ISSUE REPORT

DECEMBER 2010

PREVENTING EPIDEMICS.PROTECTING PEOPLE.

2010Ready or Not?PROTECTING THE PUBLIC’S HEALTH FROM

DISEASES, DISASTERS,

AND BIOTERRORISM

TFAH BOARD OF DIRECTORSLowell Weicker, Jr.PresidentFormer three-term U.S. Senator and Governor ofConnecticut

Cynthia M. Harris, PhD, DABTVice PresidentDirector and Associate ProfessorInstitute of Public Health, Florida A & MUniversity

Robert T. Harris, MDSecretaryFormer Chief Medical Officer and Senior VicePresident for HealthcareBlueCross BlueShield of North Carolina

John W. EveretsTreasurer

Gail Christopher, DNVice President for HealthWK Kellogg Foundation

David Fleming, MDDirector of Public HealthSeattle King County, Washington

Arthur Garson, Jr., MD, MPHExecutive Vice President and Provost and theRobert C. Taylor Professor of Health Science andPublic PolicyUniversity of Virginia

Alonzo Plough, MA, MPH, PhDDirector, Emergency Preparedness and Response ProgramLos Angeles County Department of Public Health

Eduardo Sanchez, MD, MPHChief Medical OfficerBlue Cross Blue Shield of Texas

Jane Silver, MPHPresidentIrene Diamond Fund

Theodore SpencerSenior Advocate, Climate CenterNatural Resources Defense Council

REPORT AUTHORSJeffrey Levi, PhD. Executive DirectorTrust for America’s Health andProfessor of Health PolicyThe George Washington University Schoolof Public Health and Health Services

Serena Vinter, MHSLead Author and Senior Research AssociateTrust for America’s Health

Laura M. Segal, MADirector of Public AffairsTrust for America’s Health

Rebecca St. Laurent, JDHealth Policy Research AssociateTrust for America’s Health

CONTRIBUTORDara Alpert Lieberman, MPPGovernment Relations ManagerTrust for America’s Health

PEER REVIEWERS ANDEXPERTS CONSULTEDTFAH thanks the reviewers and experts for theirtime, expertise, and insights. The opinions ex-pressed in this report do not necessarily represent theviews of these individuals or their organizations.

Anthony Barkey, MPHSenior Specialist, Public Health Preparedness &ResponseAssociation of Public Health Laboratories

Scott J. Becker, MSExecutive DirectorAssociation of Public Health Laboratories

James S. BlumenstockChief Program OfficerPublic Health Practice; Association ofState and Territorial Health Officials

Donna Brown, JD, MPHGovernment Affairs Counsel and SeniorAdvisor for Public AffairsNational Association of County and CityHealth Officials

Paul Etkind, DrPH, MPHSenior Analyst, Community Health Team /ImmunizationsNational Association of County and CityHealth Officials

Chris Mangal, MPHDirector of Public Health Preparedness & ResponseAssociation of Public Health Laboratories

Katie SellersSenior Director, Research and Evaluation Association of State and Territorial HealthOfficials

Senior StaffCenter for BiosecurityUniversity of Pittsburgh Medical Center

PUBLIC HEALTH PREPAREDNESSADVISORY BOARDTFAH thanks these former State Health Officialsfor participating in TFAH’s Public HealthPreparedness Advisory Board. The time,expertise, and insights they provided on thereport were invaluable. The opinions expressedin this report do not necessarily represent theviews of these individuals or their organizations.

Leah McCall Devlin, DDS, MPHFormer State Health Director of the Departmentof Health and Human Services in NorthCarolina, and Gillings Visiting ProfessorUniversity of North Carolina GillingsSchool of Global Public Health

Christy Ferguson, JDFormer Commissioner of the Department ofPublic Health in Massachusetts, and AssociateResearch Professor, School of Public Health andHealth Services Department of Health Policy George Washington University

Eduardo Sanchez, MD, MPHFormer Texas State Health Commissioner andChief Medical OfficerBlue Cross Blue Shield of Texas

ACKNOWLEDGEMENTS

TRUST FOR AMERICA’S HEALTH (TFAH) IS A NON-PROFIT, NON-PARTISAN ORGANIZATION DEDICATED TO SAVING LIVES

AND MAKING DISEASE PREVENTION A NATIONAL PRIORITY.This report is supported by a grant from the Robert Wood Johnson Foundation (RWJF). The opinions expressed in this report are those of the au-thors and do not necessary reflect the views of the foundation. TFAH thanks RWJF for their generous support.

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropydevoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individu-als 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. Helping Americans leadhealthier lives and get the care they need—the Foundation expects to make a difference in our lifetime. For more information, visit www.rwjf.org.

Introduction

n State cuts: 33 states and Washington, D.C. cutfunding for public health from fiscal year (FY)2008-2009 to 2009-2010, 18 of these states cutfunding for a second year in a row. Accordingto the Center on Budget and Policy Priorities(CBPP), states have experienced overall budg-etary shortfalls of $425 billion since FY 2009.1

n Local cuts: In January 2010, 53 percent oflocal health departments reported that theircore funding had been cut from the previousyear, and 47 percent anticipate cuts again inthe coming year.2 Approximately 23,000 jobs-- totaling 15 percent of the local public healthworkforce -- have been lost since January 2008.

n Federal cuts: Since FY 2005, federal supportfor public health preparedness has also beencut by 27 percent.3

Last year, one-time funding from the AmericanRecovery and Reinvestment Act (ARRA) and re-sponse efforts related to the H1N1 pandemicmeant that public health cuts were not as dras-tically felt as they otherwise would have been.

This year, the Great Recession is taking its tollon emergency health preparedness.

Nearly 10 years ago during the September 11,2001 and anthrax tragedies, it became clear thepublic health system was out-of-date to face mod-ern health threats -- and an historic investmentwas made to help upgrade the system. Signifi-cant progress was made to improve how we pre-vent, identify, and contain new disease outbreaksand bioterrorism threats and respond to the af-termath of natural disasters.

Now — the economic situation is putting almosta decade of gains at serious risk.

For the past eight years in the annual Ready orNot? Protecting the Public’s Health from Diseases, Dis-asters, and Bioterrorism report, the Trust for Amer-ica’s Health (TFAH) has documented theprogress and ongoing vulnerabilities in the na-tion’s ability to respond to health crises.

Significant progress has been made toward up-grading preparedness planning and coordination,public health laboratories, surveillance, commu-

nications, liability protections, vaccine manufac-turing, the Strategic National Stockpile, pharma-ceutical and medical equipment distribution, andincreasing and upgrading staff. Because of thisinvestment, the country was much better pre-pared over the last decade to respond to a rangeof public health emergencies -- including E.coli,Salmonella and other foodborne illness out-breaks, the oil spill in the Gulf Coast, ice storms,mudslides, tornadoes, and floods, and assist in theresponse to international crises like the IndianOcean earthquake and tsunami and the Haitianearthquake. The emergency supplemental fund-ing and efforts to respond to the H1N1 flu pan-demic built on the foundational work that hadbeen accomplished over the past decade andhelped take preparedness to the next level.

While the investment in preparedness was im-portant and led to major improvements, it wasnot sufficient to backfill long-standing gaps inthe public health infrastructure or update tech-nologies to meet modern, state-of-the-art stan-dards. Unfortunately, the latest budget cuts willclearly exacerbate the vulnerable areas in U.S.emergency health preparedness.

Some ongoing major gaps include:

n A Workforce Gap: There is already a majorshortage of trained public health workers andfunded positions. There are not enough work-ers, particularly experts, to effectively respondduring public health emergencies. The UnitedStates has 50,000 fewer public health workersthan it did 20 years ago, and one-third of pub-lic health workers will be eligible to retire withinfive years.4, 5 As baby boomers begin to retire,there is not a new generation of workers beingtrained to fill the void. Also, in some casesunder current policies, public health workersin one area are not allowed to be shifted to helpin other areas, even during emergencies. Therecent budget cuts are intensifying the prob-lem, with a reduction of 15 percent of the localpublic health workforce in the past two years.At the same time, health departments aroundthe country are experiencing furloughs orshortened work weeks.

3

There is an emergency for emergency health preparedness in the United States.The severe budget cuts by federal, state, and local governments are leaving

public health departments understaffed and without the basic capabilities requiredto respond to crises.

4

n A Surge Capacity Gap: In the event of a majordisease outbreak or attack, the health care sys-tem would be stretched beyond normal capa-bilities. Surge capacity, the ability of the medicalsystem to care for a massive influx of patients,remains one of the most serious challenges foremergency preparedness. In addition to havingenough staff, a large-scale disaster also requireshaving enough equipment and appropriatespace to treat patients. There are numerous on-going surge capacity issues in health care set-tings beyond just hospitals, including response,crisis care standards, alternative care sites, coor-dinating volunteers to help, adequate liabilityprotection for volunteers and clinicians, and re-gional coordination.

n A Surveillance Gap: The United States stilllacks an integrated, national approach to bio-surveillance -- which could significantly im-prove response capabilities for emergenciesranging from a bioterrorism attack to cata-strophic disease outbreaks to contaminationof the food supply. There is no system usingup-to-date technology and standardized re-porting, like systems major retail chains use totrack inventory and customer patterns. Cur-rently, there is substantial variation in howquickly states collect and report data, whichhampers bioterrorism and disease outbreakidentification and control efforts.

n A Gap in Community Resiliency Support:The ability to work with communities around

ways to cope with and recover from a disasteror public health emergency is another majorchallenge for preparedness. It is particularlydifficult to address the needs of at-risk, specialneeds, and vulnerable populations, such aschildren, the uninsured or underinsured, theelderly, people with underlying health condi-tions, and lower-income communities. Theexisting gaps in day-to-day public health de-partments make it challenging to build andmaintain the relationships needed to identifyand work with the most vulnerable Americanswho need the most help during emergencies.

n Gaps in Vaccine and Pharmaceutical Re-search, Development, and Manufacturing:The research and development of medicalcountermeasures (MCM)– including diagnos-tics, antiviral medications and vaccines -- is out-dated in the United States, in large partbecause it is not a particularly profitable ven-ture for pharmaceutical investors. ProjectBioShield and the Biomedical Advanced Re-search and Development Authority (BARDA)were developed to help spur innovation andinvestment in medical countermeasures, but,so far, the development of new, effective prod-ucts has been limited and we have not devel-oped new platforms for multi-use productdevelopment and manufacture. The invest-ments made in vaccine research and develop-ment did help lead to the production of avaccine for the H1N1 flu strain in record time,but manufacturers were only able to producelimited quantities by the beginning of the fluseason because of limited capacity and re-liance on an old and outdated egg-based pro-duction strategy.

