.pdf Source: FY 2012: http://rules.house.gov/Media/file/PDF_112_1/legislativetext/HR1540crSOM/psConference%20Div%20F%20-%20SOM%20OCR.pdf, p. 26 Flu Funding Totals and Select Programs FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 Flu Total1 $50,000,000 $183,000,000 $5,590,000,000* $138,000,000 $299,000,000 $8,456,000,000 $572,000,000 $300,525,000 $159,681,0002 State and Local -- -- $600,000,000^ -- -- $1,444,000,000 -- -- -- Pandemic Grants Vaccine Develop- $50,000,000 $183,000,000 $2,963,000,000 -- -- $1,944,000,000 $158,000,000 -- -- ment and Purchase 1 May include HHS agency budgets, Office of the Secretary and one-time funding. 2 This only reflects CDC’s influenza budget, other Agency budgets were unavailable as of publication ^ Appropriated in FY2006 to be used over the following three years * Obligated over three years Flu Funding Source: FY 2004-05: http://www.fas.org/sgp/crs/misc/RS22576.pdf, p. 2-3 Source: FY 2006: http://www.hhs.gov/asfr/ob/docbudget/2008budgetinbrief.pdf, p. 105 Source: FY 2007: http://www.hhs.gov/budget/09budget/2009BudgetInBrief.pdf p. 107 Source: FY 2008: http://dhhs.gov/asfr/ob/docbudget/2010budgetinbrief.pdf p. 107 Source: FY 2009: http://dhhs.gov/asfr/ob/docbudget/2011budgetinbrief.pdf, p. 9 Source: FY 2010: http://dhhs.gov/asfr/ob/docbudget/2011budgetinbrief.pdf p. 104 Source: FY 2011: Correspondence with Liz DeVoss at HHS November 4, 2011 Source: FY 2012: http://thomas.loc.gov/cgi-bin/cpquery/T?&report=hr331&dbname=112& 57 Prevention and Public Health Fund: Building Prepared Communities The Affordable Care Act (ACA) included the n orkforce training and fellowships — Grants W creation of a Prevention and Public Health Fund may help mitigate the devastating impact of (Fund) to provide communities around the budget cuts on the public health workforce, country $16.5 billion over the next 10 years to allowing more trained personnel to engage in invest in effective, proven prevention efforts preparedness and response activities. and to build the public health infrastructure. The n Immunizations — Grants have been allocated Fund is being used to support community and to improve the Immunization Information clinical prevention efforts, strengthen state and Systems (registries) and other immunization local health departments and the public health information technologies and to expand adult workforce, and support science and research. immunization programs and vaccination capac- The Fund has the potential to have a tremendous ity in schools.238 Growing the ability to quickly impact on the nation’s preparedness. The Fund and accurately vaccinate the population and is helping to build resilient communities through improving vaccine access and acceptance will investments in: be vital during an infectious pandemic that re- quires mass vaccination of the public. n Laboratory and epidemiology capacity — Pre- vention Fund money has been used to hire n Community prevention — In addition to ac- and train epidemiologists and laboratory scien- cess to vaccines and clinical prevention, the tists and expand the number of public health Fund is supporting chronic disease prevention laboratories using electronic laboratory infor- through community-level efforts to combat mation systems.236, 237 As part of public health obesity, tobacco use and poor nutrition. Indi- infrastructure grants, HHS is also promoting viduals with chronic conditions are particularly the capacity of health departments to use vulnerable during a disaster because of the electronic health records through participation need for specialized equipment and medicines in electronic laboratory reporting and training and difficulty with evacuation and sheltering. health information specialists. These special- Healthy communities, with an informed popu- ized systems are critical to the public health lation and strong connections between the system’s ability to quickly detect, pinpoint and public, healthcare system, and public health, respond to an emergency such as an emerging are better able to weather a disaster. infectious disease or foodborne outbreak. 58 EXPERT COMMENTARY A Decade of Public Health Preparedness: A Focus on Oregon By Mel Kohn, M.D., MPH, State Health Officer and Public Health Director, Oregon Health Authority I must be getting old because I remember the days before we had a public health preparedness program. Outbreak investi- gations were handled almost exclusively by our communicable dis- and monitored and helped manage our health care systems’ needs. Because Oregon is on the Pacific rim, there was a very high level of concern about how the nuclear accident in Japan would affect the ease epidemiologists. Even in Oregon, which witnessed the only safety of our food and water. Our Agency Operations Center and bioterrorist incident on U.S. soil in recent memory prior to 2001 our communications skills and infrastructure made it possible for us — the salmonella outbreak engineered by followers of Bhagwan to provide reliable information to a fearful public on these issues. Shree Rajneesh in a small town near the Dalles, Oregon — pre- While by definition none of us can predict what the next major paredness was not a core public health activity. It almost seems emergency will be, climate change, regardless of one’s beliefs quaint in retrospect, but I remember when we got our first fed- about its causes, is likely to be a major factor. Climate change-re- eral preparedness grant, and used it to hire a single staff person. lated extreme weather events such as floods, forest fires, droughts But everything changed with the 9/11 and anthrax attacks and heat waves, are already becoming more common, and each of of 2001. These events, together with the SARS outbreak of these will bring the potential for serious health effects that a robust 2003 and Hurricane Katrina in New Orleans in 2005, spurred public health preparedness system can do a great deal to mitigate. a dramatic federal investment in public health preparedness Today there is no doubt that the public expect the public health sys- at the state and local level. After many years of neglect of the tem to have the capability to competently protect their health dur- public health infrastructure, preparedness dollars were used ing emergencies. This is not an optional service. So in the face of to plug holes in our fraying epidemiologic and laboratory infra- major budget cuts, how will we be able to meet those expectations? structure, as well as to build new capacity in incident command structures, agency operations centers, and communications. We should use this budget crisis to look for efficiencies and new ways of working that will enable us to stretch our dollars further. In Oregon, here’s a list of some of the most important things For example, integration of healthcare and community-based that these investments have bought for us: preparedness activities could yield some efficiencies, and should n Capacity for laboratory testing that enables us to investigate be done whether or not there is a budget crisis. But it’s fantasy to and respond to threats in a more timely way (think the spate think that we will be able to absorb reductions of this magnitude of white powder incidents in the wake of the anthrax at- simply by finding efficiencies. Next year we are expecting ad- tacks, or the rapid testing in-state of flu samples during the ditional reductions in federal preparedness funding. Should they H1N1 influenza pandemic); come to pass, public health in Oregon will be forced to reduce our n 24-7 responsiveness of the public health system so when capacity in some serious ways that will not be overcome by finding someone calls the health department for an emergency efficiencies. We have reached the point where we will lose ground there is someone to answer the phone and provide help; on the investments we’ve made, and our ability to do this work will n Communications hardware, software and training that enable us to be seriously compromised, with life and death consequences. provide accurate and timely information to the public — the best It’s difficult to predict how or where the funding-induced deficien- antidote to the fear and anxiety that are a major part of any disaster; cies in our preparedness system will manifest themselves. New Or- n The ability to use incident command methodology so that leans survived for many years, despite design defects and insufficient we can quickly and effectively communicate with partners maintenance of its levee system. Funds that would have been spent in other agencies and utilize the state and local emergency on the levees were used for other priorities that probably seemed management system including our National Guard; and more urgent at the time. Those funding decisions either went un- n The capacity to monitor healthcare system capacity and noticed, or perhaps were even applauded as good stewardship of needs so that life-saving resources in short supply during an public funds. And each individual decision about funding may have emergency can be targeted to where they are most needed. appeared at the time as if it could be absorbed with little impact. But in the hindsight of Hurricane Katrina, it’s clear that over time These investments have yielded substantial returns numerous times the net effect of all those decisions was disastrous and tragic. in recent years. Without our preparedness program, our response to the (hopefully) once-in-a-lifetime H1N1 influenza pandemic We should think of our public health preparedness system as a levee would have been impossible to mount; we could not have effectively system that protects us at times of critical need and cannot be fixed coordinated vaccine distribution, provided information to the public on the spur of the moment. Can we really afford to let that erode? 59 Training and Exercises: Major Component of Readiness Training and exercises are essential for public health According to a June 2011 paper, The Impact of workers to be ready for emergencies. Training is State and Local Budget Cuts on Public Health important so public health workers have the skills Preparedness, by PRTM, commissioned by the to perform in situations that are outside of day-to- IOM, “from table-top exercises to more realistic day activities, so they are prepared ahead of time to event simulations, exercises provide a chance to deal with unexpected issues that arise during crises. analyze the strengths, weaknesses, and areas of improvement in public health response.”239 Exercises provide public health workers the op- portunity to test out their plans and capabilities The paper found that training “has been one of before an actual event arises, and are an impor- the first areas to be de-prioritized during budget tant aspect of training, to understand roles and cuts. In general, state and local health depart- responsibilities during crises and to understand ments are running low funding, human resources how to coordinate with other first responders. and time necessary to train staff…. Efforts to These are often the only time and mechanism standardize and align training throughout the for understanding the roles and responsibilities of states, such as by integrating core curricula and other first responders — and often the only way standardizing core competencies, have also suf- other first responders, ranging from fire and po- fered.”240 In addition, according to the paper, lice departments, gain an understanding of the ca- exercises are being cut back, particularly in scope pabilities and limits that public health departments and sophistication. have. They are essential for minimizing confusion and maximizing efficiency during emergencies. Photo courtesy of APHL: Anthony Barkey, MPH, Senior Specialist, Public Health Preparedness and Response, APHL, providing information on public health laboratory outreach to first responder communities. 