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2010 Report: Public Health Preparedness

Section 1: A National Snapshot of Public Health Preparedness Activities - Continued

Response Readiness: Communicating, Planning, Exercising, and Evaluating

While all response to public health emergencies begins at the local level, preparing for a response requires coordination among all levels of government as well as a clear understanding of expected roles and responsibilities. State and local public health departments continue to improve their response to threats by developing, exercising, and improving emergency response plans and responding to real incidents. Strengthening response capabilities and capacities also entails improving situational awareness through monitoring and communicating emerging health information.

Highlights of state and locality activities to enhance response readiness follow. See the summary table on page 34 for national-level response readiness data (Table 8).

Communicating Emerging Health Information

Rapid detection and communication of health threats allows public health officials to identify disease patterns and implement measures to lessen their spread and impact.

States and localities used rapid electronic methods to monitor and communicate emerging health information. All state and locality public health departments could receive urgent disease reports 24/7. In addition, state public health laboratories in 47 states and the District of Columbia used rapid methods to communicate with sentinel laboratories and other partners for outbreaks, routine updates, and training events.

Table 4: Communicating Emerging Health Information; 2007-2009

  2007* 2009** Percent
Increase
State Public Health Departments Responding to HAN Test Message within 30 Minutes 39 out of 50 (78%) 48 out of 50 (96%) 23%

*Data for the 50 states as of August 2007 (District of Columbia also participated and passed)
** Data for the 50 states as of July 2009
Source: CDC, OPHPR (DEO)


Participation in testing helped ensure that states received electronic information rapidly. The ability of state and local public health staff to receive urgent emerging health information from CDC helps ensure that local problems are mitigated and national events are detected sooner. CDC conducts tests to identify and address problems in its Health Alert Network (HAN) and Epidemic Information Exchange (Epi-X) systems. These tests ensure that the systems will be fully operational during a real event.

The HAN system, a component of CDC’s Public Health Information Network, transmits health alerts, advisories, and updates on urgent health events to more than one million recipients, including state and local public health practitioners, clinicians, and laboratories. The number of PHEP-funded areas responding to HAN test messages within 30 minutes increased from 2007 to 2009 (see Table 4).

Epi-X, a secure, CDC web-based communication system, enables state and local health departments, poison control centers, and other public health professionals to access and share preliminary health surveillance information quickly. Epi-X scientific staff are available 24/7 to provide assistance in editing and posting reports on the secure website. Staff also notify users routinely (by email) or as incidents arise (by pager, telephone, and email) about acute health events. To protect the sensitive nature of this information, access is limited to designated officials engaged in identifying, investigating, and responding to health threats. In FY 2008, 48% of approximately 5,500 active Epi-X users in the 50 states and the District of Columbia responded to a system-wide notification test that entailed logging into the system and viewing a report within the 3-hour targeted time frame.

Preparing for Rapid Response to Radiological Incidents


Many states are pre-positioning treatments for radiological exposures to reduce the estimated response time should an incident occur. Calcium and zinc DTPA (diethylene triamine pentaacetic acid) are agents to treat people with internal contamination from plutonium, curium, or americium exposure. As of March 2010, 89% of the 62 PHEPfunded state, locality, and U.S. insular area public health departments received 78,880 doses of calcium and zinc DTPA from CDC’s Strategic National Stockpile.

Source: CDC, Office of Public Health Preparedness and Response, Division of Strategic National Stockpile (2010)


Planning

Responding to a public health emergency often requires complex logistical planning for activities such as the distribution of medicines or other supplies to a community. Because these activities involve many different community agencies, everyone involved in emergency response must plan strategies and regularly exercise them together. All 62 states, localities, and U.S. insular areas funded by the Public Health Emergency Preparedness (PHEP) cooperative agreement have plans for receiving, distributing, and dispensing medical assets from CDC’s Strategic National Stockpile and other sources. Assets include antibiotics, chemical antidotes, antitoxins, life-supporting medications, and medical supplies.

States can request these assets when local supplies are depleted or commercially unavailable. These assets, in combination with federal, state, and local technical expertise to manage and distribute them efficiently, help ensure the availability of key medical supplies during emergencies.