Every American deserves basic health protectionsand to live in safe communities. It is impossibleto be prepared for every possibility -- but it is pos-sible and essential to maintain a basic, core levelof preparation and response capabilities.

TFAH issues the Ready or Not? report to providethe public and policymakers with an independentanalysis about progress and ongoing vulnerabili-ties in the nation’s public health preparedness.The report assesses the level of preparedness instates, evaluates the federal government’s role andperformance, and offers recommendations forimproving emergency preparedness.

This report also aims to foster greater account-ability for how effectively taxpayer dollars areused to improve the nation’s readiness forhealth emergencies. Without transparency, it ishard for the American public to know how wellthe government is protecting them from therange of threats our nation faces.

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The report:

n Informs the public and policymakers aboutthe status of public health preparedness inthe United States;

n Provides greater transparency for publichealth preparedness programs;

n Encourages greater accountability for thespending of preparedness funds; and

n Recommends ways to help the nation movetoward a strategic, capabilities-based systemable to respond effectively to health threatsposed by diseases, disasters, and bioterrorism.

This 2010 edition of the Ready or Not? report fo-cuses on reviewing state and federal public healthemergency preparedness. The contents include:

n Section 1: An examination of state-by-state pub-lic health preparedness, in which states are eval-uated on 10 key preparedness indicators, basedon input and review from public health experts.

n Section 2: An examination of federal policyissues and recommendations for improvingall-hazards and pandemic preparedness -- in-cluding considerations for the reauthoriza-tion of the Pandemic and All-HazardsPreparedness Act (PAPHA), to incorporatefunding and modernizing public health pre-paredness, improving the development ofmedical countermeasures, enhancing surgecapacity for mass emergencies, increasingcommunity resiliency, and ensuring enoughtrained public health workers.

READY OR NOT? 2010: MAJOR CONCLUSIONS

n 33 states and D.C. cut funding for public health from FY 2008-09 to FY 2009-10.

nOnly 7 states can not currently share data electronically with health care providers.

n 10 states do not have an electronic syndromic surveillance system that can report and exchange in-formation.

nOnly six states reported that pre-identified staff were not able to acknowledge notification of emer-gency exercises or incidents within the target time of 60 minutes at least twice during 2007-08.

n Six states did not activate their emergency operations center (EOC) a minimum of two times in2007-08.

nOnly two states did not develop at least two After-Action Report/Improvement Plans (AAR/IPs)after exercises or real incidents in 2007-08.

n 25 states do not mandate all licensed child care facilities to have a multi-hazard written evacuationand relocation plan.

n 21 states were not able to rapidly identify disease-causing E.coli O157:H7 and submit the lab resultsin 90 percent of cases within four days during 2007-08.

nOnly three states and D.C. report not having enough staffing capacity to work five, 12-hour days forsix to eight weeks in response to an infectious disease outbreak, such as novel influenza A H1N1.

nOnly one state decreased their Laboratory Response Network for Chemical Threats (LRN-C)chemical capability from August 10, 2009 to August 9, 2010.

Note: the most current available verifiable data is used for each indicator category. The data for indicators 4, 5,6, and 8 are from the CDC’s Public Health Preparedness: Strengthening the Nation’s Emergency Response State byState report, published in 2010.6

READY OR NOT? 2010: KEY FINDINGS

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The U.S. public health system is responsible for protecting the American people from a range of potential health threats.

Agroterrorism: The “…deliberate introduction of an animalor plant disease with the goal of generating fear, causing eco-nomic losses, and/or undermining stability.”7 Agroterrorismcan be considered a subcategory of “bioterrorism” and food-borne diseases.

Bioterrorism: The intentional or deliberate use of germs orbiotoxins that cause disease or death in people, animals, orplants. Examples include Salmonella, and E. coli or otheragents that cause anthrax, smallpox, or botulism.

Blast injuries: Explosions, whether deliberate or accidental,can cause multi-system, life threatening injuries among individ-uals and within crowds. In addition, blunt and penetrating in-juries to multiple organ systems are likely when an explosionoccurs and unique injuries to the lungs and central nervoussystem occur during explosions. Blast injuries present uniquediagnostic, triage, and management challenges for civilianhealth care providers, the majority of whom are unfamiliarwith these types of injuries and the treatment required.

Chemical terrorism: The deliberate use of manufacturedchemicals, whether they were created intentionally asweapons or for industrial purposes in order to cause illness ordeath. Examples include sarin and chlorine.

Chemical incidents and accidents: The non-deliberate ex-posure of humans to harmful chemical agents, with similaroutcomes to chemical terrorism.

Food-borne diseases: Food-borne illness is caused by inges-tion of harmful microbes or the toxins they produce. TheU.S. Centers for Disease Control and Prevention (CDC) esti-mates there are approximately 76 million pathogen-inducedcases of food-borne diseases each year in the United States,causing approximately 325,000 hospitalizations and 5,000deaths. Examples include botulism, Salmonella, E.coli0157:H7, shigella, and norovirus.

Influenza pandemic: is an epidemic of a flu virus that spreadon a worldwide scale and infects a large proportion of thehuman population. Influenza pandemics occur when a newstrain of the flu virus is transmitted to humans from anotheranimal species, like pigs, chickens, or ducks. Humans do not

have natural immunity against these new strains. The H1N1flu was the first pandemic flu of the 21st century. Historically,pandemic flu occurs two to three times every hundred yearsor so. In the 20th century the world experienced the 1918,1957/58, and 1968 pandemic flu, although the severity of thedisease varied greatly among them.

Natural disasters: Harm can be inflicted during and afternatural disasters, which can lead to contaminated water,shortages of food and water, loss of shelter, and the disruptionof regular health care. Examples include hurricanes, earth-quakes, tornados, mudslides, fires, and tsunamis.

Radiological threats: Intentional or accidental exposure to ra-diological material. For example, a terrorist attack could involvethe scattering of radioactive materials through the use of explo-sives (“dirty bomb”), the destruction of a nuclear facility, the in-troduction of radioactive material into a food or water supply,or the explosion of a nuclear device near a population center.

Vector-borne diseases: Diseases spread by vectors, such asinsects and ticks. Examples include West Nile virus, Denguefever, Chikungunya, Rocky Mountain spotted fever, Lyme dis-ease, and malaria.

Water-borne diseases: Diseases spread by contaminateddrinking water or recreational water, such as typhoid feverand cholera. According to CDC, more than 1,000 personsbecome ill from contaminated drinking water and more than2,500 persons become ill from recreational water disease out-breaks annually in the United States.8

Zoonotic/Animal-borne diseases: Animal diseases that canspread to humans and, in some cases, become contagious fromhuman to human. Examples include Avian flu, Ebola, and SARS.In 2000, the World Health Organization (WHO) identifiedmore than 200 diseases occurring in humans that were knownto be transmitted through animals.9 Experts believe that the in-creased emergence of zoonotic diseases worldwide can be at-tributed to population displacement, urbanization andcrowding, deforestation, and globalization of the food supply.HIV, the greatest pandemic of our time, was a zoonotic diseasethat became contagious from person-to-person.

ALL-HAZARDS APPROACH TO EMERGENCY PUBLIC HEALTH THREATS

EXAMPLES OF MAJOR EMERGENCY PUBLIC HEALTH THREATS

7

The Goals of 24/7 Public Health Emergency ResponseInclude:n Rapid detection of and response to emergency diseasethreats, including those caused by bioterrorism.

n Intensive investigative capabilities to quickly diagnose aninfectious disease outbreak or to identify the biological orchemical agent used in an attack.

n Surge capacity for mass events, including adequate facili-ties, equipment, supplies, and trained health professionals.

nMass containment strategies, including medicines andvaccines to stop the spread of a disease and isolation andquarantine when necessary and feasible.

n Streamlined and effective communication channels sohealth workers can swiftly and accurately communicatewith each other, other front line workers, and the publicabout 1) the nature of an emergency or attack, 2) the riskof exposure and how to seek treatment when needed, and3) any actions they or their families should take to protectthemselves.

n Communications must also be able to reach and take intoconsideration at-risk and hard-to-reach populations.

n Streamlined and effective response to address the needs ofat-risk populations during emergencies, particularly thosewith special medical needs.

n An informed and involved public who can provide mate-rial and moral support to professional responders, and canrender aid when necessary to friends, family, neighbors, andassociates.

What it will take to achieve basic levels of preparedness:n Leadership, planning, and coordination: An establishedchain-of-command and well defined roles and responsibili-ties for seamless operation across different medical and lo-gistical functions and among federal, state, and localauthorities during crisis situations, including police, publicsafety officials, and other first responders.

nWell-funded core public health infrastructure: Basicpublic health systems and equipment, including laboratorytesting and communications equipment, which keep pacewith advances in science and technology.

n An expert and fully-staffed workforce: Highly trainedand adequate numbers of public health professionals, in-cluding epidemiologists, lab scientists, public health nursesand doctors, and other experts, in addition to back-upworkers for surge capacity needs.

nModernized technology: State-of-the-art laboratory equip-ment, information collection, and health tracking systems.

n Rapid development and ability to manufacture vac-cines and medications: A streamlined, safe, effective sys-tem to ensure rapid research and production of MCM toprotect people for emerging threats.

n Pre-planned, safety-first rapid emergency responsecapabilities and precautions: Tested plans and safety pre-cautions to mitigate potential harm to communities, publichealth professionals, and first responders.

n Immediate, streamlined communications capabilities:Coordinated, integrated communications among all parts ofthe public health system, all frontline responders, and withthe public. Must include back-up systems in the event ofpower loss or overloaded wireless channels.

WHAT DOES ALL-HAZARDS PREPAREDNESS LOOK LIKE?