60 EXPERT PerSPECTIVE Improving Collaboration between Federal, State and Local agencies in Planning for a Worst Case Scenario: A Broad Aerosolized Dispersal of Weaponized Anthrax in a Major Metropolitan Area By Alonzo Plough, PhD, MPH, Director, Emergency Preparedness and Response of the Los Angeles County Department of Public Health and Member of the Board of Directors of the Trust for America’s Health O n September 8, 2011, the Los Angeles County De- partment of Public Health hosted a tabletop exercise requested by FEMA’s National Exercise Division’s. Goals were The DoD came to Los Angeles in December of 2009, and went through our anthrax response plans in detail. They quickly learned that we had been doing this planning, training to review and discuss emergency response plans, policies, and testing for nearly a decade under CRI, and that these plans and procedures for rapid MCM dispensing. The exercise was had been strengthened and honed by experiences during the prompted by Presidential Executive Order 13527 to establish H1N1 pandemic. The agency began to digest what supporting the federal capability for the timely provision of MCM follow- roles they could play to improve response to a WMD event. ing a biological attack, and involved several federal agencies In March of 2011, we met in Colorado Springs at Northern Com- including DHS, FEMA, HHS, CDC, DoD, and others. mand headquarters with representatives from DoD, DHS, HHS, Even though Los Angeles County and other large urban areas CDC, and the City of Chicago and District of Columbia health have worked extensively with the CDC, especially under the departments to develop the Commander’s estimate for deploying Cities Readiness Initiative (CRI) — which is directly responsible DoD assets (for example, the National Guard) in this kind of sce- for enhancing our ability to distribute MCMs through the SNS nario. The focus was on what kind of supports could be delivered — this work was not well known by many other federal agen- to large urban areas such as Los Angeles County in 24 hours. At this cies, including those who could play an integral role in WMD point, this project showed the wonderful interaction between pub- response. The exercise expanded the list of federal agencies lic health and DoD — something that had not previously existed. As participating in this planning, and aligned them on how they a result, DoD realized the agency had to adopt and adapt strategies could best support local and state efforts to provide prophylaxis to what public health had already built up and put in place. These to at-risk populations within 48 hours of a decision to dispense findings, plans and outcomes were taken to the Pentagon. if aerosolized weaponized anthrax was broadly dispersed using Following this planning project, this summer, we received a the newly drafted Federal Interagency Concept of Operations request from the White House to host a national level anthrax (CONOPS)—Rapid Medical Countermeasures Dispensing. exercise, with an eye toward the 10th anniversaries of the 9/11 Months before we began planning for the exercise, Los An- and anthrax tragedies. The objectives of the exercise were to: geles County had begun working with the Department of n Examine the approach and mechanisms for organizing and Defense Northern Command to develop interagency plans for managing the federal response to support medical counter- rapid medical countermeasure dispensing in an anthrax-type measure dispensing operations in a large urban area as out- event (the worst case scenario for a widespread weapons of lined in the draft the Federal Interagency CONOPS–MCM mass destruction (WMD) type event). At the request of the Rapid Dispensing; National Security Council and White House, we welcomed the opportunity to show how ready large jurisdictions are to n Assess the viability of the Federal Interagency CONOPS– respond to such an event, and how willing we are to partner MCM Rapid Dispensing; and with federal agencies to further improve timely response. n dentify policy and operational issues associated with the ef- I The goal during those meetings was to develop DoD’s concept fectiveness and timeliness of the federal capability to support of operations and to establish requirements for a federal rapid initial State and local dispensing of MCM. response to dispense MCM to an affected population following In addition to the federal agencies mentioned above, state and a large-scale biological attack. In short, the DoD wanted to learn national guards, local, county and state health departments, from us how we would respond to a WMD situation, what re- city, county and state emergency management agencies and sources and plans we had in place and how best they could sup- local/first responders (fire, police, etc.) took part. port our efforts to organize and distribute federal resources. 61 EXPERT PerSPECTIVE continued Improving Collaboration between Federal, State and Local agencies in Planning for a Worst Case Scenario The exercise was based on a massive anthrax quirements that go with the CRI — there wasn’t attack that was identified by multiple Biowatch widespread understanding of the accountability monitors across the county. It was designed for mechanisms that have been in place for years. a “worst case” type scenario: broad aerosolized While the exercise was successful, it did expose dispersal of weaponized anthrax. We did not some gaps in a unified federal-state-local response design the exercise to test capabilities beyond to a WMD. There is clearly still confusion and lack dispensing to focus the play (i.e., what happens of widespread information on the capabilities of once an attack is identified and whether 10 mil- large urban areas (especially if you look the WMD lion people could receive prophylaxes in 48 Center Bio-Response Report Card which was hours). Hopefully, at the end, we would have the released on October 12, 2011). The exercise and framework of how the federal family could assist that report card reflects a lack of engagement and state and local government in improving timely understanding of the great successes and advances response during such a situation. that have been made in high threat areas as a re- The exercise went extremely well. Planning for sult of CDC funding, particularly for MCMs. it opened a dialogue between federal response As a result of these meetings and the exercise, agencies and public health. Prior to this exercise, we were able to show how federal investment there had not really been a deep knowledge has improved local response to WMDs, and at DHS, FEMA or DoD of all that was accom- how closer interagency planning can improve plished by the CDC investments, especially in response even further. This work is not finished; directly funded cities like LA. Federal agencies if these resources don’t continue or are cut, came out of the exercise with a much clearer we’re in trouble. The public health emergency idea of what local and state capabilities had been preparedness budget should be protected the built up through CDC funding. Specifically, op- same way other national security budgets are portunities for federal MCM support in the first protected. 48-hours were identified in the area of logistics (drivers and vehicles, or access to federal logis- Over the last ten years, through the CDC fund- tics contractors to move supplies to dispensing ing and CRI, large urban areas have built up a sites), and less so on access to federal personnel tremendous capacity to respond to and stave off to assist with dispensing because of planning ef- a WMD attack. CDC should be applauded for forts with DoD. The exercise also provided the what they have put on the ground, especially in backdrop for a good discussion of what types of highly populated high threat large urban areas. nearby federal resources can be put into place Quite simply, there is a logic of preparedness and (postal trucks, military bases, people etc.) in the response that operates inside the Beltway that is 48 hour dispensing window. sometimes divorced from what has been accom- Basically, the participating federal agencies learned plished by and what would happen in the rest of about the return on investment from the CDC the country during a WMD attack. It is encourag- dollars and saw that local MCM distribution plans ing that federal agencies are reaching out to local were solid and had been tested both through and state governments to see what has been annual exercises and actual response during the built, and to develop interagency plans to improve H1N1 pandemic. Before the exercise, there just readiness to response. This enhanced partnership wasn’t a lot of knowledge about the planning, will allow us to save lives, reduce human suffer- training, exercises and performance measure re- ing, and speed recovery after a WMD attack. 62 B. Improving Biosurveillance: The United States lacks an integrated, national vance what they will need to know, and thus the approach to biosurveillance — which hampers most comprehensive approach to data collection the country’s ability to rapidly detect and track is needed. Right now, the fragmented system of bioterrorism attacks or disease outbreaks. data reporting drastically weakens our nation’s defense against emergency outbreaks. In a 2009 review, the National Biosurveillance Advisory Subcommittee (NBAS) found that there Improving the system means harnessing the op- “are more than 300 separate biosurveillance ef- portunities afforded by the nation’s transition forts underway in various federal, state and local to an integrated health information technology government agencies. These efforts are, for the (HIT) system with electronic health records at most part, neither integrated nor interoperable, the core. This could create economies of scale and propose to serve an array of purposes. The and provide more useful information to public effectiveness of many of these systems remains health and national security officials. Currently, untested and, in some cases, undefined.”241 the White House is examining the national bio- surveillance system. TFAH believes that any The existing structure is an assortment of many new national strategy should examine means to different systems that were built one disease or achieve interoperability, efficiency, and trans- crisis at a time, and the result is a set of frag- parency among various surveillance systems in mented, uncoordinated systems that cannot order to create an integrated biosurveillance share information effectively or quickly. operation. In particular, HIT must strengthen Remaining constantly aware of surrounding meaningful use requirements, which currently threats and our capacity to respond is critical to contain weak public health reporting require- dealing with emergencies. The U.S. disease sur- ments. Building the capacity of health depart- veillance system has been built one disease or cri- ments to receive this data started through grants sis at a time, resulting in archaic and static silos from the Recovery Act and Prevention and Pub- of information rather than as an interoperable lic Health Fund, but these investments need to system with a focus on prevention. Fixing the continue and grow. TFAH also urges ongoing, system will require that the nation fundamentally enhanced communication between Congress, rethinks how to do biosurveillance — for both CDC and the Office of the National Coordinator emergencies and routine public health issues. for Health IT (ONC) to ensure that ONC con- The particular challenge in the field of prepared- siders the preparedness implications of EHRs. ness is that officials don’t necessarily know in ad- RECOMMENDATIONS TFAH recommends modernizing and coordinat- n everaging new epidemiological data that L ing the biosurveillance system — using up-to-date results from health IT developments and health information technology (HIT) to be able electronic health records (EHRs) through to receive, compile and analyze data in a more enhanced communication between CDC and rapid and accessible fashion. This requires: the Office of the National Coordinator for Health Information Technology (ONC); n mplementing a new national strategy that I examines means to achieve interoperability, n nsuring the system includes electronic report- E efficiency and transparency among various ing of laboratory test requests and results; and surveillance systems in order to create an in- n llowing Poison Control Centers to be eligible for A tegrated biosurveillance operation; grants to establish surveillance networks, along with hospitals, public health and other facilities. 63 The Current State of Biosurveillance Biosurveillance is complicated by the fact that: (2) ensuring adequate workforce, training, and systems; and (3) the lack of strategic planning and n Different data is required for detecting and leadership to support long-term investment in managing different types of emergencies; cross-cutting core capabilities, integrated biosur- n Health departments rely on receiving informa- veillance, and effective partnerships.”243 tion from hospitals and doctors — and there Key findings from a November 2011 article ex- is often a lag time in the transmission of that amining the state of biosurviellance in the United information and another lag in the types of States today in Biosecurity and Bioterrorism: technologies used (phone reports, faxes, emails Biodefense Strategy, Practice, and Science by the that are not linked directly to databases). Center for Biosecurity of UMPC included that:244 Currently, only a small number of health de- partments have agreements with hospitals to 1. A single comprehensive biosurveillance sys- obtain direct access to a hospital’s electronic tem is probably not possible, and many sys- medical records for investigations; and tems would be needed. n Many health departments lack the capacity 2. Rapid laboratory reporting or clinical care to receive and analyze data from electronic reporting are the most important means by health records. which health departments detect outbreaks. Recent developments in HIT — both from the 3. Public health departments have systems to standpoint of technologies and standardization — answer a number of the key outbreak ques- are providing new opportunities to rethink and har- tions, but this takes time. ness new capabilities for biosurveillance. Issues of 4. Private sector medical resource and logistical how to quickly and effectively standardize, transfer, information is often not readily available to sort, analyze and store data are keys for building an public health departments. effective system. Major retail chains, which rapidly track inventories and customer patterns, and insur- 5. State and local health agencies do not have ance companies, could serve as models for devel- sufficient numbers of professionals with the