Planning and Training Critical to California’s Rapid Response to the H1N1 Influenza Pandemic

Planning and Training Critical to California’s Rapid Response to the H1N1 Influenza Pandemic
All states, localities, and insular areas receiving PHEP funding develop and exercise plans to receive, store, distribute, and dispense supplies from the Strategic National Stockpile in the event of a public health emergency. Comprehensive planning and extensive training and testing prepared the California Department of Public Health to respond rapidly to the 2009 H1N1influenza pandemic. The state health department established an emergency operations center and activated the state warehouse. Operating on a 24/7 schedule, the state warehouse deployed about two million courses of antiviral drugs to local health departments in the first month of the pandemic alone, with the majority of shipments received by local health departments within 24 hours of request. Like the state health department, California’s local health departments report that previous Stockpile planning made efficient receipt, distribution, and dispensing of antiviral drugs possible.

Source: Association of State and Territorial Health Officials (2010)


Ability of states to receive, distribute, and dispense medical assets improved. CDC conducts annual technical assistance reviews (TAR) to assess Stockpile plans and works closely with state and local agencies to identify and address gaps. Areas of assessment include the public health department’s coordination with traditional and nontraditional community partners; the state’s ability to receive, store, stage, distribute, and dispense medical assets; the state’s legal statutes that aid rapid dispensing of assets; and the type and frequency of trainings and exercises.

The number of states performing within an acceptable range in their plans to receive, stage, distribute, and dispense medical assets received from the Stockpile or other sources increased from 37 to 50 between 2006 and 2009 (Table 5). (On a scale of zero to 100, a score of 69 or higher indicates that a state performed within an acceptable range.41) See individual fact sheets in Section 2 for statespecific scores.


Table 5: CDC Technical Assistance Review of State Strategic National Stockpile Plans; 2006-2009

  2006-2007 2007-2008 2008-2009
Acceptable (score of 69 to 100) 37 out of 50 (74%) 46 out of 50 (92%) 50 out of 50 (100%)
Unacceptable (score of 0 to 68) 13 out of 50 (26%) 4 out of 50 (8%) -

Source: CDC, OPHPR (DSNS)


Major metropolitan statistical area scores improved over time. The Cities Readiness Initiative (CRI) of CDC’s Strategic National Stockpile focuses on enhancing preparedness in the nation’s largest cities and metropolitan statistical areas (MSAs), where more than 50% of the U.S. population resides. Through CRI, state and large metropolitan public health departments have developed plans to respond to a large-scale bioterrorist event within 48 hours. CRI has also enhanced communication and collaboration among state and local public health departments, resulting in optimal use of shared resources.

The CRI project began in 2004 with 21 cities and expanded to a total of 72 MSAs, with at least one CRI MSA in every state.

  • 2004: CDC funded 21 cities (Cohort I)
  • 2005: CDC funded 15 additional MSAs (Cohort II), for a total of 36 MSAs
  • 2006: CDC funded an additional 36 MSAs (Cohort III), for a total of 72 MSAs

MSAs can consist of one or more jurisdictions (e.g., counties, cities, and municipalities) and can extend across state borders, resulting in the representation of several states within one MSA. Reviews are conducted annually in each local jurisdiction to ensure continued readiness. Scores (ranging from 0 to 100) for each planning jurisdiction are combined to compute an average score for the CRI MSA. A score of 69 or higher indicates that the CRI location performed in an acceptable range in its plan to receive, distribute, and dispense medical assets from the Stockpile or other sources. Average scores for each CRI cohort demonstrate that scores improve the longer MSAs are in the program. The average scores for each CRI cohort are presented in Table 6. (See appendix 6 for individual jurisdiction scores.)