The federal role: Includes policymaking, funding programs,overseeing national disease prevention efforts, collecting anddisseminating health information, building capacity, providingsubject matter expertise and technical assistance, and directlymanaging some services, and supporting biomedical researchand production capability.10 Some public health capabilities,such as the Strategic National Stockpile (SNS), are federal as-sets managed by federal agencies that are available to supple-ment a state’s and community’s response to a public healthemergency that overwhelms or may overwhelm their capabili-ties. Public health functions are widely diffused across eightfederal agencies and two offices.

State and local roles: Under U.S. law, state governments haveprimary responsibility for the health of their citizens. Consti-tutional “police powers” give states the ability to enact lawsand issue regulations to protect, preserve, and promote thehealth, safety, and welfare of their residents. In many states,state laws charge local governments with responsibility forthe health of their citizens. State and local health depart-ments and first responders are the front line in any publichealth emergency.

FEDERAL, STATE, AND LOCAL PUBLIC HEALTH JURISDICTIONS

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In December 2009, U.S. Department of Healthand Human Services released the first NationalHealth Security Strategy (NHSS) outlining a na-tional vision for a prepared country and popula-tion. The NHSS was one of the majordeliverables outlined by the 2006 Pandemic andAll-Hazards Preparedness Act (PAHPA) and it isto be updated every four years. According to theNHSS, “National health security is achieved whenthe Nation and its people are prepared for, pro-tected from, respond effectively to, and able torecover from incidents with potentially negativehealth consequences.”12 Underscoring the entiredocument is an emphasis on public health, pre-vention, and community resilience. “Simply put,”the strategy says, “the health of a nation’s peoplehas a direct impact on that nation’s security.”13

The NHSS recognizes the progress that has beenmade over the past nine years while highlightingsome of the challenges that remain, including med-ical surge capacity, public health and medical work-force, medical countermeasures, and communityresilience. However, the NHSS also highlights the“considerable variation [that] remains in the de-gree to which individual states, territories, tribes,and local jurisdictions are prepared to addresslarge-scale health threats.”14 Additionally, the strat-egy notes that “few evidence-based performancemeasures and standards exist to gauge the effec-tiveness of national health security efforts andprogress towards goals — that is, to assess the ex-tent to which the Nation is prepared for the typesof health incidents that we have experienced in thepast and may have to confront in the future.”

The NHSS also recognizes that in order for ourpublic health and medical systems to be truly pre-pared, this requires the entire health care sector— not just emergency departments — to planand be ready to help out in a mass casualty event.

To help the nation achieve this vision of healthsecurity, HHS followed up with the release ofthe draft Biennial Implementation Plan (BIP) forthe NHSS.15 The BIP outlines two overarchinggoals: 1) build community resilience; and 2)strengthen and sustain health and emergency re-sponse systems. These two goals are supportedby 10 strategic objectives:

1. Foster informed, empowered individualsand communities.

2. Develop and maintain the workforceneeded for national health security.

3. Ensure situational awareness.

4. Foster integrated, scalable health care deliv-ery systems.

5. Ensure timely and effective communications.

6. Promote an effective countermeasuresenterprise.

7. Ensure prevention or mitigation of environ-mental and other emerging threats to health.

8. Incorporate post-incident health recoveryinto planning and response.

9.Work with cross-border and global partnersto enhance national, continental, and globalhealth security.

10. Ensure that all systems that support nationalhealth security are based upon the bestavailable science, evaluation and quality im-provement methods.

HHS solicited and received thousands of com-ments on the draft BIP and continues to refinethe plan. The BIP acknowledges that there areno significant new funds to implement the newnational health security strategy so existing fed-eral resources must be leveraged and used ef-fectively and efficiently to accomplish the goals.

“PREVENTION IS A CORNERSTONE TO BOTH HEALTH SECURITY AND NATIONAL SECURITY.”

— NATIONAL HEALTH SECURITY STRATEGY11

NATIONAL HEALTH SECURITY STRATEGY

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In addition to the health toll that diseases, disasters, andbioterrorism can take, they also have major economic implica-tions. For example:

n September 11, 2001 Tragedies: The total economic losshas been estimated at roughly $80 billion, of which $32.5billion was insurable.16 The insurance industry paid the$32.5 billion in insured losses from business interruption,property, workers’ compensation, aviation liability, andother liability costs.17 In addition, World Trade Centerworkers received a $625 million settlement for their expo-sure to toxic dust.18

n Anthrax Attacks: According to a report in the WashingtonPost and the U.S. Federal Bureau of Investigations (FBI), theclean up from the 2001 anthrax attacks exceeded $1 billion.19A reported $42 million was spent to decontaminate the HartSenate Office Building and other Capitol Hill offices and itcost in excess of $200 million to decontaminate the Brent-wood and Hamilton Township, New Jersey postal facilities.20This does not include the cost of the public health responseand laboratory testing of specimens around the country.

s According to a report in the New York Times, under a hy-pothetical scenario developed by the U.S. Department ofHomeland Security (DHS) involving an anthrax attack, ifterrorists were to spray aerosolized anthrax from a vanin three cities initially, followed by two more citiesshortly afterward, casualties could well exceed 13,000,and result in a loss of billions of dollars.21 Other esti-mates are that anthrax could result in more than 13,000deaths in a single city.

s According to a study by Towers Perrin Consulting, oneanthrax attack in New York City could lead to $90 billionin workers’ compensation losses, which would be threetimes greater than the entire $30 billion workers’ com-pensation industry.22

s Risk Management Solutions (RMS), a leading risk consult-ing firm, believes an attack on downtown New York Citycould result in 173,000 casualties. In this scenario, an-thrax is weaponized and dispersed in aerosol form, re-sulting in inhalation of anthrax by approximately onemillion people. Incredibly, RMS estimates economiclosses of $91 billion from workers compensation alone.23

nNuclear, Biologic, or Chemical Attacks and the Insur-ance Industry: In 2005, the CEO of Allstate Corp, a leadinginsurance company, stated that nuclear, biological or chemicalterrorist attacks “could literally destroy the entire capital baseof the insurance industry.”24 As a point of reference, the capi-tal base for the insurance industry in 2003 was $347 billion.25

n Foodborne Illness and Agroterrorism: Agriculture rep-resents 1.2 percent of the U.S. gross domestic product

(GDP), or $173 billion a year.26 Agriculture and the foodsector employed approximately 12.5 million workers in2008, or nearly nine percent of the total U.S. workforce.27

s In 2001, a foot-and-mouth disease outbreak in Britain ledto an estimated economic loss of $6 to $18 billion, andled to the destruction of four million animals.28 A 1999report estimated that an outbreak of foot-and-mouth inCalifornia would lead to economic losses of $6 billion.29

sOver the last few decades, the United Kingdom has bat-tled bovine spongiform encephalopathy (BSE), betterknown as “mad cow” disease. As of March 2005, 149people who were infected with the disease have died,and nearly four million cows have been slaughtered.30

s In 1978, the Arab Revolutionary Council engaged in bioter-rorism, using mercury to poison Israeli oranges. A dozenchildren in Holland and West Germany were hospitalizedas a result. Ultimately, this act helped sabotage the Israelieconomy, resulting in a 40 percent reduction in orange ex-ports.31 At the time, oranges accounted for about a tenthof all Israeli exports.32 The United States produces over 20percent of the world’s citrus, or approximately 15.6 milliontons in 2004.33 U.S. citrus exports are roughly $1 billion,while U.S. consumers spend more than $3 billion on citrusproducts (orange and grapefruit juice and fresh fruit).34

s In 1982 in the United States, an unknown suspected tam-pered with Tylenol by putting cyanide into capsules andreturning bottles to stores. The tampering resulted in 7deaths in Chicago. A massive recall effort was under-taken, and Tylenol’s market share dropped from 37 per-cent to seven percent.35

nNew Infectious Disease Outbreak: In 2003, SevereAcute Respiratory Syndrome (SARS) swept through South-east Asia, infecting over 8,000 people and leaving 774 dead.36Its reach demonstrates the tremendous speed in which dis-ease can spread. Originating in China, the SARS outbreakeventually infected individuals from 29 nations around theworld. Overall, the economic losses, due to deaths, quaran-tines, and lost tourism dollars, may have been $30 to $50 bil-lion, according to some estimates.37 In Toronto alone (manythousands of miles away from the initial outbreak), more than27,000 people in and around the city were forced into quar-antine during two outbreaks, which led to an estimated eco-nomic loss of nearly $1 billion.38

n Severe Pandemic Flu Outbreak: A severe pandemic flusimilar to the 1918 could lead to a drop in the GDP of morethan 5.5 percent — totaling around $683 billion in losses.39

n Gulf Coast Oil Spill: An estimated $1.2 billion in eco-nomic output and 17,000 jobs have been lost in 2010 ac-cording to an analysis from Moody’s Analytics.40

ECONOMICS AND PUBLIC HEALTH PREPAREDNESS

State-by-State PublicHealth PreparednessIndicators and Scores

All Americans have the right to expect fundamental health protections during public health emergencies, no matter where they live.

To help assess health emergency preparedness,this section of the Ready or Not? report examinesa series of 10 indicators of preparedness acrosseach state that, taken collectively, offer a com-posite snapshot of strengths and vulnerabilities.

While federal, state, and local health depart-ments, and private health providers all have rolesto play in public health preparedness, states haveprimary legal jurisdiction and responsibility forthe health of their citizens.41 Since the terroristattacks of September 11, 2001, CDC has pro-vided nearly $8 billion in preparedness fundingto states, localities, and four major cities.

States differ in how they structure, deliver andfund public health services, and different stateshave different strengths and vulnerabilities in ca-pabilities. States with multiple, high-density urbanareas may function very differently than those withfewer residents spread across smaller cities andtowns. However, all states should be able to meetbasic preparedness goals as defined by federalhealth officials.

This report was developed to provide taxpayersand policymakers with information about howwell-prepared their states and communities arefor different types of health threats. The Amer-ican people deserve to know how prepared theirstates and communities are for different types ofhealth threats, particularly when their taxpayerdollars are being spent to support preparednessefforts. Currently, the American public is notequipped with enough information to monitorand hold public officials accountable forwhether their communities are adequately pre-pared. The Ready or Not? report provides an in-dependent review of progress and ongoingvulnerabilities to the public and policymakers.

A number of efforts are underway to provide in-creased transparency and accountability aroundpreparedness. Post-September 11th prepared-ness is a new field and developing tools to assessand measure capabilities and progress is not asimple process. Currently, there is no standardset of performance measures to evaluate emer-gency preparedness.