oping such a system that tracks health patterns, special skills needed to build or run biosur- claims and billings, among other factors. veillance systems. According to a recent study from Harvard University 6. Federal grant language may prevent health researchers, allowing practitioners (hospitals, doctors departments from reassigning staff during a and clinicians) access to data on infections in their public health crisis. community as diagnoses occur would greatly im- 7. xchange of electronic health information E prove patient care. While hospitals, clinics and doc- between clinical and public health communi- tors report symptoms to public health departments, ties has the potential to substantially improve the information typically stops there. If two doctors biosurveillance. in different hospitals report the same symptoms, it is unlikely they will ever know there are similar 8. State and local public health information technol- cases in a neighboring hospital. However, based on ogy infrastructure has improved over time, but the Harvard study, if there were real-time relays of budget cuts threaten to erode this infrastructure. information, more than 166,000 patients would be The authors provided a series of recommenda- prevented from receiving unnecessary antibiotics to tions, including to: treat suspected strep throat, for example.242 1. Provide appropriate levels of funding and ex- Moving from the current system, which is com- plicit grant guidance for state and local public prised of a range of different systems in each state health surveillance. and for different diseases and health conditions, to a standardized, interoperable, rapid system will 2. Improve public health agencies’ ability to ac- require a full modernization of U.S. biosurveil- cess and use electronic health information. lance. For instance, a recent report from GAO 3. Promote the integration of electronic labora- outlined a set of common challenges state and tory reporting and electronic death registries. city official identified as obstacles to developing and maintaining their biosurveillance capabili- 4. ddress key gaps in biosurveillance for respond- A ties: “(1) state policies that restrict hiring, travel, ing to public health emergencies: advanced epi- and training in response to budget constraints; demiology and supply/logistical information. 64 EXPERT COMMENTARY Surveillance: Essential for Public Health Preparedness and Response By, Jeffrey Engel, M.D.; State Health Director, Division of Public Health, North Carolina Department of Health and Human Services Surveillance, the Science of Gathering Because pandemic H1N1 had its origins in North America, Data on Populations international port plans were already out of play: the first Surveillance has always been a core public health function and step in disease prevention is to keep it off shore as long as it is essential to effectively monitor the health of a community. possible. Instead, public health had to shift and rely on rapid assessments of community disease, which was based on Over the last 60 years, the science of surveillance has been existing biosurveillance systems. refined and is the cornerstone on which we base every public health intervention. As public health practice is largely per- At the local and state level, surveillance begins with clinician formed at the state and local level, so it is for surveillance. and lab reporting. Public health relies heavily on the medi- cal care system to be the “boots on the ground” for initiating The U.S. Constitution leaves this responsibility up to states in reports and intelligence. North Carolina has two systems for their police powers. The major role of the federal government, influenza reporting. largely through CDC, lies in coordinating and standardizing surveillance across jurisdictions to ensure reports can be com- The first is the CDC’s sentinel provider network which in- pared and to provide a national profile. cludes volunteer clinics/private care providers that file reports to CDC on a weekly basis. Our State Laboratory of Public After the 9/11 and anthrax attacks, gaps in surveillance systems Health uses the sentinel sites (we have 70 in North Caro- became apparent: most notably there was no formal portal lina serving our population of 9.5 million people) to request into the hospitals (anthrax disease was best tracked in emer- that approximately one of every ten patients presenting with gency departments). This was just a decade ago, yet, basically, influenza-like illness (fever and respiratory symptoms) submit our surveillance system was a handful of epidemiologists on a nasal swab for inoculation. The samples are then transported the phone calling hospitals to obtain information and ask if they to the state lab for isolation and characterization of flu viruses. had seen patients with particular symptoms. Out of this experi- ence, public health and the hospitals recognized that they had The second system is a syndromic surveillance system oper- to build a more robust and real time system — which is what ated through the emergency departments across the state. North Carolina has now. The emergency departments gather data elements for every hospital emergency department visit and state law mandates Implementation of Surveillance: Influenza reporting all visits electronically. To my knowledge, we are the only state that has mandated emergency department report- During 2009 pandemic influenza A (H1N1), surveillance was ing. For every visit, we collect 18 data elements and use natural essential for understanding the activity and severity of the pan- language algorithms from the chief complaint and nurses notes demic. To monitor seasonal flu and potential flu pandemics, to categorize a human illness into various syndromes. For flu, public health departments rely on non-specific case definitions the surveillance system looks for temperature (if it is greater because of the common nature of flu. than 100.5 degrees) and respiratory symptoms. With pandemic H1N1, public health had to quickly understand This syndromic surveillance system is much timelier because it the activity of the strain, in particular the proportion of the is reported to the state every 12 hours via an automated trans- population that would be affected and the subsequent severity fer to our analytical partner, the University of North Carolina measured by hospitalizations and mortality. In the early days of School of Medicine. They then analyze the data and provide the pandemic, states needed to understand rapidly what was aggregated summaries to state public health officials and to the going on since there was no available vaccine. Antiviral stock- CDC’s BioSense system. piles needed to be deployed to providers in a way that made sense based on the surveillance. Community isolation and Consequently, we rely on our two parallel systems to track quarantine decisions relied on timely and accurate estimates of and understand the development of pandemics and other seri- disease activity and severity. ous public health threats. 65 EXPERT COMMENTARY continued Surveillance: Essential for Public Health Preparedness and Response North Carolina also has a third system that focuses on mor- When it comes to fully optimizing EHRs, a larger barrier is bidity and mortality of unusual events. This system revolves going to be confidentiality and permissions for health informa- around public health epidemiologists which are stationed in 10 tion exchanges and proper governance of the exchanges. While of the largest hospital systems in the state. The epidemiolo- in public health we have certain exemptions (HIPAA exemp- gists report on patients admitted to the hospital with suspected tions for reportable diseases and conditions within state laws, reportable community acquired infections. While the other for example), public health and state law has to sort what falls systems are centered more on population dynamics, this last under these exemptions and then how the information can be surveillance system would be the most important one early on transferred securely. in the event of an anthrax attack or other bioterror event. Lastly, sustainability is a huge piece. Currently, we are build- The hospital emergency department syndromic surveillance ing systems largely on federal dollars via health information system and hospital-based epidemiologist positions were made technology grants and others. However, there is a big question possible by the CDC’s emergency preparedness funding to the of where sustained funding will come from. Ultimately is this states after 9/11 and the anthrax attacks. Unfortunately, these going to be funded by the health care financing system? Or will funds have been dwindling for the past two years and we have it be the duty of government to pay for? This remains an unan- lost some hospital positions. swered issue because we do know that funding for health care financing is getting less and less and state governments don’t The Ideal Surveillance System have money to invest in these systems. Enhanced electronic health records (EHRs) and reporting has the potential to be, at least on the data collection side, completely The Future of Surveillance automated from the second a patient has an encounter with the We are now on the cusp of modernization of our state and health system. Ideally, if a person presents with an illness and goes federal public health surveillance system. That said, the system to a “doc in a box”, emergency department or any other provider, will always rely on the standardization and epidemiologic sci- all symptoms and information are entered into the EHR and key ence that was established and promulgated over the last 60 data elements are automatically reported to a repository where years by the CDC and state and local public health depart- they are analyzed and translated into actionable information. ments. Regardless of the technological advancements, accurate and timely surveillance will always need the human element to The steps would be synchronous and automated: a patient has determine national case definitions for reporting, data collec- the clinical encounter, then a specimen is obtained, then the lab tion tools, analysis and communication of actionable informa- isolates an organism on the specimen and health data and re- tion to the agencies and people that need to know. ports are sent to the relevant parts of the public health system. There are two possible, realistic scenarios for the development The lab reporting is actually the easiest to automate first and we of automated surveillance systems: are beginning to do this. In North Carolina, we have implemented the CDC’s National Electronic Disease Surveillance System Surveillance systems will be built steadily and slowly one brick (NEDSS) that can capture lab reports through a health information at a time, i.e., one hospital system will agree to submit EHR lab exchange interface. For example, a patient has diarrhea: a speci- reports and pay for it and set up the interface, then others will men is transferred to lab, toxin-producing E. coli is identified and follow as they see fit. This is, mostly, what is happening now. the information is electronically transferred to the local and state Occasionally we will find federal dollars to assist, but mostly health department. The local health department contacts the modernization is born from public-private partnerships with patient and begins an investigation as to where the E. coli came private entities taking on a large burden. Here, modernization from. Electronic lab reporting is beginning to work; the problem is of surveillance will be an iterative accomplishment. This is slow every lab needs its own interface to NEDSS, and this is costly. and not strategic, because progress will involve whether it is financially advantageous for a system to come on board. This Barriers to Building the Future is, likely, the best case scenario. Surveillance Systems The worst case scenario would be a horrible event that is exac- A completely seamless, ideal surveillance system faces several erbated by weaknesses in the system. The public and policymak- barriers at the moment. ers will be appalled and there will finally be the political will to do The barrier to building the electronic lab reporting mentioned something and modernize the surveillance systems. That event above is finding the money to create the interfaces: each lab will likely be an act of bioterrorism — the biggest and most plau- would need to communicate via standard messaging to NEDSS sible fear that everyone is concerned about in public health. and this function can cost up to $50,000 per lab. 66 History of Biosurveillance in the United States n April 2004: HSPD-10: Biodefense for the 21st Century be- gins the process of developing a system capable of quickly A modern biosurveillance system would allow public health recognizing and analyzing potential biological attacks. departments to quickly detect a catastrophic biological event and then rapidly share pertinent and accurate information n December 2006: Pandemic and All-Hazards Preparedness across jurisdictions, counties and states. Act of 2006 calls for the creation of a nationwide, intercon- nected, electronic surveillance system. How Federal Policies and Biosurveillance have n August 2007: Implementing Recommendations of the 