Table 6: CDC Technical Assistance Reviews of Strategic National Stockpile Plans for Cities Readiness Initiative Locations; 2008

  Cohort I
(established in 2004)
Cohort II
(established in 2005)
Cohort III
(established in 2006)
Acceptable (score of 69 to 100) 18 out of 21 (86%) 10 out of 15 (67%) 17 out of 36 (47%)
Unacceptable (score of 0 to 68) 3 out of 21 (14%) 5 out of 15 (33%) 17 out of 36 (47%)
Did not report scores - - 2 out of 36 (6%)

Source: CDC, OPHPR (DSNS)


Excercises and Incidents

State emergency operations centers (EOCs) conduct exercises and drills to practice response to emergency incidents. These hands-on sessions educate responders about response plans and their roles during an incident and identify needed improvements. Exercises help organizations assess their capabilities objectively, so that strengths and areas for improvement are identified, corrected, and shared as appropriate before a real incident. Exercises also help build working relationships across disciplines that do not work together routinely.

During a real incident, the state EOC serves as a facility for carrying out response planning and management of emergency situations, including ensuring continuity of operations. The common functions of all EOCs are to collect, gather, and analyze data; make decisions that protect life and property; maintain continuity of the organization and disseminate decisions to all concerned agencies and individuals.

One of the most critical components of an EOC is its staff. They must be properly trained and have the authority to carry out actions necessary to respond to an emerging disaster. All 50 states and 4 localities must comply with National Incident Management System requirements, which includes training for staff in their roles and responsibilities during an emergency as outlined by the Incident Command System (ICS). The ICS specifies that states and localities have a pre-identified list of personnel required to cover eight core ICS functional roles: Incident Commander, Public Information Officer, Safety Officer, Liaison Officer, Operations Section Chief, Planning Section Chief, Logistics Section Chief, and Finance/Administration Section Chief.


Operation “Cache-Out” Exercise

Photo: Action shots of bank and credit union employees distributing antibiotics.

With funding from the Cities Readiness Initiative, two local health departments in Utah collaborated with community partners to conduct exercises that tested the ability to use bank and credit union drive-through windows for dispensing antibiotic or antiviral drugs to the public during an emergency.

These exercises required coordination by public health, the private sector, law enforcement, fire and emergency medical services, search and rescue, emergency management, and public information groups.

Photo source: Utah Department of Health



New Mexico and Illinois Ensure Availability of Drugs for the 2009 H1N1 Influenze Pandemic

New Mexico and Illinois Ensure Availability of Drugs
for the 2009 H1N1 Influenze Pandemic
To ensure that local providers could respond rapidly to the 2009 H1N1 influenza pandemic, the New Mexico Department of Health pre-positioned (placed ahead of need) antiviral drugs with 178 public and private organizations that agreed to receive, distribute, and dispense the drugs. These arrangements helped ensure that their population, especially high-risk groups, had quick access to the medications. The state provided assets to acute care hospitals, health centers and clinics, pharmacies, and the Indian Health Service.

Illinois pre-positioned both antiviral drugs and personal protective equipment with local health departments and hospitals as it anticipated an increase in 2009 H1N1 influenza during the holidays and winter. The state also developed a backup transportation plan that did not rely on state-owned trucks – often needed for plowing snow – to resupply and pre-position the medical countermeasures.

Source: CDC, Office of Public Health Preparedness and Response, Division of Strategic National Stockpile (2009)


All of the functional areas may or may not be used based on incident needs. The widespread use of ICS by all levels of government – federal, state, local, and tribal – as well as by many nongovernmental organizations and the private sector, enables personnel to work together using common terminology, procedures, and organizational structures.

CDC’s EOC supports state response by serving as the point of contact for state agencies reporting potential public health threats. This centralized facility organizes the agency’s scientific experts in one location during an emergency, allowing efficient information exchange and connection with local, state, federal, and international partners. For multistate or severe emergencies, CDC can provide additional public health resources and coordinate response efforts across multiple jurisdictions. To support state and local efforts during an emergency, CDC’s EOC also coordinates deployment of CDC staff and equipment.

States and localities demonstrated abilities to ensure rapid response. To ensure timely and effective coordination within the public health agency and with key response partners in a complex incident, PHEP-funded states and localities must demonstrate the capability to rapidly notify staff to report for EOC duty. They must also track staff responses to this notification to ensure that each of the eight ICS functional roles can be filled. Rapid notification of staff depends, in part, on maintaining accurate contact information for pre-identified public health agency staff to fill each ICS functional role.