A number of assessment studies and efforts havebeen undertaken. Limited data has been sharedwith the public from these projects. One of themost recent efforts was the September 2010 re-port Public Health Preparedness: Strengthening theNation’s Emergency Response State by State from theCDC, which was a follow up to a February 2008report. The report represents a major step for-ward in improving accountability and trans-parency -- following up on Congress’s expresseddesire for CDC to continue to report state-by-state data -- allowing Americans to see how theirtax dollars are being used to better protect theirfamilies and communities from a range ofhealth threats. It differs from the Ready or Not?report in that it only reports on data collectedfrom the 50 states and four cities from CDC’sPublic Health Emergency Preparedness Coop-erative Agreement.

The Ready or Not? report compiles indicatorsbased on the best publicly available data or datareceived from surveying states directly. Eachstate receives a score based on 10 key indicators.States receive one point for achieving an indi-cator or zero points if they do not achieve theindicator. Zero is the lowest possible overallscore, and 10 is the highest. (For more informa-tion, please see Appendix B: Data and Methodologyfor State Indicators.)

11

1SECT ION

12

SCORES BY STATE

WA

NV

AZ

CO

NE

ND

MN

WI

IL

KY VA

NY

HI

MD DC

DE NJ

NH

VT

MA

RI CT

NC

LA

AR

MS AL

SD

KS MO

TN

GASC

FL

IN OH

WV

PA

ME

MIIA

OK

TX

NM

ORID

MT

WY

UT

AK

CA

10(3 states)

ArkansasNorth DakotaWashington

9(11 states)

AlabamaCaliforniaKentuckyLouisianaMarylandMississippiOhioUtahVirginiaWest VirginiaWisconsin

8(18 states)

Alaska ArizonaColoradoConnecticutDelawareFloridaIndianaMichigan MinnesotaNebraskaNew HampshireNew JerseyNew YorkNorth CarolinaOklahomaPennsylvaniaVermontWyoming

7(7 states & D.C.)

D.C.GeorgiaHawaiiMaineMissouriOregonTennesseeTexas

6(9 states)

IdahoIllinoisKansasMassachusettsNevadaNew MexicoRhode IslandSouth CarolinaSouth Dakota

5(2 states)

IowaMontana

Number of Indicators Color

5

6

7

8

9

10

13

STATE PREPAREDNESS SCORES(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)

State increased State can State health State health State public State developed State requires State is able State has the State or maintained currently send department has department has health at least two all licensed to rapidly necessary lab increased

level of and receive an electronic the ability to department After-Action childcare identify workforce Laboratory funding for electronic syndromic convene an activated its Report/ facilities to disease- staffing to Response public health health surveillance emergency EOC as part Improvement have a causing E.coli work five, Network for 2010 services from information system that response team of a drill, Plans multi-hazard O157:H7 and 12-hour days Chemical Total FY 2008-09 with health can report within exercise, or (AAR/IPs) written submit for six to Treat Score

to FY 2009-10. care providers. and exchange 60 minutes. real incident after an evacuation results by eight weeks in (LRN-C) information. at least twice a minimum of exercise or and PulseNet response to an capability.

during 2007-08. two times in real incident relocation within four infectious disease 2007-08. during 2007-08. plan. working days outbreak, such

90% of the as novel time during influenza

States 2007-08. A H1N1.Alabama 3 3 3 3 3 3 3 3 3 9Alaska 3 3 3 3 3 3 3 3 8Arizona 3 3 3 3 3 3 3 3 8Arkansas 3 3 3 3 3 3 3 3 3 3 10California 3 3 3 3 3 3 3 3 3 9Colorado 3 3 3 3 3 3 3 3 8Connecticut 3 3 3 3 3 3 3 3 8Delaware 3 3 3 3 3 3 3 3 8DC 3 3 3 3 3 3 3 7Florida 3 3 3 3 3 3 3 3 8Georgia 3 3 3 3 3 3 3 7Hawaii 3 3 3 3 3 3 3 7Idaho 3 3 3 3 3 3 6Illinois 3 3 3 3 3 3 6Indiana 3 3 3 3 3 3 3 3 8Iowa 3 3 3 3 3 5Kansas 3 3 3 3 3 3 6Kentucky 3 3 3 3 3 3 3 3 3 9Louisiana 3 3 3 3 3 3 3 3 3 9Maine 3 3 3 3 3 3 3 7Maryland 3 3 3 3 3 3 3 3 3 9Massachusetts 3 3 3 3 3 3 6Michigan 3 3 3 3 3 3 3 3 8Minnesota 3 3 3 3 3 3 3 3 8Mississippi 3 3 3 3 3 3 3 3 3 9Missouri 3 3 3 3 3 3 3 7Montana 3 3 3 3 3 5Nebraska 3 3 3 3 3 3 3 3 8Nevada 3 3 3 3 3 3 6New Hampshire 3 3 3 3 3 3 3 3 8New Jersey 3 3 3 3 3 3 3 3 8New Mexico 3 3 3 3 3 3 6New York 3 3 3 3 3 3 3 3 8North Carolina 3 3 3 3 3 3 3 3 8North Dakota 3 3 3 3 3 3 3 3 3 3 10Ohio 3 3 3 3 3 3 3 3 3 9Oklahoma 3 3 3 3 3 3 3 3 8Oregon 3 3 3 3 3 3 3 7Pennsylvania 3 3 3 3 3 3 3 3 8Rhode Island 3 3 3 3 3 3 6South Carolina 3 3 3 3 3 3 6South Dakota 3 3 3 3 3 3 6Tennessee 3 3 3 3 3 3 3 7Texas 3 3 3 3 3 3 3 7Utah 3 3 3 3 3 3 3 3 3 9Vermont 3 3 3 3 3 3 3 3 8Virginia 3 3 3 3 3 3 3 3 3 9Washington 3 3 3 3 3 3 3 3 3 3 10West Virginia 3 3 3 3 3 3 3 3 3 9Wisconsin 3 3 3 3 3 3 3 3 3 9Wyoming 3 3 3 3 3 3 3 3 8Total 17 43 + D.C. 40 + D.C. 44 + D.C. 44 + D.C. 48 + D.C. 25 + D.C. 29 47 49 + D.C.

Low scores are not intended to be punitive -- infact, they point out areas where increased invest-ments and resources are needed to fill gaps. Thisreport is intended to help identify where suffi-cient resources have not been made available byfederal or state governments to support adequatepublic health preparedness and where and howstates could improve or overcome obstacles to anall-hazards approach to public health prepared-ness. In addition, providing information aboutwhich states have particular strengths allows oth-ers to know which states to turn to for best prac-tices and models to guide their own preparednessefforts. The indicators are not a comprehensivestudy of preparedness, but provide a snapshotcomposite of strengths and vulnerabilities.

The indicators in this report were selectedbased on:

n Reflection of a fundamental, systemic publichealth need;

n Consultation with key experts about areas im-portant to serving basic public health emer-gency needs; and

n The availability of state level data that wereverified through independent means or inconsultation with states.

TFAH is only able to assess states comparativelywhere there are data available for all 50 statesand D.C. Many states have taken action in otherareas of preparedness and developed strengthsor may be in the process of increasing certaincapabilities not reflected in this report.

Data from these indicators were drawn from arange of publicly available sources, includingCDC, a survey conducted by the Association ofPublic Health Laboratories (APHL), the Officeof the Civilian Medical Reserve Corps, the Asso-ciation of State and Territorial Health Officials(ASTHO), states’ public documents, and inter-views with government officials.

14

The Ready or Not? report has documented thesignificant progress that states have made inpreparing for public health emergencies.

The 10 indicators are adapted annually to reflectchanging expectations for preparedness and changesin the state preparedness data that are made pub-licly available. Updating the indicators each year al-lows the report to reflect a range of preparednessissues, including emphasizing what is of the highestconcern in any given year, but all of the issues areconsidered to be important and integral parts ofoverall public health emergency capabilities. The re-port does maintain some consistency between yearsto help balance measuring ongoing concerns withnew, revised, or highlighted concerns.

This year, two important new data sets wereavailable for the first time, and TFAH includeddata from both of these sources in this year’sReady or Not? report:

n New detailed, verified data about importantpreparedness areas were made publicly avail-

able for the first time in CDC’s Public HealthPreparedness: Strengthening the Nation’s Emer-gency Response State By State; and

n Information from a survey of State Health Of-ficers conducted by the Association of Stateand Territorial Health Officers.

The availability of new detailed data is animportant step toward increased accountabilityand transparency.

TFAH used three indicators from last year’sReady or Not? report — state funding for publichealth; whether a state has the necessary labworkforce staffing to work five, 12-hour daysfor six to eight weeks in response to an infec-tious disease outbreak, such as novel influenzaA H1N; and whether the state require all li-censed child care facilities to have a multi-haz-ard written evacuation and relocation plan.Progress on some additional highlight past indi-cators is also included.

READY OR NOT? DOCUMENTS PREPAREDNESS PROGRESS

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A. 2010 READY OR NOT? STATE-BY-STATE INDICATORS

Indicators1. Funding Commitment — Did the state maintain or increase funding for public health programsfrom FY 2008-09 to FY 2009-2010?

2. Health Information Technology — Does the state currently send and receive electronic healthinformation to health care providers and community health centers?

3. Electronic Syndromic Surveillance — Does the state health department have an electronicsyndromic surveillance system that can report and exchange information?

4. Incident Response Capacity — Did the state acknowledge pre-identified staff of emergencyexercises or incidents within the target time of 60 minutes at least twice during 2007-08.

5. Emergency Operations Center (EOC) — Did the state public health department activate itsEOC as part of a drill, exercise, or real incident a minimum of two times in 2007-08?

6. After Action Reports — Did the state develop at least two After-Action Report/ImprovementPlans (AAR/IPs) after an exercise or real incident in 2007-08?

7. Community Resilience — Children and Preparedness — Does the state require all licensed childcare facilities to have a multi-hazard written evacuation and relocation plan?

8. Foodborne disease detection and reporting — Is the state able to rapidly identify disease-causing E.coli O157:H7 and submit results by PulseNet within four working days 90% of the time?

9. Public Health Laboratories — Surge Workforce — Does the state have the necessary labworkforce staffing to work five, 12-hour days for six to eight weeks in response to an infectiousdisease outbreak, such as novel influenza A H1N1?