9/11 developed over time: Commission Act of 2007 requires the creation of the Na- n uly 2002: Public Health Security and Bioterrorism Prepared- J tional Biosurveillance Integration Center. ness and Response Act of 2002 requires the establishment n October 2007: HSPD-21: Public Health and Medical Prepared- of a system of public health alerts and surveillance. ness calls for establishing an operational national epidemiologic n anuary 2004: Homeland Security Presidential Directive-9 J surveillance system for human health, with international con- (HSPD): Defense of United States Agriculture and Food nectivity where appropriate and created the National Biosur- directs several federal agencies to create surveillance veillance Advisory Subcommittee (NBAS) and requires the systems coordinated across agencies for animals, plants, United States to develop biosurveillance capabilities across the wildlife, food, human health and water. country that can link with international systems. Homeland Security Presidential Directive-21 (HSPD-21) was CDC, Homeland Security, Department of Defense, USDA and oth- largely focused on surveillance. Dr. Engel was co-chair of the Na- ers that have a hand in surveillance. tional Biosurveillance Advisory Subcommittee to the Advisory Com- 2. Information exchange: methods used in acquiring biosurveillance mittee to the Director of CDC sanctioned under HSPD-21. data are highly variable; efficient and comprehensive aggregation The directive, which began under President Bush, was extended of these data must occur among the human health, animal, food, by President Obama to allow the committee to publish the vector and environmental sectors. second report in April 2011 (www.cdc.gov/osels/pdf/NBAS_Final_ 3. Workforce development: need more skilled workers, particularly Report_2011.pdf). in the area of public health informatics and social and behavioral The report identified four major areas for recommendation for im- epidemiology (community resiliency). provement for national biosurveillance: 4. Research and development: the federal government needs to 1. Governance: coordinate under the Executive Office of the Presi- invest in new areas including information technology, molecular and dent the federal agencies that oversee biosurveillance, including cellular sciences and communication. “Biosurveillance in the context of human health is a new term for the science and practice of managing health-related data and information for early warning of threats and hazards, early detection of events, and rapid characterization of the event so that effective actions can be taken to mitigate adverse health effects. It represents a new health information paradigm that seeks to integrate and efficiently manage health-related data and information across a range of information systems toward timely and accurate population health situation awareness.”245 — National Biosurveillance Strategy for Human Health “Biosurveillance is the process of active data-gathering with appropriate analysis and interpretation of biosphere data that might relate to disease ac- tivity and threats to human or animal health — whether infectious, toxic, metabolic, or otherwise, and regardless of intentional or natural origin — in order to achieve early warning of health threats, early detection of health events, and overall situational awareness of disease activity.”246 – HSPD-21 BioSense 2.0 BioSense 2.0, launched in November 2011, is the first HHS n Having a health monitoring infrastructure and workforce ca- program to move to a distributed computing platform (Internet pacity where needed at the state, local, tribal, and territorial cloud) which allows for rapid sharing of data across jurisdic- (SLTT) levels; tions and with CDC. It is also designed to support enhanced n Having a user-centered approach to increase local and interchange of critical public health information necessary for state jurisdictions’ participation in BioSense; accurate early notification of outbreaks, pandemics, and terror- n Supporting Meaningful Use adoption at the SLTT levels; and ist events. By integrating local and state-level information, it is expected that BioSense will be able to provide a more timely n Supporting state and local capability to conduct syndromic and cohesive picture at regional and national levels by: surveillance is key in helping to implement Meaningful Use.  67 C. I mproving Medical Countermeasure Research, Development and Manufacturing Anthrax vaccine, botulinim antitoxin and small- Since release of the Review, the national coun- pox vaccine all have something in common: the termeasure enterprise has made progress in government is the only real customer for these some notable ways: products. As a result of the lack of a natural n ARDA has issued a request for proposals for B marketplace, the U.S. government has invested Centers for Innovation in Advanced Develop- in the research, development and stockpiling ment and Manufacturing (CIADM), a strategy of emergency MCM for a pandemic, bioterror from the Review which would create flexible attack or emerging infectious disease outbreak. facilities to produce MCM on a routine basis Development of medical products for the na- for CBRN threats as well as a manufacturing tion’s biodefense is a key piece of any public process for emergency or pandemic condi- health emergency response. By preparing for tions.248 The proposals are currently being a bioterror attack with adequate supplies of reviewed, with awards expected in FY2012. countermeasures, the nation can effectively HHS is using $478 million in unspent H1N1 neutralize that threat. A successful domestic funds for these facilities. MCM enterprise will prepare the nation for n DA launched the Medical Countermeasures F new threats, expected or unexpected, by build- Initiative (MCMi) to establish regulatory ing the science, policy and production capacity pathways to accelerate MCM development, in advance of an outbreak. including modernizing the review process Congress created Project BioShield in 2003 to and updating the legal and policy framework spur development and procurement of MCM for regulating these products.249 FDA has al- and authorized BARDA in 2006 to support the located $170 million from H1N1 emergency development of domestic manufacturing capac- funds for this initiative. ity. However, industry was still reluctant to invest n he National Institute for Allergy and Infectious T in vaccine and countermeasure development in Diseases (NIAID) has introduced the Concept large part due to limited profit incentives and Acceleration Program, which enables coordina- slow bureaucratic processes. tion of teams of scientific, medical and product In August 2010, the Secretary of HHS released development experts to guide MCM research- The Public Health Emergency Medical Counter- ers with the goal of nurturing promising con- measures Enterprise Review, which laid out strat- cepts that might otherwise not be pursued.250 egies for addressing chokepoints in research and NIH has begun staffing the program.251 advanced development, improvements in domes- n SPR has convened interagency coordina- A tic manufacturing capacity and enhancing pub- tion, including an Enterprise Senior Coun- lic-private partnerships.247 The review concluded cil, which meets regularly to discuss lifecycle that new strategies were needed to creative in- management of biodefense products. Par- centives for private industry while protecting the ticipants include representatives from ASPR, public’s interest and safety, including: CDC, FDA, NIAID, DHS, Veterans Affairs n nhancing regulatory innovation, science E (VA), USDA and DOD. and capacity; n ARDA has issued significant new contracts, B n mproving domestic manufacturing capacity; I including for recombinant vaccine technol- ogy, which could significantly shorten the n roviding core advanced development and man- P production timeline for seasonal and pan- ufacturing services to development partners; demic flu vaccine;252 and new contracts under n reating novel ways for the enterprise to work C the Broad Spectrum Antimicrobial Program, with partners; including what would be the first new class of antibacterial agents to treat Gram-negative n eveloping financial incentives; D infections in 30 years.253 n ddressing roadblocks from concept develop- A n HS has begun to develop a five-year bud- H ment to advanced development; and get planning process to help project fund- n mproving management and administration I ing needs for development and stockpiling within the enterprise. throughout the countermeasure lifecycle.254 68 The national countermeasure enterprise still n fter its initial investment, future funding for A faces challenges in fully implementing the strat- FDA’s MCM Initiative is uncertain, and pro- egies laid out in the Review, including: posed cuts to that agency could significantly hamper the program’s potential. n ARDA has requested congressional authori- B zation as well as $100 million to launch a MCM n uts to the public health workforce could hin- C Strategic Investor, which would be an inde- der the success of any dispensing plans. ASPR pendent 501(c)(3) venture capital firm that has begun outreach to the public health com- would provide both investment and business munity to discuss these plans, but these con- management to biotechnology companies to versations need to be more extensive and take bring commercially-viable platforms to frui- into account drastic workforce reductions. tion. Although the Strategic Investor would n he Bipartisan WMD Terrorism Research T be independent, BARDA would house an In- Center recently issued a “D” grade for the na- terface Center to communicate with the firm. tion’s MCM development and approval pro- n unding for research and development is still F cess, based on failure to meet criteria such far below recommended levels.255 Although the as clearly defined requirements, a common President requested $655 million for BARDA set of prioritized research and development for FY 2012, in addition to funding for the Stra- goals, coordinated budget requests and suf- tegic investor, the enacted FY 2012 budget only ficient, sustained funding.257 approved $415 million. RECOMMENDATIONS TFAH recommends that the United States must n mproving oversight and management of I place a higher priority on research and develop- national stockpiles through ongoing replace- ment of MCM, including vaccines, medicines and ment of expiring products and expansion of technology. Policymakers must ensure that the the Shelf-Life Extension Program (SLEP) to public health system is involved in this process, state stockpiles to maintain supplies in a cost- from initial investment through distribution and effective manner; dispensing. The nation’s MCM enterprise could n uilding increased flexibility for FDA to issue B be advanced through the following activities: Emergency Use Authority of medical products n uthorizing the President’s requests for MCM A necessary to respond to an emergency; and advancement: building an MCM Strategic Inves- n ncreased focus on special pediatric needs, I tor to leverage capital for new technologies; and including in the development, testing and developing end-to-end leadership to oversee dosages of MCMs. products from initial research to dispensing; Examples of BARDA Activities In September 2010, BARDA awarded contracts, In September 2011, BARDA awarded $153 mil- worth up to $100 million over three years, to lion to Cellerant Therapeutics, a biotech firm eight biotech and pharmaceutical companies working on a new drug that may protect humans researching a range of innovative countermea- from nuclear radiation and awarded up to $94 mil- sures. One company, Pfenex, is working to lion to GlaxoSmithKlein for a dual-purpose broad develop a faster way to make anthrax vaccine; spectrum antibiotic with potential to treat illnesses others, including Novartis and Rapid Micro Bio- caused by bioterrorism threats such as plague and systems, are looking into methods to speed up tularemia, as well as certain life-threatening infec- flu vaccine manufacturing.258 tions, known as Gram-negative infections, associ- ated with prolonged hospitalization.259, 260 69 Innovations for FDA and Medical Countermeasures FDA is responsible for getting lifesaving drugs n Expanding testing on cell cultures created in labs and devices to market as quickly as possible combined with more research into how humans while ensuring safety. The spectrum of the are likely to react differently than test animals MCM enterprise includes vaccines, antiviral conducted lab-created materials or rodents; and other lifesaving drugs and devices such n mplementing supercomputing and IT en- I as diagnostics that are used to determine if hancements to better simulate the effect of someone has been exposed to a biologic, MCMs on humans; chemical, nuclear or radiologic threat. n Creating research metrics, such as bio- MCMs pose unique challenges, since it is often im- mimetrics, which create artificial ways to possible or unethical to safely test these products on model natural biology; humans. For instance, while it is possible to test a product for safety in humans, it is not feasible to ex- n esearching adjuvants to maximize the R pose people to the threat itself to test whether the amount of vaccine available during crises; vaccine or