Activation of Emergency Plan Speeds New York Response to the 2009 H1N1 Influenza Pandemic

Activation of Emergency Plan Speeds New York
Response to the 2009 H1N1 Influenza Pandemic
When the 2009 H1N1 influenza pandemic struck in spring 2009, New York activated the state’s public health emergency preparedness response plan. This action focused attention on the imminent public health threat and streamlined processes expediting successive emergency responses. A number of measures were implemented that enabled state, city, and county health departments to keep close surveillance of emerging cases and to react quickly to reduce the transmission rates and impact of the disease. Measures included developing a testing protocol to ensure identification of severe illness; monitoring resources for the most efficient use of medicines, masks, and other supplies; and implementing rapid internet reporting of suspected illness to provide complete, real time understanding of the unfolding situation. The Department of Health also maintained ongoing communication with counties, hospitals, other health care providers, and schools across the state to assure the most up-to-date information was available.

Source: New York State Office of the Governor (2009)


In 2008, 53 out of 54 states and localities conducted or responded to a minimum of two drills, exercises, or real incidents to demonstrate rapid notification of preidentified staff that the EOC was activated.

States and localities activated public health EOCs. An activation is defined as rapidly staffing all eight core ICS functional roles42 in the public health EOC with one person per position. PHEP-funded states and localities activated and staffed EOCs and evaluated response performance through after action reports.

The number of states and localities that activated their public health EOC at least twice as part of a drill, exercise, or real incident (a CDC performance measure – see page 12) increased from 2007 to 2008 (see Table 7). In addition, 47 out of 54 states and localities conducted at least one unannounced activation.

In a related performance measure, in 52 out of 54 states and localities, pre-identified staff reported to the public health EOC within the target time of 2.5 hours at least once.43 Although not every incident requires full staffing of the ICS, this capability is critical to maintain in case of large-scale or complex incidents.


Table 7: Activation of State and Locality Emergency Operations Centers; 2007-2008

  2007* 2008** Percent
Increase
Public health EOC activated at least twice as part of a drill, exercise, or real incident 46 out of 54 (85%) 48 out of 54 (89%) 5%

*Data for the 50 states and 4 localities of Chicago, the District of Columbia, Los Angeles County, and New York City from the PHEP cooperative agreement Budget Period 7 (August 31, 2006 to August 30, 2007)
**Data for the 50 states and 4 localities of Chicago, the District of Columbia, Los Angeles County, and New York City from the PHEP cooperative agreement Budget Period 8 (August 31, 2007 to August 9, 2008)
Source: CDC, OPHPR (DSLR)


Evaluating Response Capabilities

States and localities evaluate their actions during both exercises and real incidents, identify needed improvements, and prepare plans for making improvements by developing after action reports and improvement plans (AAR/IPs). AAR/IPs should include how response operations did and did not meet objectives, recommendations for correcting gaps or weaknesses, and a plan for improving response operations.

In 2008, 52 out of 54 states and localities developed AAR/IPs at least twice following an exercise or real incident. In addition, 51 out of 54 states and localities re-evaluated response capabilities following the approval and completion of corrective actions identified in AAR/IPs.

National Snapshot of Response Readiness Activities

A summary table of national-level data on response readiness activities in 2008 and 2009 appears on the following page (Table 8). Note that these items represent available data for preparedness activities and do not fully represent all state and locality response efforts. For individual state and locality information in the area of response readiness, see Section 2. See appendix 1 for an explanation of data points.