10. Public Health Laboratories — Did the state increase or maintain Laboratory Response Network for Chemical Treat (LRN-C) capability?

1. Indicator: PUBLIC HEALTH FUNDING COMMITMENT -- STATE PUBLIC HEALTH BUDGETSFINDING: 17 states increased or maintained funding for public health from FY 2008-09 to FY 2009-10.

17 states increased or maintained levelfunding for public health services from FY 2008-09 to FY 2009-10 (1 point)

State and percent increase (adjusted for inflation)

Alabama (5.5%)Alaska (24.8%)2Arkansas (4.6%)Hawaii (4.2 %)2, 5Indiana (1.4%)Kentucky (0.1%)Louisiana (7.5%)Maine (14.7%)2Montana (7.5%)5Nebraska (0.6%)New Hampshire (7.8%)North Dakota (25.5%)4 ,5Ohio (7.5%)South Dakota (4.4%)Texas (17.4%)5Washington (2.0%)3West Virginia (1.5%)

33 states DECREASED funding for publichealth services from FY 2008-09 to FY 2009-10 (0 points)

State and percent decrease (adjusted for inflation)

Arizona (-23.3%) Missouri (-15.4%)California (-8.5%)5 Nevada (-3.6%)Colorado (-7.5%) New Jersey (-5.3%)5Connecticut (-11.3%)2, 5 New Mexico (-9.5%)Delaware (-18.7%)2 New York (-6.7%)D.C. (-18.3%)5 North Carolina (-2.2%)2Florida (-14.9)2 Oklahoma (-3.6%)1Georgia (-34.5%) Oregon (-3.9%)Idaho (-4.7%) Pennsylvania (-21.0%)2Illinois (-2.6%) Rhode Island (-4.0%)Iowa (-13.1%) South Carolina (-14.6%)Kansas (-10.1%) Tennessee (-8.3%)Maryland (-17.2%)2 Utah (-3.7%)Massachusetts (-15.7%) Vermont (-2.5%)Michigan (-11.2%)3 Virginia (-0.3%)3Minnesota (-12.0%)2 Wisconsin (-15.7%)Mississippi (-8.9%)2 Wyoming (-2.8%)

NOTES:Biennium budgets are bolded.1 May contain some social service programs, but not Medicaidor CHIP.

2 General funds only.3 Budget data taken from appropriations legislation.4 North Dakota’s budget data for the 2009-2011 bienniumtaken from appropriations legislation.

5 State did not respond to the data check TFAH coordinated withASTHO that was sent out November 4, 2010. States weregiven until December 1, 2010 to confirm or correct the informa-tion. The states that did not reply by that date were assumed tobe in accordance with the findings.

Source: Research by TFAH of publicly available state budget docu-ments and interviews with health and budget officials in the states.

This indicator, adjusted for inflation, illustratesa state’s commitment to funding public healthprograms that support the infrastructure — in-cluding workforce — needed to adequately re-spond to emergencies.

Every state allocates and reports its budget indifferent ways. States also vary widely in thebudget details they provide. This makes com-parisons across states difficult. For this analysis,TFAH examined state budgets and appropria-tions bills for the agency, department, or divi-sion in charge of public health services for FY2009-2010, using a definition as consistent aspossible across the two years, based on how eachstate reports data. TFAH defined “public healthservices” broadly, including most state-levelhealth funding. The analysis examines the to-tality of public health funding in a state, not justresources devoted to preparedness, since main-taining a core infrastructure is essential for anydepartment to maintain basic functions in addi-tion to being able to respond effectively duringemergencies.

Based on this analysis, 33 states and D.C. madecuts in their public health budgets. Last year, 23states and Washington, D.C. increased or main-tained their public health budgets, while 27states made cuts.

With the current recession, states are in severeeconomic distress and many states have tried toclose shortfalls by increasing taxes and/or cut-ting spending. According to CBPP, 48 states areexperiencing shortfalls in their budgets for FY2010, and the shortfalls for FY 2010 total $168billion, which is one-quarter of state budgets.42Future predictions are that the situation will get

worse in FY 2011.43 Public health funding is dis-cretionary spending in most states and, there-fore, is at high risk for significant cuts duringeconomic downturns. While few states allocatefunds directly for public health preparedness,state and local funding is essential for support-ing public health infrastructure and core ca-pacities of health departments. TFAH is deeplyconcerned about state budget cuts and the ef-fect they will have on state and local govern-ments’ ability to be prepared for healthemergencies over the next few years. Severalstates that received points for this indicator maynot have actually increased their spending onpublic health programs. The ways some statesreport their budgets, for instance, by includingfederal funding in the totals or including pub-lic health dollars within health care spending to-tals, make it very difficult to determine “publichealth” as a separate item.

Few states allocate funds directly for bioterror-ism and public health preparedness as part oftheir public health budgets. Instead, most relyon federal funds to support these activities.The infrastructure of other public health pro-grams, however, also support their underlyingpreparedness capabilities.

While this indicator examines whether states’public health budgets increased or decreased, itdoes not assess if the funding is adequate tocover public health needs in the states. This alsodoes not take into account ongoing hospitalneeds and funding.

For additional information on the methodologyof the budget analysis, please see Appendix B:Methodology for Select State Indicators.

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This indicator helps assess the state publichealth department’s ability to communicate rap-idly and quickly with health care providers, acrucial need during a public health emergency.As we saw during the H1N1 pandemic, this typeof communication is crucial to ensure publichealth departments have an accurate picture ofthe on-ground events and that health care prac-titioners are given the most up-to-date, accurate

information to correctly identify problems andprovide effective treatment.

The data for this indicator were provided byASTHO from their 2010 Profile Survey, which is asurvey of health officers in each state. Accordingto this survey, seven states cannot currently sharedata electronically with health care providers.

Source: ASTHO 2010 Profile Survey

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2. Indicator: BIOSURVEILLANCE — HEALTH INFORMATION TECHNOLOGYFINDING: 43 states and D.C. can currently send and/or receive electronic health information with healthcare providers.

43 states and D.C. can currently send and/or receive electronic health information with health care providers. (1 point)

Alaska MinnesotaArizona MississippiArkansas MissouriCalifornia NebraskaColorado New JerseyConnecticut New YorkDelaware North CarolinaD.C. North DakotaFlorida OklahomaGeorgia OregonHawaii PennsylvaniaIdaho Rhode IslandIllinois South DakotaIndiana TennesseeIowa TexasKansas UtahKentucky VermontLouisiana VirginiaMaine WashingtonMaryland West VirginiaMassachusetts WisconsinMichigan Wyoming

7 states can NOT currently share dataelectronically with health care providers.(0 points)

AlabamaMontanaNevadaNew HampshireNew MexicoOhioSouth Carolina

18

Source: ASTHO Profile Survey

Since the terror attacks of September 2001 andthe subsequent anthrax mailings in October, stateand local public health departments have workedto increase their ability to perform syndromic sur-veillance to rapidly detect public health threats.According to CDC, “the term ‘syndromic surveil-lance’ applies to surveillance using health-relateddata that precede diagnosis and signal a sufficientprobability of a case or an outbreak to warrantfurther public health response.”44 Syndromic sur-veillance is often used to target investigations ofdisease outbreaks, and officials continue to ex-plore how to also use it for detecting outbreaksassociated with intentional acts of terrorism.

Delivering effective public health services dependson timely and reliable information. Health de-partments cannot protect people from existing oremerging health threats, such as a pandemic flu,or a bioterrorist attack, without correct and perti-nent information. The lack of timely and com-prehensive data can delay the identification of andresponse to serious and mass emergency healthproblems. In addition, federal, state and localhealth departments and private health careproviders must all work together to effectively trackinformation about and respond to health threats.

Fortunately, the United States has never expe-rienced the type of bioterrorism or mass casu-alty events that syndromic surveillance wasinitially designed to help detect. However,states report that syndromic surveillance hasbeen extremely useful for monitoring seasonaland H1N1 flu activity. In fact, according to theInternational Society for Disease Surveillance(ISDS), a growing body of evidence suggeststhat syndromic surveillance can “herald theonset of influenza seasons in advance of virusisolation by public health laboratories, providemore timely and geographically detailed infor-mation compared to information from net-works of sentinel health care practices, andprovide detailed, age-specific information thatcan characterize annual variations in the pat-tern of influenza morbidity.”45

The data for this indicator were provided byASTHO from the 2010 Profile Survey, which isa survey of health officers in each state. Ac-cording to this survey, 40 states and Washing-ton, D.C. report having an electronic syndromicsurveillance system that can report and ex-change information.

3. Indicator: BIOSURVEILLANCE — ELECTRONIC SYNDROMIC SURVEILLANCEFINDING: 40 states and D.C. have an electronic syndromic surveillance system that can report and ex-change information.

40 states and D.C. have an electronicsyndromic surveillance system that canreport and exchange information (1 point).

Alabama NebraskaArizona New HampshireArkansas New JerseyCalifornia New YorkColorado North CarolinaConnecticut North DakotaDelaware OhioD.C. OklahomaFlorida PennsylvaniaGeorgia Rhode IslandHawaii South CarolinaIndiana TennesseeKentucky TexasLouisiana UtahMaine VermontMaryland VirginiaMassachusetts WashingtonMichigan West VirginiaMinnesota WisconsinMississippi WyomingMissouri

10 states do NOT have an electronicsyndromic surveillance system that canreport and exchange information (0 points).

AlaskaIdahoIllinoisIowaKansasMontanaNevadaNew MexicoOregonSouth Dakota

19

Notes:

* Pre-identified staff acknowledged notification within the tar-get time of 60 minutes at least 75 percent of the time.

^ Pre-identified staff acknowledged notification within the tar-get time of 60 minutes at least 50 percent of the time.

° New Mexico failed to notify pre-identified staff a minimum oftwo times.

Source: CDC Strengthening the Nation’s Emergency ResponseState by State report.

The indicator assesses the ability of pre-identi-fied staff to acknowledge notification of a drill,exercise or real incident. It is essential for a stateto then be able to convene team members tohandle an emergency response. Timeliness isan essential component of any emergency re-sponse effort. If states are unable to bring theneeded personnel together quickly, it slows re-sponse and containment strategies and can putthe public at increased risk. It is based on themeasure from the September 2010 CDC reportPublic Health Preparedness: Strengthening the Na-tion’s Emergency Response State by State if pre-iden-tified staff acknowledged notification to fill alleight Incident Command System (ICS) core

functional roles due to a drill, exercise, or realincident within the target time of 60 minutes aminimum of two times from 2007-2008.