the treatment works. It is essential that n Advancing treatment for acute radiation new vaccines, antiviral medications and devices in- syndrome; tended to save lives do not cause unintentional harm and endanger the health of Americans — but it is n Enhancing the ability to test for multiple also essential to have effective countermeasures in pathogens simultaneously; place to respond to man-made and natural threats. n mproving the ability to rapidly and accurately I FDA must take steps to minimize red tape, maxi- test for new potential threats; and mize innovation and maintain safety when it comes n ocusing significant research on the impact of F to reviews and standards for medical countermea- MCMs on children and other at risk patients. sures. Additional coordination with BARDA and private industry is essential to understand priorities Examples of FDA efforts to expand and be and to find ways to improve processes to make more flexible to ensure life-saving drugs and them less burdensome on companies. devices are sped to market and available for use in crises include: The agency is developing new scientific and analytic tools to speed the approval of lifesaving n Enhancing clarity and flexibility for emergency use drugs and devices. Innovative approaches can be authorization (EUA), which permits FDA to ap- used to more efficiently manage the movement prove the emergency use of drugs, devices, and of potential treatments from idea to reality. medical products (including diagnostics) that were not previously approved, cleared, or licensed by In August 2010, the agency launched a new the agency or the off-label use of approved prod- Medical Countermeasures Initiative (MCMi), ucts in certain well-defined emergency situations; which was first limited to preparing for respond- ing to a flu pandemic.261 In April 2011, Congress n ssuing an EUA so doxycycline can be used as I enacted legislation to allow the project to also a prophylaxis for people exposed to anthrax; address chemical, biological, radiological and n Expanding the shelf-life extension program to nuclear (CBRN) threats.262 use drug stockpiles beyond formal expiration Examples of the efforts FDA is taking to expand dates when safe; and be more flexible in testing and review of n mproving risk-benefit analyses; and I products include: n eveloping models for predicting and mitigat- D n eveloping genetically modified animals for test- D ing the potential for shortages of MCM drugs, ing, such as an engineered modified mouse to test biologics and devices during emergencies. the smallpox vaccine and potential side effects; “The mission of the FDA should continue to ensure that new devices and drugs reaching the public in the U.S. are safe and effective. We encourage fostering innovation, without lowering evidence standards or putting the public at risk.”263 —Testimony from America’s Health Insurance Plans (AHIP) to the House Oversight and Government Reform Committee in June 2011 70 D. Enhancing Surge Capacity The ability of our health care system to quickly remains the single, most challenging issue for provide care for an influx of patients during an public health and medical preparedness.264 emergency is critical. In public health emergencies, such as a new dis- During a severe health emergency, the health care ease outbreak, a bioterror attack, or catastrophic system would be stretched beyond normal limits. natural disaster, U.S. hospitals and health care Patients would quickly fill emergency rooms and facilities are on the front lines providing triage doctors’ offices, exceed the existing number of and medical treatment to individuals. In the available hospital beds, and cause a surge in de- best of times, however, most emergency rooms mand for critical medicines and equipment. and intensive care units (ICUs) must confront bed shortages and staffing issues; in a mass casu- The challenge of how to equip hospitals and train alty event — particularly a pandemic influenza health care staff to handle the large influx of criti- or mass bioterror attack — the situation could cally injured or ill patients who show up for treat- quickly spiral out of control. ment after or during a public health emergency RECOMMENDATIONS TFAH recommends: of HHS to implement Section 1135 waivers to allow rapid availability of healthcare services n nhancing the HPP to create coalitions E for individuals affected by a disaster; and among hospitals to share surge burdens within a region with emphasis on develop- n larifying federal laws to implement a broad C ing creative strategies, intensive training and liability protection that applies to all volun- providing additional funding, particularly in teer health professionals during a nationally- large urban centers; declared public health emergency, creating a Federal Tort Claims Act protection for Medical n larifying crisis standards of care via creation of C Reserve Corps volunteers year-round, as these a national framework to guide states and local personnel participate in public health drills and entities in the event of a mass casualty or crisis; training during times of non-disaster, and mech- n liminating the need for dual declarations to E anisms for ensuring hospital and provider costs be made by the President and U.S. Secretary incurred during disaster response are covered. 71 E. I mproving Community Resilience: Helping Communities Cope and Recover Ensuring communities can cope with and re- morbidly obese or on oxygen.266 Currently, two- cover from emergencies is a significant chal- thirds of Americans are overweight or obese. lenge to public health preparedness. Experts recommend that improving resiliency, par- The most vulnerable members of a community, ticularly among vulnerable populations, requires: such as children, the elderly, people with un- n mproving the overall health status of com- I derlying health conditions and racial and ethnic munities, so they are in better condition to minorities, face special challenges that must be weather and respond to emergencies, such as planned for prior to emergencies happening. through initiatives and programs supported Building community resilience is one of the by the Public Health and Prevention Fund’s two overarching goals identified by HHS in the Community Transformation Grants (CTGs); release of the draft Biennial Implementation n roviding clear, honest, straightforward guid- P Plan for the National Health Security Strategy. ance to the public; It calls for fostering informed, empowered indi- viduals and communities. n ealth officials developing ongoing relation- H ships with members of the community, so, Improving relationships with the community when emergencies arise, they are trusted and and the health of the community are both understood; and strongly tied to resiliency. The aftermath of Hurricane Katrina provides a strong reminder n ngaging members of the community directly E of the importance of engaging all members of in emergency planning efforts. a community to be prepared for emergencies. To reach diverse communities, experts also For instance, according to one study in the An- recommend information must be provided in nals of Emergency Medicine, 55.6 percent of channels beyond the Internet, such as radio and individuals displaced in the aftermath of Hur- racial and ethnic publications and television, and ricane Katrina had a chronic disease, such as in languages other than English. In addition, hypertension, hypercholesterolemia, diabetes idiomatic translations are important to reach or pulmonary disease, which compounded the specific cultural perspectives effectively, and challenges of evacuation and support.265 Simi- messages should be delivered by trusted sources, larly, during Hurricanes Gustav and Ike, 40 such as religious and community leaders. percent of evacuees were obese and many were unable to stay in local shelters because they were RECOMMENDATIONS TFAH recommends leveraging new opportunities sectors, such as housing, transportation, created by the ACA, which includes several provi- education and businesses, to ensure healthy sions to improve overall health of communities choices are more widely available and that support community resiliency, including: accessible to Americans in their daily lives and during emergencies; n he Prevention and Public Health Fund pro- T vides a $16.5 billion investment over the next n s part of the Prevention Fund, CTGs, in A 10 years for communities around the coun- particular, support building community coali- try to use for proven, effective ways to keep tions to address obesity, tobacco and other Americans healthier and more productive; public health problems, which also help forge ongoing relationships between the community n National Prevention Strategy which aims to A and public health professionals, particularly improve health and reduce disease rates by with underserved communities. ensuring health departments work with other 72 Prevention, Preparedness, the Armed Forces and Total Force Fitness “Total Force Fitness is more than a physical fitness. It is the sum total of the many facets of individuals, their families, and the organizations to which they serve. It is not something someone achieves twice a year for a test. It is a state of being.”267 — ADM Michael Mullen, (former) Chairman of the Joint Chiefs of Staff In 2009, the Chairman of the Joint Chiefs of Staff (JCS), ADM Michael Mullen asked the Con- sortium for Human and Military Performance (CHAMP) to develop what has become known as Total Force Fitness (TFF) to ensure service members and their families are prepared for the rigors of war and a constant state of readiness. Lessons learned from the Total Force Fitness initiative can be used to help inform engagement and resiliency planning for communities around the country. During wartime, service members are trained and forced to adapt to chaotic and life-threatening situ- ations. When they return home, service members Total Force Fitness: 1) Physical, 2) Nutritional, must maintain a state of preparedness while, at the 3) Medical, 4) Environmental, 5) Behavioral, 6) same time, living according to the norms of a civil Psychological, 7) Spiritual and 8) Social. society. Consequently, the fitness of service mem- As the military views it, total fitness is a state bers is not merely physical, it has to be holistic. where mind and body are one: the perfect bal- Per the Chairman’s directive, CHAMP coordinated ance between readiness and well-being, where with the Samueli Institute, the Institute of Alterna- each condition supports the other. A service tive Futures and members of the JCS to create a member who achieves total fitness is healthy, new fitness doctrine that took a holistic approach to ready and resilient. Under TFF, to support service military preparedness and the fitness and resiliency members, the military takes the preventive steps of service members. The project sought to expand to ensure health across all fronts. For example, the definition of health promotion and prevention diet and nutrition are just as important as mental and create a different model from the typical medi- acuity and physical strength. To be completely fit, cal approach, i.e. one that is more comprehensive. a service member must go beyond maintaining an ideal body weight to instead combine diet, nutri- The group worked with over 70 scientists, health, tion and physical and mental training. social, community and spiritual leaders to define, evaluate and measure everything involved in keep- Consequently, TFF provides the foundation ing service members fit, resilient and prepared. for how any military fitness program could be evaluated and measured. The framework in- Ultimately, the group created a framework fo- cludes metrics that could be used for monitoring cused on the mind, body and the communities program effectiveness and for improving and and environments supporting a service member. comparing programs that already exist. TFF has The final structure depicts the service member become a new military doctrine that builds a surrounded by family, community and environ- dialogue and strategy among everyone involved ment as these impact health and resiliency. In with health. addition, the framework found eight domains of 73 EXPERT PerSPECTIVE Vulnerability, Resilience and Mental Health Considerations in Disaster Planning and Response: Do Resources Match the Rhetoric? By David Abramson, PhD, MPH and Irwin Redlener, MD, Columbia University Mailman School of Public Health O ver the past decade, policymakers, leading public health officials and scientists have acknowledged the importance of addressing mental health issues in the wake of were more susceptible to poor mental health outcomes, par- ticularly if they were married and had children in the home. Furthermore, those individuals who had lost confidence in their a disaster, but the practice of disaster mental health has yet to ability to cope or control outcomes, or who had few social re- match the rhetoric. This rhetoric, embodied in such recent sources, were highly susceptible to mental health problems. policy documents as the President’s policy directive on national Community-level factors make a difference in survivors’ mental preparedness (PPD-8, released March 30, 2011)268 and the health as well. Disasters can sever social networks, particularly CDC’s Public Health