Table 8: National Snapshot of Response Readiness Activities

Response Readiness: Communication
Communicating emerging health information

54 out of 54 state and locality public health departments had a 24/7 reporting capacity system that could receive urgent disease reports any time of the day

State and locality data; 10/1/2007- 9/30/2008

48 out of 50 states responded to Health Alert Network (HAN) test message within 30 minutes

CDC, OPHPR (DEO); 7/2009

47 out of 51 state public health laboratories and DC used HAN or other rapid method (blast email or fax) to communicate with sentinel laboratories and other partners for outbreaks, routine updates, training events, and other applications

APHL; 8/31/2007-8/30/2008

48% of approximately 5,500 Epidemic Information Exchange users in 50 states and DC responded to a system-wide notification test within 3 hours

CDC, OPHPR (DEO); 4/3/2008

Improving public health information exchange

53 out of 54 states and localities participated in a Public Health Information Network forum (community of practice) to leverage best practices for information exchange

CDC, OSTLTS; as of 9/30/2008

Response Readiness: Planning
Assessing plans to receive, distribute, and dispense medical assets from the Strategic National Stockpile and other sources

States with acceptable* CDC technical assistance review scores:

  • 50 out of 50 states for 2008-2009
  • 46 out of 50 states for 2007-2008
*A score of 69 or higher (out of 100) indicates state performed in an acceptable range in its plan to receive, distribute, and dispense medical assets. See state fact sheets for individual scores.

CDC, OPHPR (DSNS); 2007-2008 scores are associated with funding from the PHEP cooperative agreement Budget Period 8 (8/13/2007-8/9/2008); 2008-2009 scores are associated with funding from Budget Period 9 (8/10/2008-8/9/2009)

Cities Readiness Initiative (CRI) locations with acceptable* scores:

  • 18 out of 21 locations in CRI Cohort I (MSAs that enrolled in 2004)
  • 10 out of 15 locations in CRI Cohort II (MSAs that enrolled in 2005)
  • 17 out of 36 locations in CRI Cohort III (MSAs that enrolled in 2006)
*A score of 69 or higher (out of 100) indicates CRI location performed in an acceptable range in its plan to receive, distribute, and dispense medical assets. See appendix 6 for individual scores.

CDC, OPHPR (DSNS); as of 7/30/2008

Enhancing response capability for chemical events

1,941 CHEMPACK nerve-agent antidote containers placed in the 50 states and 4 localities

CDC, OPHPR (DSNS); as of 7/30/2008

Improving public health information exchange

150 local health departments in 24 states met voluntary Project Public Health Ready preparedness standards

NACCHO; as of 9/30/2008

Response Readiness: Exercises and Incidents
Notifying emergency operations center staff

53 out of 54 states and localities notified pre-identified staff to fill all eight Incident Command System core functional roles at least twice due to a drill, exercise, or real incident.
Note: States and localities must report 2 and could report up to 12 notifications.

CDC, OPHPR (DSLR); 8/31/2007-8/9/2008

53 out of 54 states and localities had pre-identified staff acknowledge notification at least once within the target time of 60 minutes

CDC, OPHPR (DSLR); 8/31/2007-8/9/2008

52 out of 54 states and localities conducted at least one unannounced notification outside of normal business hours

CDC, OPHPR (DSLR); 8/31/2007-8/9/2008

Activating the emergency operations center (EOC)

48 out of 54 states and localities activated their public health emergency operations center (EOC) at least twice as part of a drill, exercise, or real incident
Note: States and localities must report 2 and could report up to 12 activations.

State and locality data; 10/1/2007- 9/30/2008

52 out of 54 states and localities had pre-identified staff report to the public health EOC at least once within the target time of 2.5 hours

CDC, OPHPR (DSLR); 8/31/2007-8/9/2008

47 out of 54 states and localities conducted at least one unannounced activation

CDC, OPHPR (DSLR); 8/31/2007-8/9/2008

Response Readiness: Evaluation
Assessing response capabilities through after action report/improvement plans (AAR/IPs)

52 out of 54 states and localities developed AAR/IPs at least twice following an exercise or real incident
Note: States and localities must report 2 and could report up to 12 AAR/IPs.

CDC, OPHPR (DSLR); 8/31/2007-8/9/2008

52 out of 54 states and localities developed at least one AAR/IPs within the target time of 60 days

CDC, OPHPR (DSLR); 8/31/2007-8/9/2008

51 out of 54 states and localities re-evaluated response capabilities following approval and completion of corrective actions identified in AAR/IPs

CDC, OPHPR (DSLR); 8/31/2007-8/9/2008



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