While every state but one notified pre-identifiedstaff to fill all eight ICS core functional roles at leasttwice, only 34 states and D.C. were able to get thepre-identified staff to acknowledge their notifica-tion within the target time of 60 minutes for eachdrill, exercise, or real incident. Another sevenstates were able to get the pre-identified staff to ac-knowledge their notification within the target timeof 60 minutes for at least 75 percent of the drills,exercises, or real incidents, while another six wereable to do this at least 50 percent of the time.

4. Indicator: — INCIDENT RESPONSE CAPACITYFINDING: 44 States and D.C. reported that pre-identified staff were able to acknowledge notification ofemergency exercises or incidents within the target time of 60 minutes at least twice during 2007-08.

44 states and D.C. reported that pre-iden-tified staff were able to acknowledge noti-fication of emergency exercises or incidentswithin the target time of 60 minutes atleast twice during 2007-08. (1 point).

Alabama Missouri*Alaska MontanaArizona NebraskaArkansas* NevadaCalifornia* New HampshireColorado New JerseyConnecticut New YorkD.C. North CarolinaFlorida North DakotaGeorgia OhioHawaii Oregon*Idaho PennsylvaniaIllinois Rhode IslandIndiana^ South CarolinaIowa South Dakota^Kansas Tennessee^Kentucky* UtahLouisiana VirginiaMaine Washington*Maryland West VirginiaMichigan WisconsinMinnesota WyomingMississippi*

6 states reported that pre-identifiedstaff were NOT able to acknowledge noti-fication of emergency exercises or incidentswithin the target time of 60 minutes atleast twice during 2007-08. (0 points).

Delaware^MassachusettsNew MexicoOklahoma^TexasVermont^

5. Indicator: RESPONSE READINESS — EMERGENCY OPERATIONS CENTERFINDING: 44 states and D.C. activated their Emergency Operations Center (EOC) a minimum of twotimes in 2007-08.

Source: CDC Strengthening the Nation’s Emergency Response State by State report.

This indicator assesses whether the state acti-vated its EOC at least twice during 2007-08. Ac-tivation is defined as “rapidly staffing all eightcore Incident Command System (ICS) func-tional roles in the public health emergency op-erations center with one person per position.”46Even though not every public health emergencywill require the full staffing of the ICS, this ca-pability is critical. EOCs help drive emergency

response efforts, providing leadership, direction,communication, and coordination to personnelinvolved in the emergency response efforts.

CDC required each state to conduct at least twoEOC activations, whether as part of a drill, ex-ercise, or real incident. Of the 50 states andD.C., six states did not conduct the minimum oftwo activations.

20

44 states and D.C. activated their emergencyoperations center (EOC) a minimum of twotimes in 2007-08 (1 point).

Alabama MissouriAlaska MontanaArizona NebraskaArkansas NevadaCalifornia New HampshireColorado New JerseyConnecticut New MexicoD.C. New YorkDelaware North CarolinaFlorida North DakotaGeorgia OhioIdaho OklahomaIllinois OregonIndiana PennsylvaniaIowa Rhode IslandKansas UtahKentucky VermontLouisiana VirginiaMaine WashingtonMaryland West Virginia Michigan WisconsinMinnesota WyomingMississippi

6 states did NOT activate their emergencyoperations center (EOC) a minimum of twotimes in 2007-08 (0 points).

HawaiiMassachusettsSouth CarolinaSouth DakotaTennesseeTexas

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6. Indicator: RESPONSE READINESS — AFTER ACTION REPORTSFINDING: 48 states and D.C. developed at least two After-Action Report/Improvement Plans (AAR/IPs)after an exercise or real incident in 2007-08.

Note:* The state developed 75 percent to 99 percent of all AAR/IPs within 60 days.^ The state developed 50 percent to 74 percent of all AAR/IPs within 60 days.Source: CDC Strengthening the Nation’s Emergency Response State By State Report

This indicator demonstrates a state’s capabilityto analyze response actions, describe needed im-provements, and prepare a plan for making im-provements in a timely manner.

AAR/IPs are used to assess what worked well dur-ing an exercise or real incident and what can beimproved. By evaluating the state’s response andidentifying gaps and areas that need improve-

ment, state health departments can improvetheir preparedness and response operations.

CDC required state and local grantees to de-velop a minimum of two AAR/IPs after an ex-ercise or public health emergency operation.The target time for completion of AAR/IPs was60 days. Of the 50 states and D.C, two failed todevelop the minimum of two AAR/IPs.

48 states and D.C. developed at least twoAfter-Action Report/Improvement Plans(AAR/IPs) after an exercise or real incidentin 2007-08 (1 point).

Alabama MontanaAlaska NebraskaArizona* NevadaArkansas^ New Hampshire*California New MexicoColorado New JerseyConnecticut New York^Delaware^ North CarolinaD.C. North DakotaFlorida OhioGeorgia OklahomaHawaii OregonIdaho PennsylvaniaIllinois* South CarolinaIndiana South DakotaIowa TennesseeKansas TexasKentucky* Utah^Louisiana Vermont^Maryland VirginiaMassachusetts* Washington^Michigan^ West Virginia* Minnesota WisconsinMississippi^ WyomingMissouri

2 states did NOT develop at least twoAfter-Action Report/Improvement Plans(AAR/IPs) after an exercise or real incidentin 2007-08 (0 points).

MaineRhode Island

Source: Save the Children47

22

If terrorists deliberately released deadly anthraxspores in a densely populated, urban area,would your city, county, and state officials knowhow to respond? That’s the scenario the De-partment of Homeland Security (DHS) hastested in each of the 10 Federal EmergencyManagement Agency (FEMA) regions, as well asconducting a Federal Interagency workshop inthe nation’s capitol. The Anthrax Response Ex-ercise Series (ARES) scenario uses a local trig-ger, such as a BioWatch Actionable Report(BAR), which tips off local and state authoritiesto the attack and requires them to work to-gether and with federal counterparts to mounta rapid response.

FEMA, together with the DHS Office of HealthAffairs (OHA), coordinate with local, state, andregional stakeholders to develop the table-topexercises which help federal, state, and localofficials analyze their response capabilities andpotential gaps or barriers. Each exercise gen-erally includes representatives from BioWatch,public health, emergency management, military,law enforcement, first responders, public af-fairs, and state and local leadership, as well asfederal officials.

Each exercise attempts to address the followingfour objectives:

n Emergency Public Safety and Security: De-termine the federal, state, and local officials’ criti-cal decisions and the execution of applicableresponse plans following the detection of anthrax.

n Emergency Public Information and Warn-ing: Identify unified public information strate-gies, applicable plans, and messages to beutilized to communicate accurate and timelyemergency information to the public.

nMass Prophylaxis: Determine methods ofidentifying the at-risk population, the establish-ment of local distribution processes, the con-duct of mass prophylaxis, and the employmentof countermeasures to include national assets.

n Critical Resource Logistics and Distribution:Identify resource management requirements andexpectations for the implementation of a unifiedresponse from federal, state, regional, and localauthorities to protect and care for the public.

Each exercise is developed through multipleplanning and coordination meetings in the hostjurisdiction and followed up with an After ActionConference.

ANTHRAX RESPONSE EXERCISE SERIES (ARES)

7. Indicator: COMMUNITY RESILIENCY — CHILDREN AND PREPAREDNESS FINDING: 25 states and D.C. mandate all licensed child care facilities to have a multi-hazard writtenevacuation and relocation plan.

25 states and D.C. mandate all licensed childcare facilities to have a multi-hazard writtenevacuation and relocation plan (1 point).

Alabama North CarolinaArkansas North Dakota California OhioDelaware OklahomaD.C. PennsylvaniaHawaii South CarolinaMaryland TexasMassachusetts UtahMississippi VermontNevada VirginiaNew Hampshire WashingtonNew Mexico West VirginiaNew York Wisconsin

25 states do NOT mandate all licensed childcare facilities to have a multi-hazard writtenevacuation and relocation plan (0 points).

Alaska MaineArizona Michigan Colorado Minnesota Connecticut MissouriFlorida MontanaGeorgia NebraskaIdaho New JerseyIllinois OregonIndiana Rhode IslandIowa South DakotaKansas TennesseeKentucky WyomingLouisiana

Planning to care for 67 million children inAmerican schools and child care settings duringa public health emergency presents complexconsiderations and challenges. Children are not“small adults” and special consideration needsto be given to complicated issues ranging fromchild-appropriate doses of medications and vac-cines, to caring for children if schools and childcare facilities are closed for extended periods.Parents and other caregivers may also becomesick or injured during a disaster, complicatingtheir ability to care for children.

In 2010, Save the Children reviewed state laws andregulations to determine to what extent the needsof children were incorporated into preparednessplanning. Save the Children examined four basicemergency preparedness standards for licensedchild care facilities and K-12 schools:

n Evacuation Plan: A law or regulation requiringall licensed or regulated child care facilities tohave a written multi-hazard plan for evacuatingand safely moving children to an alternate relo-cation site. A multi-hazard plan must cover man-made and natural emergencies and addressevacuation, shelter-in-place, and lock-down situ-ations. A state may have more than one classifi-cation for licensed or regulated child care, butthe standard must apply to all facilities equally;

n Reunification Efforts: A law or regulation re-quiring all licensed child care facilities to havea written plan to notify parents of an emer-gency and reunite them with their children;

n Children with Special Needs: A law or regu-lation that requires all licensed child care fa-cilities to have a written plan that accounts forchildren with special needs; and

n K-12 Disaster Planning: A law or regulation re-quiring schools to have a multi-hazard disas-ter plan.

This indicator awards states a point if they meetthe first standard: a law or regulation requiring

all licensed child care facilities to have a multi-hazard written evacuation and relocation plan.In 2010, 25 states and D.C. met this standard, animprovement from 2009 when only 20 states andD.C. met this standard. The five states that im-proved over the past year are New Mexico, Vir-ginia, Washington, West Virginia, and Wisconsin.

Failing to plan for these worst-case scenariosputs children and adolescents at increased riskof injury.