Emergency Preparedness Capabilities when populations are evacuated or displaced. Disasters also un- (March 2011),269 appropriately links mental health with disas- dermine the capability of civic institutions to support the physical ter resilience. The capacity of individuals and communities to and social welfare of people in the community — hospitals and withstand, adapt or recover quickly from emergency events health systems, as well as social services and systems of justice. and disasters is clearly related to their mental welfare both International disaster mental health providers have witnessed this before and after a disaster. And yet the practice of disaster time and again. When the social supports and institutions in a mental health is mired in old and generally untested thinking, community unravel, the mental health of its residents plummets.272 still mainly focused on the identification and treatment of Post- Traumatic Stress Disorder (PTSD), using practices that are Our own studies of the mental health of individuals affected only minimally-related to an evidence base. Moreover, public by the 2005 Hurricane Katrina and the 2010 Deepwater Ho- health practice is often overseen by public health systems gen- rizon Oil Spill have certainly reinforced these findings. Our erally ill-equipped and under-funded to coordinate or provide Gulf Coast Child & Family Health Study, which followed 1,079 complex mental and behavioral health services. randomly sampled households in Louisiana and Mississippi for five years after the hurricane, revealed the long tail of mental Mental health effects health distress, and how much of it was due to neighborhood Disasters and complex emergencies leave their mark on those conditions, chronic uncertainty, and pre-disposing economic exposed to them, although perhaps in ways contrary to popu- risk factors. When we first interviewed parents in 2006, over lar belief. Responders to a disaster can certainly suffer psycho- 60 percent were suffering mental health distress and disability. logical consequences, as can the populations affected by them. By the fourth time we spoke to them in 2010, things had im- But in one recent comprehensive review of the disaster mental proved — although 40 percent of them were still experiencing health research, the authors pointed out that severe cases lingering mental health effects. And among their children, even of PTSD, in which survivors “re-experience” the event, may years after the hurricane they were five times as likely as similar occur at most in 30 percent or fewer of the exposed popula- “non-exposed” children to be experiencing serious emotional tion, and that generally within one to two years people have disturbance. Over one in three children was still experiencing returned to a psychological “equilibrium”.270 The bigger issues depression, anxiety or behavioral effects.273 These mental health noted in this seminal review are those pre-disposing factors of effects were far subtler than PTSD, since they reflected depres- risk and resilience which protect individuals and communities sion, anxiety, and complicated grief, and interfered with people’s or make them more vulnerable. ability to recover and return to stable and productive lives. Nearly a decade ago, Norris and colleagues reviewed the re- Shortly after the rupture of the Deepwater Horizon Macando search literature regarding the individual-level risk factors com- well in the Mississippi Gulf last year, we conducted town hall plicit in poor mental health outcomes following a disaster.271 meetings and focus groups in communities along the Gulf One very important finding was that the exposure to the dev- Coast. Residents were clearly distressed by the environmen- astating effects of a disaster were compounded by pre-disaster tal disaster, and even children expressed concerns for their stressors in people’s lives, such as living in blighted communities futures and for their way of life. When we followed this with and dealing with the stresses of poverty. A household’s compo- a random survey of 1,203 residents living within ten miles of sition made a difference as well: regardless of income, women the coast in Louisiana and Mississippi, we found that slightly 74 less than 20 percent of parents reported that their children useful, and effective, and do not have training in principles of di- had emotional or behavioral problems since the Oil Spill, and saster behavioral health” (p. 6).278 The source of the problem, among those families who thought they might have to move the authors conclude, is that, “Federal Agencies do not have as a result of the oil spill, over a third reported mental health a clear understanding of State and local capabilities in disaster problems among their children.274 mental and behavioral health response (p. 10).” These studies, and many others, serve to illustrate the complex- The responsibility sits with public health, but it is essentially an ity of the problem. Communities are more resilient to a disaster unfunded mandate. As the country’s economic crisis deepens, when they are psychologically stronger before the event occurs, public health and emergency preparedness have absorbed yet there is little political impetus to recognize this link. After the enormous funding cuts. Over one year’s time, preparedness event, mental health problems are not restricted to PTSD, can and response funding within DHHS and DHS dropped by nearly last for years after an event, and are often the consequence of $900 million, from $5.3 billion in FY10 to $4.4 billion in FY11, household, neighborhood, and larger political forces. The solu- a 17 percent overall reduction. According to the NACCCHO tion has to extend beyond “Psychological First Aid” (PFA), the 2010 health department survey, the average local health depart- “intervention du jour” in most disaster response circles. ment receives $2 per capita within its catchment for emergency preparedness activities, and even that meager amount is being The disaster mental health practice environment eroded. With that money, smaller health departments fund a .5 Although not the sole mental health intervention, PFA is one FTE to do their emergency preparedness, and the largest agen- of the federal government’s primary tools. Under provisions cies fund an average of 4 FTE. As often occurs in public health, of the Stafford Act, FEMA employs the Crisis Counseling As- its mandate increases even as its budget shrinks. sistance and Training Program, in consultation with SAMHSA, Conclusion to fund states and localities to deliver PFA, often through the Many challenges remain with respect to meeting the complex use of community health workers. As noted in a recent report mental health needs of individuals and communities exposed to the National Biodefense Science Board, the administrative to disasters. Perhaps most challenging — and most demand- rules and constraints imposed by this program are so restric- ing of resources — is the capacity to reduce vulnerability and tive that some states have decided not to even apply for the increase resilience prior to a major catastrophic event. This, of funds after a disaster.275 When deployed, these community course, speaks to broader public policy issues such as poverty health workers serve a critical community outreach function, reduction, improved access to health care and early, effective although once cases have been identified there are meager or intervention for mental health concerns long before the disas- no resources available for addressing complex psychological ter exposure. In the current economic environment, where problems. The case-finding may be good, but the follow- public spending on discretionary programs is on a clearly through treatment is often non-existent; furthermore, the Staf- downward trajectory, the likelihood of substantive investments ford Act cannot adequately pay for the treatment needed.276 in these critical areas is virtually inconceivable. Perhaps most importantly, the “treatment” needs to be able to address the larger household and community factors that have Where does this leave us? led to the mental health problems. This requires a systems- At the very least, we have to develop strategies that: view entirely absent from most recovery efforts — not be- cause it’s not valued, but because it’s not funded. • aximize existing resources; m Organizationally, the responsibility for disaster mental health • everse the cuts which have left the nation’s public health r efforts falls within Emergency Support Function 8, as articulated workforce dangerously depleted and underfunded; in the National Response Framework, and is squarely within • nsure that interventions deployed in post-disaster public e the public health domain, although crisis counseling is a task health practice are based on data-driven, evidence-influ- designated to Emergency Support Function 6 (Mass Care, led enced recommendations; and, by FEMA and the American Red Cross). Compounding the problem is that local public health has little experience oversee- • emove bureaucratic barriers which have been memo- r ing or assuring networks of mental health services. According rialized in existing regulations or legislation (a poignant to a 2010 profile of 2,033 local health departments conducted example being the service restrictions imposed by current by the National Association of City and County Health Officials Stafford Act provisions). (NACCHO), over 84 percent of all health departments do not Failure to provide pro-active improvements in U.S. capac- offer mental health or behavioral services, nor do they oversee ity to prevent and intervene effectively with respect to the them.277 And, as noted in the report to the National Biodefense mental health consequences of disasters will leave the nation Science Board, “Responders often do not know what mental increasingly vulnerable to the catastrophic events which are and behavioral health resources and interventions are available, sure to appear with regularity in the years to come. 75 Public Communication and Social Media Usage during H1N1 Reaching diverse communities during a public social media to ensure messages about the out- health emergency requires providing informa- break reached younger populations which were tion to the public via multiple channels including most at-risk during H1N1.282 The agency also the Internet, social media and traditional, racial continues to use Twitter and Facebook to com- and ethnic publications and broadcast outlets. municate about H1N1 and other public health information programs, and their Facebook page According to the Pew Internet & American Life has more than 20,000 “fans.”283 Project, 93 percent of 12-17 year-olds go online and 65 percent utilize a social networking plat- Going beyond communication and education, form; 87 percent of 18-32 year-olds go online the National Institutes of Health (NIH) used and 67 percent use social media.279 Meanwhile, Twitter to monitor the spread of the H1N1 older generations prefer traditional media: 56 outbreak.284 percent of 64-72 year-olds are online and 31 Increased outreach on social media and via the percent of those older than 73 go online.280 Internet may be necessary to reach a younger au- During the 2009 outbreak of H1N1, while tra- dience during a pandemic. In addition, traditional ditional media was utilized, social media played media is important when trying to reach older and a special role in the government’s response, poorer populations that typically do not engage in especially because of that medium’s ability to comparable rates of Internet communication. reach younger populations.281  CDC focused on F. oordinating Overall Preparedness and Food C Safety Prevention: Strategic Implementation of the FDA Food Safety Modernization Act of 2011 In addition to the reauthorization of overall TFAH recommends that sufficient resources public health emergency preparedness, the and administration actions be taken to fully FDA Food Safety Modernization Act was signed implement the law. into law in 2011. The law contained many pro- TFAH asked Erik Olson, Director of Food Pro- visions to help reorient the nation’s food safety grams for The Pew Charitable Trusts to provide system to prevent outbreaks instead of detecting an overview of the opportunities and challenges problems after they already occurred. for implementing the new act. 76 EXPERT perspective Food Safety: New Law Takes a Big Bite Out of the Problem, but Leaves Much on the Plate285 By Erik D. Olson, Director of Food Programs at The Pew Charitable Trusts The Promise of the Food Safety Modernization Act 2012 above the previous year’s budget; these additional funds The FDA Food Safety Modernization Act (FSMA), a landmark would help the agency beef up its scientific staff, expand its law passed with broad bipartisan support in December 2010 inspection efforts, strengthen its ability to check up on imports, and signed into law by President Obama on January 4, 2011, and take other key steps to improve the safety of the food sup- will help tackle foodborne illness by setting up a new, preven- ply. The House of Representatives disagreed with the proposed tion-based safety system for the 80 percent of our food supply increase, and, instead, passed an austere budget for FDA, slash- that is regulated by FDA. This was the first significant