Twelve states meet all four basic emergency pre-paredness standards in the Save the Childrenanalysis: Alabama, Arkansas, California, Hawaii,Maryland, Massachusetts, Mississippi, NewHampshire, New Mexico, Vermont, Washingtonand Wisconsin. In 2009, only seven states metall four standards. California, Mississippi, NewMexico, Washington, and Wisconsin all im-proved over the past year.

Almost two-thirds of states (33 states) do not re-quire all licensed child care facilities to have awritten plan that accounts for children with spe-cial needs. Only 10 states and D.C. do not requireK-12 schools to have a multi-hazard disaster plan.

In the Report Card, a state is not judged to meeta particular standard unless (1) the substance ofthe state’s policy meets the minimum require-ments of the standard; (2) the policy is man-dated; and (3) all licensed or regulated child care-- or in the case of the 4th criteria -- all K-12schools are subjected to the policy. A rule is con-sidered mandated if it is (1) in statute (2) in reg-ulation or (3) is provided by the relevant agencyas mandatory guidance. Mandatory guidance in-cludes forms, templates, and technical assistancethat are provided to all licensed or regulatedchild care facilities and are required to be com-pleted or implemented.

For additional information on the methodologyof the Save the Children report, please see Ap-pendix B: Methodology for Select State Indicators.

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8. Indicator: FOOD SAFETY — DISEASE DETECTION AND REPORTINGFINDING: 29 states were able to rapidly identify disease-causing E.coli O157:H7 and submit the lab re-sults in 90 percent of cases within four days during 2007-08.

The intent of this indicator is to determine if a lab-oratory can rapidly receive, test, and report disease-causing bacteria within a specified time-frame.

The ability to rapidly detect and determine theextent and scope of foodborne disease out-breaks — and other infectious disease outbreaksor bioterror attacks — is crucial to minimizingthe impact of these outbreaks on the public’shealth. CDC requires state public health labs to

be able to use CDC’s pulsed-field gel elec-trophoresis (PFGE) protocols to rapidly identifyspecific strains of E. coli. In addition, labs mustthen be able to submit these results within fourworking days to the PulseNet database at least90 percent of the time. The PulseNet databaseis used to determine whether the pathogen re-sponsible for the outbreak is responsible forother outbreaks across the nation.

24

29 states were able to rapidly identifydisease-causing E.coli O157:H7 and submitthe lab results in 90 percent of cases within4 days during 2007-08 (1 point).

Alabama MississippiAlaska New JerseyArizona New MexicoArkansas North DakotaCalifornia OhioColorado OklahomaConnecticut OregonDelaware TennesseeFlorida UtahIllinois VermontKentucky VirginiaLouisiana WashingtonMaryland WisconsinMichigan WyomingMinnesota

21 states were NOT able to rapidly identifydisease-causing E.coli O157:H7 and submitthe lab results in 90 percent of cases within4 days during 2007-08 (0 points).

Georgia NevadaHawaii New HampshireIdaho New YorkIndiana North CarolinaIowa PennsylvaniaKansas Rhode IslandMaine South CarolinaMassachusetts South DakotaMissouri TexasMontana West Virginia Nebraska

Note: As D.C. did not report receiving any E.coli samples, the city is not evaluated on this indicator.

Source: CDC Strengthening the Nation’s Emergency Response State by State report.

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Hidden Outbreaks and Inspection Gaps PosePublic Health RisksBy Caroline Smith DeWaal*

EXPERT PERSPECTIVE

When it comes to food safety, state and local public health de-partments — and the people who staff them — are vital to

protecting the public. They serve as the front-line detectives in investi-gating disease outbreaks, many of which are traced to food. They con-duct restaurant inspections, along with inspections of the food servicefor hospitals, day care centers and nursing homes. States also play a rolein inspecting food plants that sell products both locally and nationally.Yet, as states face critical shortfalls in funding, many state and local pub-lic health departments may not have the staff or resources to do thesecritically important jobs.

Over the last 10 years, foodborne-illness outbreak reports to CDC haveranged from 1,400 to less than 1,000 annually, with dramatic year-to-year fluctuations. When controlled for population, nearly half of the statesare reporting only one to three outbreaks per million population, signif-icantly lower than benchmark states like Minnesota and Oregon that re-port 10 outbreaks per million. Many of the lowest-reporting states arein the southern area of the country where warm temperatures alonecould lead to increased risks of foodborne illnesses and outbreaks. Andseveral states with connecting borders that would seem quite similarwith respect to climate or population showed wide differences in out-break reporting. Equally troubling is the decline in the quality of their in-vestigations: overall, states reported 33 percent fewer “solved”outbreaks to CDC in 2007 than in 2002 — meaning an outbreak whereinvestigators identify both the pathogen and the food involved.

Outbreak investigations are vital to identifying contaminated food and re-moving it from the market. A prompt investigation that identifies a con-taminated food can result in faster recalls and prevent many people frombecoming ill. This on-the-spot information is highly valuable from a publichealth standpoint. Equally important, however, is that the informationfeeds into preventive controls systems — called “HACCP” for HazardAnalysis Critical Control Points — in use throughout the food industry.These systems begin with a hazard analysis which uses data from outbreaksto help identify key hazards linked to specific foods, leading to the devel-

opment of facility-specific control plans to manage those hazards. Out-break investigations provide highly reliable information for these systems.

Public health programs in some states are so strapped for resources thatwhen emerging concerns, like bioterrorism or swine flu, required large-scale training, the quality of outbreak investigations noticeably declined.That occurred in 2003, when bioterrorism concerns triggered Congres-sional spending on state training exercises. While this training was certainlyuseful, agencies must be staffed adequately to maintain their ongoing mis-sions. After all, it would be unfortunate to miss a real outbreak while an in-vestigator participates in an outbreak “table top” training exercise.

Restaurant inspections are another vital service performed at the state orlocal level that helps prevent outbreaks. Contrary to the common be-lief that most outbreaks happen at home, restaurant outbreaks are twiceas frequent as and larger than those associated with home-preparedfoods. Yet research conducted by the Center for Science in the Public In-terest has shown that in many cities, infrequent restaurant inspectionsoften disclose critical violations that could result in contaminated food.An inspector conducting simple checks of cooking and holding temper-atures and proper storage can literally prevent tens or even hundreds ofillnesses. Also important is the reality that even twice-a-year inspection,with the possibility of adverse publicity and closure, prompts many man-agers to prioritize food safety in their restaurant’s operation.

Pressures on state budgets are growing and these essential food safetyfunctions are already facing significant cuts. As one response, some in thefederal government have proposed turning more responsibility for in-specting food processors over to state inspection programs, along withsome federal funding. Unfortunately these programs might start to com-pete for scarce food safety staff. With millions sickened each year frompreventable foodborne illnesses and outbreaks, it is more important thanever for food safety programs to survive these challenging times.

* Caroline Smith DeWaal is director of food safety for the Center for Science in the Pub-lic Interest and co-author of “Is Our Food Safe?” (2002, Three Rivers Press)

WA

NV

AZ

CO

NE

NDMN

WI

IL

KY VA

NY

HI

MDDC

DENJ

NH

VT

MA

RICT

NC

LA

AR

MS AL

SD

KS MO

TN

GASC

FL

IN OH

WV

PA

ME

MIIA

OK

TX

NM

OR ID

MT

WY

UT

AK

CA

Reported Outbreaks per Million Population (2007)

■ 1 ■ 2 - 3 ■ 4 - 5 ■ 6 - 9 ■ 10 - 12 ■ 13 - 15 ■ 15+

0

200

400

600

800

1000

1200

1400

1600

0

200

400

600

800

1000

1200

1400

1600

398 545 514 548 560 418 499 415 454 378

916 890 903 690 772 655 820 567 793 719

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Foodborne Illness Outbreaks Reported to CDC (1998 - 2007)

■ Identified food and etiology ■ Unidentified food and/or etiology

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9. Indicator: PUBLIC HEALTH LABORATORIES — SURGE WORKFORCEFINDING: 3 states and D.C. report not having enough staffing capacity to work five, 12-hour days for sixto eight weeks in response to an infectious disease outbreak, such as novel influenza A H1N1.

In the initial phases of an outbreak of a novel in-fluenza virus, public health labs are on the frontlines conducting diagnostic testing becauseother labs generally lack this capacity. Once anovel virus is established in the population, di-agnostic testing is no longer as important andpublic health labs switch to surveillance testing.The surveillance testing allows public health of-ficials to gather enough information to track thepandemic and monitor any genetic mutationsor changes in the virus.

During a pandemic flu or other infectious dis-ease outbreak, the demand on the public healthlab workforce is great -- and in some cases, ex-

ceeds supply. According to a survey APHL con-ducted of state public health laboratories in thefall of 2010, three states and Washington, D.C.reported not having enough staffing capacity towork five, 12-hour days for six to eight weeks inresponse to an infectious disease outbreak, suchas novel influenza A H1N1.

Funding for public health laboratories is a majorconcern. Of the $600 million for pandemic pre-paredness that was distributed to states in FY2006 and FY 2007, public health laboratories re-ceived little. Even the emergency supplementalsigned June 24, 2009 provided very little for lab-oratory preparedness.

47 states report having enough staffingcapacity to work five, 12-hour days for sixto eight weeks in response to an infectiousdisease outbreak, such as novel influenza AH1N1 (1 point).

Alabama NevadaAlaska New HampshireArizona New JerseyArkansas New MexicoCalifornia New YorkColorado North CarolinaConnecticut North DakotaDelaware OhioFlorida OklahomaGeorgia OregonIdaho PennsylvaniaIllinois Rhode IslandIndiana South CarolinaKansas South DakotaKentucky TennesseeLouisiana TexasMaine UtahMaryland VermontMassachusetts VirginiaMichigan WashingtonMinnesota West VirginiaMississippi WisconsinMissouri WyomingNebraska

3 states and D.C. report NOT havingenough staffing capacity to work five, 12-hour days for six to eight weeks inresponse to an infectious disease outbreak,such as novel influenza A H1N1 (0 points).

D.C.HawaiiIowaMontana

Source: APHL 2010 Survey of State Public Health Laboratories

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10. Indicator: PUBLIC HEALTH LABS -- CHEMICAL TERRORISM PREPAREDNESSFINDING: 49 states and D.C. increased or maintained their Laboratory Response Network for Chemi-cal Threats (LRN-C) chemical capability from August 10, 2009 to August 9, 2010.