overhaul ing its food safety budget by $87 million compared to the previ- of FDA’s food safety authorities since the Great Depression ous year (FY 2011). The Senate approved a modest $40 million when President Franklin Roosevelt signed an update of the law increase, and in the final law enacted in November, Congress in 1938. Major advances anticipated under this important new approved a $39 million bump-up in FDA’s food safety funding. law include new national standards for the safety of produce A wide range of stakeholders — the food industry(including and processed foods, stronger inspection requirements, stricter the Grocery Manufacturers Association, which represents food imports controls, and more muscular FDA authorities to help processing companies), consumer and public health groups (in- the agency deter practices that can cause foodborne illnesses. cluding Pew and the Trust for America’s Health), organizations However, as the late-summer 2011 outbreak of Listeria mono- representing the victims of foodborne illness and their families, cytogenes infections from Colorado cantaloupe that killed at and others — have been urging Congress to provide FDA with least 28 people (with a staggering fatality rate of over 20 per- the resources it needs to carry out the critical components of cent) has reminded us, substantial challenges lie ahead. For all the food safety law to enable the agency to protect the Ameri- of the crucial steps forward included in the new FSMA law, it can public and reduce the scourge of foodborne illness. will take many years to reverse over 100 years of accumulated neglect of the food safety system’s basic infrastructure, which Concerns with Heavy Non-Therapeutic Use of was designed primarily to track down the causes of illnesses Antibiotics in Animal Agriculture and contamination problems after they have occurred. These Even if the FSMA were to be fully funded, however, key food problems have gradually manifested themselves since the origi- safety issues untouched by the 2011 statute include the lack of nal Pure Food and Drug Act of 1906 was enacted. effective restrictions on antibiotic use in animal agriculture, and aging laws governing meat and poultry safety, and the use of Remaining Concerns with Foodborne Illness chemicals in food. These laws should be reviewed and updated According to CDC, each year, an estimated 47 million Americans as necessary — using the latest science — to tighten the focus suffer from foodborne illnesses caused by pathogens — disease- on preventing disease. causing microbes such as bacteria or viruses. These illnesses send Of particular continuing concern is the extensive non-therapeu- 127,000 people to the hospital and kill approximately 3,000, CDC tic use of antibiotics in animal agriculture — that is, antibiotic estimates.286,287 In addition, according to CDC, about two to three use to promote the animal’s growth or to compensate for the percent of those who are stricken with the illnesses will suffer effects of overcrowding or unsanitary conditions, not to treat from long-term chronic complications — approximately one mil- clinically ill animals with curative doses. Such practices carry the lion Americans, many of whom were not originally hospitalized for potential to breed antibiotic-resistant bacteria, which can cause their infection. These complications can include reactive arthritis, human illnesses that do not respond to the most commonly used autoimmune thyroid disease, kidney disease, neural and neuro- antibiotics.289 In one example of a serious public health prob- muscular dysfunctions, and heart and vascular disease.288 lem that some experts have been warning about for years there To more effectively reduce foodborne illnesses, FDA needs was a large outbreak of multi-drug resistant Salmonella infec- substantial additional human, scientific, and financial resources tions linked to consumption of ground turkey; as of September and quite honestly needs to reinvent itself — to make the shift 29, 2011 CDC confirmed that 129 people were sickened by a to a prevention-based approach in order to give real life to the Salmonella strain a strain that is resistant to many forms of com- ambitious new food safety law. The President identified FDA’s monly-prescribed antibiotics.290 CDC noted that this “antibiotic overhaul of its food safety program as a top priority, recom- resistance may be associated with an increased risk of hospital- mending an increase of $118 million dollars for Fiscal Year (FY) ization or possible treatment failure in infected individuals.”6 77 EXPERT perspective continued New Law Takes a Big Bite Out of the Problem FDA data show that 29.2 million pounds of anti- outdated system, food companies or trade as- microbial active ingredients were sold for use in sociations are allowed to make their own de- food-producing animals in 2010, an increase of termination that a chemical they want to add to nearly 1.3 percent from the previous year.291 Be- the food supply is “generally recognized as safe,” cause the agency does not publicly track compara- or “GRAS,” and they need not inform FDA or ble data for human use, it currently is not possible the public of this determination. Moreover, this to determine with certainty the exact percentage analysis found that in order to encourage food of antibiotics sold for use in food animals. How- companies to voluntarily ask FDA to examine the ever, recent estimates are that approximately 70 safety of chemicals they want to add to food, FDA percent of all antibiotics in the United States are has moved almost exclusively to a system in which used non-therapeutically in food animal produc- it evaluates chemicals without notifying the public tion; earlier estimates were lower.292, 293, 294 or providing an opportunity for the public to com- ment on the chemical’s safety. CDC, FDA, the U.S. Department of Agriculture, the World Health Organization, and others have In sum, under the current system, FDA is unaware noted the link between the use of non-therapeutic of a large number of chemical uses in food and, antibiotics in animal agriculture and antibiotic- therefore, cannot ensure that safety decisions re- resistant pathogens that can impair the useful- garding these uses were properly made. ness of antibiotics prescribed to treat human Additionally, food manufacturers are not required disease.295, 296, 297, 298 Some representatives of the to notify FDA of relevant health and safety stud- meat and poultry industry, however, contend that ies, thereby placing the agency in the difficult the problem of antibiotic resistance in humans is position of tracking safety information for more “overwhelmingly an issue related to human anti- than 10,000 chemicals with limited resources and biotic use,” rather than from the consumption of information. Moreover, the agency’s expedited antibiotics in food animals.299 approach to reviewing safety decisions in the past decade and a half occurs with little public engage- Concerns with Chemicals Added to Food ment. Finally, Pew’s research concluded FDA lacks In addition to pathogen-related illnesses attribut- the resources and information needed to identify able to food production, processing, handling, and prevent potential health problems or to set or preparation, there are other risks posed by priorities for systematic reevaluation of safety chemicals that are added, intentionally or not, to decisions made during the past half-century. This the food supply. Often these chemical hazards are is a troublesome set of findings, and Pew expects less well characterized than the microbiological to look at carefully at potential policy solutions to risks, which have been studied for decades. these and other concerns identified in its ongoing According to a review published in a peer-re- scrutiny of the FDA food additives program, and to viewed journal by experts from the Pew Health recommend changes as needed in 2012. Group’s food additives program, more than 10,000 chemicals were allowed to be added to The Need for Additional Reforms human food in the United States as of January The FDA Food Safety Modernization Act of 2011 2011.300 Of particular concern, the study found and the pesticide residue provisions in the Food that the safety of more than 3,000 chemicals Quality Protection Act of 1996 have addressed added to food has not been reviewed or evalu- some of the more serious risks posed by contami- ated by FDA. This is because under the current nants in food. 78 The newly enacted food safety law will not ful- Accountability Office recommended.305 Issues fill its promise, however, if the FDA lacks the that have been proposed for evaluation include resources to carry out its new responsibilities. whether there is a need for regular reevaluations The House of Representatives’ originally-passed of current research on the risks posed by all sub- version of the food safety legislation included a stances added to food, and for establishing a an measure, which did not make it into the final act, open and publicly transparent system to evaluate that would have established a registration fee for all risks in assessing the safety of these compounds. food facilities to help fund the FDA’s food-safety Legislative or administrative actions should be con- activities.301 Congress should consider establishing sidered to prevent problematic nontherapeutic uses a similar fee through another appropriate act, to of antibiotics in animal agriculture, to reduce the ensure that the FDA has a stable source of funding risk of creating and spreading antibiotic-resistant for its food safety program. “superbugs.” Bills to mandate such reform were It also is important to note that the new food- introduced in Congress in 2009 and reintroduced in safety law does not address the shortcomings in 2011, but they have not moved beyond the hearing the U.S. Department of Agriculture’s powers to stage.306, 307, 308 FDA has proposed a voluntary guid- prevent or address meat and poultry contami- ance document intended to encourage the judicious nation. For example, a court decision handed use of antibiotics in food-producing animals, but has down under the decades-old meat safety law not yet finalized it.309 Completion of a strong guid- has blocked the department from closing down ance could be a helpful first step, but ultimately, meat processing plants where repeated tests have mandatory requirements are needed. found Salmonella contamination.302 Additionally, Finally, measures that prevent the tainting of there is continued discussion about consolidat- food by environmental contaminants, such as un- ing all federal food safety activities into a single treated sewage or manure that enter waters and agency: a Government Accountability Office re- pollute crops downstream, and requirements to port issued in 2011 has reiterated its previous rec- strengthen controls on air and water discharges ommendation that serious consideration be given of mercury and other common pollutants that are to consolidating or restructuring the fragmented widely found in the food supply would help to re- food safety system, which they found is splintered duce the health risks to the American public. among 15 federal agencies, including USDA and FDA, implementing 30 laws.303 In the end, while the new 2011 food safety law will update and strengthen portions of the nation’s Moreover, the FDA’s science and risk analysis are food- safety net, there remain significant gaps. in need of modernization and additional resources; America’s food safety infrastructure must take FDA’s Science Board found that the “agency suf- advantage of rapidly-developing scientific knowl- fers from serious scientific deficiencies and is not edge, meet the ever-growing needs for scientific positioned to meet current or emerging regula- capacity and other resources at FDA, address tory responsibilities” because the demands on emerging pathogens and other newly-recognized the FDA have soared in recent years, and the health risks, and keep up with the constantly- resources have not increased in proportion to the morphing global food industry. We must review demands.304 The agency’s oversight of food ad- and, as necessary, update our mid-20th Century ditives—especially the procedures for substances food laws and programs, to ensure that they are that are generally recognized as safe—in par- preventing 21st Century threats to public health. ticular needs closer scrutiny, as the Government 79 APPENDIX A: CDC AND ASPR PREPAREDNESS GRANTS BY STATE All-Hazards Preparedness Funding by Source and Year FY 2010 FY 2011 % Change FY 10 - FY 11 State CDC ASPR Total State CDC ASPR Total Alabama $10,048,584 $5,959,171 $16,007,755 Alabama $8,633,983 $5,386,508 $14,020,491 -12.4% Alaska $5,165,000 $1,295,371 $6,460,371 Alaska $5,177,600 $1,211,937 $6,389,537 -1.1% Arizona $14,047,671 $7,819,583 $21,867,254 Arizona $11,894,861 $7,051,765 $18,946,626 -13.4% Arkansas $7,393,805 $3,836,580 $11,230,385 Arkansas $6,469,981 $3,486,575 $9,956,556 -11.3% California $49,301,738 $31,967,442 $81,269,180 California $41,661,534 $28,666,533 $70,328,067 -13.5% Colorado $10,875,195 $6,142,385 $17,017,580 Colorado $9,397,930 $5,550,503 $14,948,433 -12.2% Connecticut $8,719,806 $4,660,301 $13,380,107 Connecticut $7,553,479 $4,223,889 $11,777,368 -12.0% Delaware $5,150,000 $1,513,099 $6,663,099 Delaware $5,422,932 $1,406,825 $6,829,757 2.5% D.C. $6,616,482 $1,682,835 $8,299,317 D.C. $6,730,903 $1,558,756 $8,289,659 -0.1% Florida $33,481,834 $21,973,177 $55,455,011 Florida $27,687,829 $19,720,658 $47,408,487 -14.5% Georgia $18,481,819 $11,615,246 $30,097,065 Georgia $15,653,814 $10,449,266 $26,103,080 -13.3% Hawaii $5,249,782 $2,025,920 $7,275,702 Hawaii $5,260,290 $1,865,852 $7,126,142 -2.1% Idaho $5,495,096 $2,240,733 $7,735,829 Idaho $5,181,907 $2,058,131 $7,240,038 -6.4% Illinois $19,496,622 $12,357,745 $31,854,367 Illinois $16,845,953 $11,113,877 $27,959,830 -12.2% Indiana $12,995,857 $7,994,316 $20,990,173 Indiana $11,146,909 $7,208,168 $18,355,077 -12.6% Iowa $7,565,448 $4,039,814 $11,605,262 Iowa $6,595,869 $3,668,490 $10,264,359 -11.6% Kansas $7,530,021 $3,781,030 $11,311,051 Kansas $6,595,020 $3,436,853 $10,031,873 -11.3% Kentucky $9,455,848 $5,492,721 $14,948,569 Kentucky $8,275,695 $4,968,989 $13,244,684 -11.4% Louisiana $9,999,458 $5,589,694 $15,589,152 Louisiana $8,632,297 $5,055,790 $13,688,087 -12.2% Maine $5,259,067 $2,068,743 $7,327,810 Maine $5,206,160 $1,904,184 $7,110,344 -3.0% Maryland $12,720,551 $7,166,017 $19,886,568 Maryland $11,057,196 $6,466,757 $17,523,953 -11.9% Massachusetts $15,229,770 $8,141,119 $23,370,889 Massachusetts $13,459,602 $7,339,572 $20,799,174 -11.0% Michigan $20,143,034 $12,483,796 $32,626,830 Michigan $16,543,509 $11,226,706 $27,770,215 -14.9% Minnesota $12,911,644 $6,633,486 $19,545,130 Minnesota $10,842,711 $5,990,088 $16,832,799 -13.9% Mississippi $7,527,286 $3,954,888 $11,482,174 Mississippi $6,565,242 $3,592,473 $10,157,715 -11.5% Missouri $12,572,343 $7,435,455 $20,007,798 Missouri $10,717,722 $6,707,932 $17,425,654 -12.9% Montana $5,166,198 $1,621,303 $6,787,501 Montana $5,178,911 $1,503,679 $6,682,590 -1.5% Nebraska $5,876,388 $2,599,056 $8,475,444 Nebraska $5,234,954 $2,378,867 $7,613,821 -10.2% Nevada $7,511,623 $3,462,259 $10,973,882 Nevada $6,585,802 $3,151,521 $9,737,323 -11.3% New Hampshire $5,349,356 $2,060,815 $7,410,171 New Hampshire $5,398,877 $1,897,087 $7,295,964 -1.5% New Jersey $18,015,661 $10,856,284 $28,871,945 New Jersey $16,184,853 $9,769,919 $25,954,772 -10.1% New Mexico $7,643,606 $2,820,161 $10,463,767 New Mexico $6,526,120 $2,576,778 $9,102,898 -13.0% New York $22,932,149 $13,666,210 $36,598,359 New York $19,284,669 $12,285,085 $31,569,754 -13.7% North Carolina $16,552,440 $11,012,906 $27,565,346 North Carolina $14,020,450 $9,910,111 $23,930,561 -13.2% North Dakota $5,021,860 $1,254,791 $6,276,651 North Dakota $5,180,405 $1,175,614 $6,356,019 1.3% Ohio $20,947,527 $14,124,698 $35,072,225 Ohio $17,618,925 $12,695,478 $30,314,403 -13.6% Oklahoma $8,487,239 $4,748,620 $13,235,859 Oklahoma $7,509,542 $4,302,943 $11,812,485 -10.8% Oregon $8,871,324 $4,892,898 $13,764,222 Oregon $7,829,790 $4,432,087 $12,261,877 -10.9% Pennsylvania $22,808,671 $15,267,347 $38,076,018 Pennsylvania $19,774,638 $13,718,265 $33,492,903 -12.0% Rhode Island $5,150,000 $1,767,281 $6,917,281 Rhode Island $5,302,058 $1,634,345 $6,936,403 0.3% South Carolina $11,034,653 $5,629,437 $16,664,090 South Carolina $9,308,851 $5,091,363 $14,400,214 -13.6% South Dakota $5,150,000 $1,428,159 $6,578,159 South Dakota $5,169,600 $1,330,796 $6,500,396 -1.2% Tennessee $12,711,428 $7,668,219 $20,379,647 Tennessee $10,845,628 $6,916,279 $17,761,907 -12.8% Texas $43,194,539 $28,404,362 $71,598,901 Texas $37,545,665 $25,477,218 $63,022,883 -12.0% Utah $7,328,511 $3,526,992 $10,855,503 Utah $6,464,082 $3,209,463 $9,673,545 -10.9% Vermont $5,193,078 $1,240,595 $6,433,673 Vermont $5,192,031 $1,162,908 $6,354,939 -1.2% Virginia $17,063,098 $9,572,306 $26,635,404 Virginia $14,483,987 $8,620,629 $23,104,616 -13.3% Washington $13,731,541 $8,091,982 $21,823,523 Washington $11,711,066 $7,295,589 $19,006,655 -12.9% West Virginia $5,898,188 $2,658,572 $8,556,760 West Virginia $5,336,731 $2,432,140 $7,768,871 -9.2% Wisconsin $13,276,438 $7,095,720 $20,372,158 Wisconsin $11,235,615 $6,403,834 $17,639,449 -13.4% Wyoming $5,000,000 $1,111,323 $6,111,323 Wyoming $5,169,600 $1,047,196 $6,216,796 1.7% CDC Total ASPR* Total Grand Total CDC Total ASPR* Total Grand Total Grand Total FY 10** FY 10** FY 10** FY 11** FY 11** FY 11** Percent Change FY 10 - FY 11 $633,349,277 $356,452,963 $989,802,240 $553,303,778 $321,736,271 $875,040,049 -11.6% * Note that state CDC total funding include funding for Cities Readiness Initiative funding, Level 1 chemical laboratory funding, EWIDS funding and Risk funding although not every state receives funding in all of these supplemental categories.**Note that totals do not include funds for three major U.S. metropolitan areas, Chicago, L.A. County, and New York City, U.S. Territories, such as Puerto Rico and Guam, and Freely Associated States of the Pacific, such as the Marshall Islands. Source: FY2011 Funding 1) CDC. Public Health Emergency Preparedness Cooperative Agreement Budget Period 11 (FY 2011) Funding. <http://www.cdc.gov/phpr/ documents/FundingTable_FY_2011.pdf> (accessed September 8, 2011). 2) HHS.gov. HHS Grants Boost Disaster Preparedness in Hospitals, Health Care Systems. News Release, July 1, 2011. <http://www.hhs.gov/news/press/2011pres/07/20110701a.html> FY2010 Funding 1) CDC. Public Health Emergency Preparedness Coop- erative Agreement Budget Period 10 Extension (FY 2010) Funding. <http://www.bt.cdc.gov/cdcpreparedness/coopagreement/10/Revised_PHEP_BP10_Extension_Fund- ing_Table_Aug2010.pdf> (accessed October 14, 2010). 2) HHS.gov. HHS Provides $390.5 Million to Improve Hospital Preparedness and Emergency Response. News Release, July 7, 2010. <http://www.hhs.gov/news/press/2010pres/07/20100707h.html> (accessed July 8, 2010.) 80 APPENDIX B: ata and Methodology for State Public D Health Budgets TFAH conducted an analysis of state spending cases, only general revenue funds were used in on public health for the last budget cycle, fiscal order to separate out federal funds; these ex- year 2010-2011. For those states that only report ceptions are also noted. their budgets in biennium cycles, the 2009-2011 Because each state allocates and reports its bud- period (or the 2010-2012 and 2010-2011 for Vir- get in a unique way, comparisons across states ginia and Wyoming respectively) was used, and are difficult. This methodology may exclude the percent change was calculated from the last programs that, in come cases, the state may con- biennium, 2007-2009 (or 2008-2010 and 2009- sider a public health function, but the method- 2010 for Virginia and Wyoming respectively). ology used was selected to maximize the ability This analysis was conducted from August to to be consistent across states. As a result, there October of 2011 using publicly available bud- may be programs or items states may wish to get documents through state government web be considered “public health” that may not be sites. Based on what was made publicly avail- included in order to maintain the comparative able, budget documents used included either value of the data. executive budget document that listed actual Finally, to improve the comparability of the expenditures, estimated expenditures, or final budget data between FY 2009-2010 and FY appropriations; appropriations bills enacted by 2010-2011 (or between biennium), TFAH ad- the state’s legislature; or documents from legis- justed the FY 2010-2011 numbers for inflation lative analysis offices. (using a 0.9652 conversion factor based on the “Public health” is defined to broadly include all U.S. Dept. of Labor Bureau of Labor Statistics; health spending with the exception of Medic- Consumer Price Index Inflation Calculator at aid, CHIP, or comparable health coverage pro- http://www.bls.gov/cpi/).   grams for low-income residents. Federal funds, After compiling the results from this online mental health funds, addiction or substance review of state budget documents, TFAH coor- abuse-related funds, WIC funds, services related dinated with the Association of State and Terri- to developmental disabilities or severely dis- torial Health Officials (ASTHO) to confirm the abled persons, and state-sponsored pharmaceu- findings with each state health official.  ASTHO tical programs also were not included in order sent out emails on October 26, 2011 and state to make the state-by-state comparison more ac- health officials were asked to confirm or correct curate since many states receive federal money the data with TFAH staff by November 11, 2011.  for these particular programs. In a few cases, ASTHO followed up via email with those state state budget documents did not allow these pro- health officials who did not respond by the No- grams, or other similar human services, to be vember 11, 2011 deadline and were given until disaggregated; these exceptions are noted. For November 18, 2011 to respond. The states that most states, all state funding, regardless of gen- did not reply by that date were assumed to be in eral revenue or other state funds (e.g. dedicated accordance with the findings.   revenue, fee revenue, etc.), was used. In some 81 Endnotes 1 ublic Health Infrastructure — A Status Report. Atlanta, P 18 he White House, (2010). FACT SHEET: Executive T Georgia: Centers for Disease Control and Prevention, Order on Optimizing the Security of Biological Select 2001. Agents and Toxins in the United States. [Press Release]. 2 he Future of the Public’s Health in the 21st Century. Wash- T 19 ederal Register. Possession, Use, and Transfer of Se- F ington, D.C.: Institute of Medicine, 2003 lect Agents and Toxins; Biennial Review. Proposed Rule 3 HS Bioterrorism Preparedness Programs: States Reported H 42 CFR Part 73, October 3, 2011. http://www.selecta- Progress But Fell Short of Program Goals in 2002. Washing- gents.gov/resources/HHS%20Federal%20Register. ton, D.C.: Government Accountability Office, 2004. pdf. (accessed November 2011). 4 udget Cuts Continue to Affect the Health of Americans: Up- B 20 ingh S. APHL Briefs Experts on Biosecurity in Pub- S date November 2011. Washington, D.C.: Association of lic Health Laboratories. Association of Public Health State and Territorial Health Officials, November 2011. Laboratories Lablog, September 28, 2010. http://blog. aphl.org/?s=aphl+briefs+experts+on+biosecurity+in+p 5 ocal Health Department Job Losses and Program Cuts: L ublic+health+laboratories. (accessed December 2011). Findings from July 2011 Survey. Washington, D.C.: Na- tional Association of County and City Health Officials, 21 arkey T. Nods of Agreement in a Federal Work- B September 2011; and Budget Cuts Continue to Affect the group Meeting? Association of Public Health Labo- Health of Americans: Update November 2011. Washing- ratories Lablog, August 3, 2011. http://blog.aphl.or ton, D.C.: Association of State and Territorial Health g/?s=nods+of+agreement+in+a+federal+workgroup+ Officials, November 2011. meeting. (accessed December 2011). 6 djusted for inflation. To improve the comparabil- A 22 epartment of Health and Human Services. Federal D ity of the budget data between FY 2005 and FY 2012, Experts Security Advisory Panel: Recommendations TFAH adjusted the FY 2005 numbers for inflation Concerning the Select Agent Program, June 13, 2011. (using the U.S. Dept. of Labor Bureau of Labor Sta- http://www.phe.gov/Preparedness/legal/boards/ tistics Consumer Price Index Inflation Calculator at fesap/Documents/fesap-recommendations-101102. http://www.bls.gov/data/inflation_calculator.htm). pdf. (accessed December 2011). 7 nstitute of Medicine (IOM). The Future of the Public’s I 23 areer Epidemiology Field Officer Program. In U.S. C Health in the 21st Century. Washington, D.C.: National Centers for Disease Control and Prevention. http:// Academies Press, 2002. www.cdc.gov/phpr/science/cefo.htm. (accessed September 2011). 8 ities Readiness Initiative. In U.S. Centers for Disease C Control and Prevention. http://www.bt.cdc.gov/cri/ (ac- 24 aper S. Battling Disease Outbreaks in the Big Apple. H cessed September 2011). U.S. Centers for Disease Control and Prevention, Public Health Matters Blog, February 11, 2011. http://blogs.cdc. 9 ities Readiness Initiative. In Washington County, Or- C gov/publichealthmatters/2011/02/battling-disease-out- egon, Department of Health and Human Services. http:// breaks-in-the-big-apple-2/ (accessed September 2011). www.co.washington.or.us/HHS/EmergencyPrepared- ness/cities-readiness-initiative.cfm (accessed Septem- 25 EFO Field Locations. In U.S. Centers for Disease Con- C ber 2011). trol and Prevention. http://www.cdc.gov/phpr/sci- ence/cefomap.htm. (accessed September 2011). 10 lternative Methods of Dispensing: Model Highlights. A Washington, D.C.: National Association of County 26. DC Awards $13 Million for Preparedness and Response C and City Health Officials, 2008, http://www.naccho. Learning Centers. 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In U.S. F Undermining National Disaster Readiness?” Political Centers for Disease Control and Prevention. http://www.bt.cdc. Machine July 19, 2011 gov/lrn/factsheet.asp. (accessed September 8, 2011). 30 omestic Preparedness Cuts in the Current Federal D 14 acts About the Laboratory Response Network. In U.S. F Budget Threaten Infrastructure Gains and Public Health Centers for Disease Control and Prevention. http://www.bt.cdc. Preparedness. In Columbia University Mailman School of gov/lrn/factsheet.asp. (accessed September 8, 2011). 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