Public health laboratories around the countryparticipate in the Laboratory Response Network(LRN) to ensure an effective laboratory re-sponse to bioterrorism. The network helps im-prove the nation’s public health laboratoryinfrastructure, which, once, had limited abilityto respond to bioterrorism.

According to CDC, “the LRN is charged with thetask of maintaining an integrated network ofstate and local public health, federal, military,and international laboratories that can respondto bioterrorism, chemical terrorism and otherpublic health emergencies. The LRN is a uniqueasset in the nation’s growing preparedness forbiological and chemical terrorism. The linkingof state and local public health laboratories, vet-erinary, agriculture, military, and water- andfood-testing laboratories is unprecedented.”48

Formed in 1999 by CDC, APHL and the FBI,the LRN is the nation’s premier system for iden-tifying, testing, and characterizing potentialagents of biological and chemical terrorism,emerging infectious diseases, and other publichealth threats.49

State and local health laboratories comprise ap-proximately 70 percent of the 169 LRN BiologicalReference Laboratories and almost 100 percent ofthe LRN Chemical Laboratories. These laborato-ries produce high-confidence test results that arethe basis for threat analysis and intervention by bothpublic health and law enforcement authorities.

The LRN for Bioterrorism is organized as athree-tiered pyramid. At the base are thousandsof sentinel clinical laboratories, which performinitial screening of potential pathogens. Whensentinel clinical laboratories cannot rule out thepresence of a bioterrorism agent, they refer spec-imens and isolates to the appropriate LRN ref-erence laboratory. More than 160 state, local,and federal facilities provide reference testing.At the apex are the national laboratories, such asthose at CDC and the U.S. Department of De-fense. These laboratories test and characterizesamples that pose challenges beyond the capa-bilities of reference laboratories, and providesupport for other LRN members during a seri-ous outbreak, public health emergency, or ter-rorist event. The most dangerous or perplexingpathogens are handled only at BSL-4 laborato-

49 states and D.C. increased or maintainedtheir LRN-C chemical capability (1 point).

Alabama NevadaAlaska New HampshireArizona New JerseyArkansas New MexicoCalifornia New YorkColorado North CarolinaConnecticut North DakotaDelaware OhioFlorida OklahomaGeorgia OregonIdaho PennsylvaniaIndiana Rhode IslandKansas South CarolinaKentucky South DakotaLouisiana TennesseeMaine TexasMaryland UtahMassachusetts VermontMichigan VirginiaMinnesota WashingtonMississippi West VirginiaMissouri WisconsinNebraska Wyoming

1 states DECREASED their LRN-C chemi-cal capability (0 points).

Illinois

Source: APHL 2010 Survey of State Public Health Laboratories

ries at CDC and the U.S. Army Medical ResearchInstitute of Infectious Diseases.

Fifty-three laboratories within U.S. states, terri-tories, or metropolitan areas make up the chem-ical component of the LRN -- and areresponsible for collecting and detecting expo-sure to toxic chemical agents.

n Ten labs are “Level 3” laboratories -- whichmaintain the basic functions that all of theLRN labs have -- to be able to work with hospi-tals and other first responders within their ju-risdiction to maintain competency in clinicalspecimen collection, storage, and shipment.

n Thirty-seven labs are “Level 2”, meaningchemists who are trained to detect exposureto a number of toxic chemical agents are pres-ent. Analysis of cyanide, nerve agents, andtoxic metals in human samples are examplesof Level 2 activities.

n Ten labs are “Level 1.” These laboratoriescan serve as surge capacity for CDC and alsocan detect exposure to an expanded numberof chemical agents, including mustardagents, nerve agents, and other toxic indus-trial chemicals. These labs expand CDC’sability to analyze large number patient sam-ples when responding to large-scale expo-sure incidents.

This indicator is based on a question from theAPHL survey of states, asking whether theirLRN chemical capability increased, decreased,or was maintained from August 10, 2009 to Au-gust 9, 2010.

Forty-nine states and Washington, D.C. re-ported they increased or maintained their LRNchemical capabilities, and only one reported adecrease. This is based on their status as partof the LRN.

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Labs provide the means to recognize and alertofficials to outbreaks of newly-emergent and re-current disease by serving as testing sites for pri-vate physicians, hospitals and clinics, as well asserving as a direct interface between state andfederal epidemiologists. Public health laborato-ries safeguard entire communities. Without theability to manage laboratory data themselves,labs cannot disseminate information timely andaccurately to those responsible for managing,controlling and responding to an event. Thiscannot be achieved without sustained funding toensure labs have access to technologically-ad-vanced information systems in times of crisis.

Virtually every government agency has createdan information network within the past fiveyears to try and support web-based exchange oflaboratory data. The problem is that these ef-forts have not been coordinated, nor adequatelyfunded, resulting in a multitude of siloed, ineffi-cient, often homegrown systems.

Electronic Laboratory Messaging would promoterapid information dissemination and mitigation ofexposure. Test orders and results would nolonger be inefficiently reported by telephone, faxand email. Improvements in health informationtechnology must include the laboratories thatperform testing of public health significance.

Modernizing these systems and enabling interop-erability is a huge challenge. Public health scien-tists and IT experts from APHL memberlaboratories working with CDC on the PublicHealth Laboratory Interoperability Project(PHLIP) to define the necessary infrastructureand expertise that a public health laboratorymust have to enable two-way electronic datatransmission with public health and clinical part-ners in a recognized standard format. Accordingto a recent report from Analytic Services, Inc., apanel of subject matter experts identified a fund-ing level of $200 million annually would beneeded to build and support this system.

LABORATORIES AND THE ABILITY TO TRANSMIT TEST AND RESULT DATA ELECTRONICALLY50

B. PAST INDICATORS UPDATE

Source: CDC Strengthening the Nation’s Emergency Response State by State report.

States have made significant progress in pre-paredness since September 11, 2001. The fol-

lowing are some key past indicators that demon-strate important advances.

1. Strategic National Stockpile (SNS)Since the first edition of the Ready or Not? reportin 2003, TFAH has tracked states plans to receiveand distribute emergency vaccines, antidotes,pharmaceuticals, and medical supplies from theSNS. In 2003, only two states had adequate plansbased on a CDC evaluation. Now, based on CDC’stechnical assistance review (TAR), all 50 states andD.C. have adequate plans to receive and distrib-ute supplies from the SNS. It should be empha-sized that the scoring system assesses planning andmanagement of the stockpile. It does not reflectthe actual capacity of the state to deploy counter-measures and other supplies from the SNS.

State and local health departments plan andtrain in order to: 1) receive SNS assets from thefederal government; 2) distribute, or move,those assets from the storage facility to the pointof dispensing (POD); and 3) dispense, or pro-vide or administer, the medical countermeasureto the affected person(s).

It is worth noting that CDC has changed its eval-uation system, and that scores still vary greatlybased on this system, ranging from a high of 100in eight states (California, Indiana, Louisiana,Michigan, New Jersey, New York, Texas, and Vir-ginia) to a low of 70 in Alaska and Idaho. Be-tween 2007-08 and 2008-09, the majority of stateswere able to increase or maintain their SNS TARscores, although there were some exceptions. Inseven states, SNS TAR scores fell between budgetyears (Alabama, Alaska, Idaho, Kentucky, Mis-souri, New Hampshire, and Ohio).

CDC set a goal for states to obtain a score of 69 orhigher on the SNS TAR by December 31, 2008.Currently, all 50 states and D.C. meet this goal;however, moving forward states must score 79 orhigher in order to meet grant requirements.Presently, only three states (Alaska, Idaho, andNew Mexico) fail to meet this objective.

29

State SNS TAR score SNS TAR score State SNS TAR score SNS TAR score (2008-09) (2007-08) (2008-09) (2007-08)

Alabama 86 92 Missouri 89 96Alaska 70 80 Montana 96 91Arizona 85 83 Nebraska 85 81Arkansas 97 93 Nevada 89 55California 100 100 New Hampshire 81 86Colorado 96 94 New Jersey 100 98Connecticut 94 84 New Mexico 78 71Delaware 98 96 New York 100 97DC pending 94 North Carolina 98 93Florida 98 95 North Dakota 83 77Georgia 90 73 Ohio 89 90Hawaii 84 74 Oklahoma 98 97Idaho 70 90 Oregon 86 85Illinois 99 96 Pennsylvania 82 60Indiana 100 96 Rhode Island 99 93Iowa 95 93 South Carolina 93 87Kansas 94 93 South Dakota 91 87Kentucky 83 86 Tennessee 89 89Louisiana 100 94 Texas 100 97Maine 90 51 Utah 88 85Maryland 96 93 Vermont 98 93Massachusetts 93 91 Virginia 100 100Michigan 100 95 Washington 97 94Minnesota 88 84 West Virginia 83 61Mississippi 99 95 Wisconsin 92 86

Wyoming 80 80

2. Pandemic Flu Plans and Response CapabilitiesEvery state and D.C. developed pandemic fluplans that had been reviewed by HHS before the2009 outbreak of the H1N1 pandemic. In 2003,only 13 states had developed pandemic plans.

In addition, in 2005, a National Strategy for Pan-demic Influenza was issued, creating a strong,in-depth national response plan which definedand delegated roles and responsibilities forevery federal agency and grants to support pre-paredness in states.

The response to the H1N1 outbreak showed thecountry was much better prepared to respond toa pandemic than it was a few short years ago.There was an unprecedented large-scale nation-wide response that included surveillance, labo-ratory testing, public and practitioner education,medical countermeasure management, and thedistribution and launch of a national vaccinationcampaign in a very short period of time.

30

The SNS maintains a variety of critical pharma-ceuticals and medical supplies including antibioticssuch as ciprofloxacin and doxycycline, chemicalnerve agent antidotes like atropine and prali-doxime, antiviral drugs such as Tamiflu® and Re-lenza®, pain management drugs such asmorphine, vaccines for agents like smallpox, andradiological countermeasures such as Prussianblue and DTPA. In addition to pharmaceuticals,the SNS contains supportive care supplies like en-dotracheal tubes and IV supplies, burn and blastsupplies such as sutures and bandages, ventilators,personnel protective equipment such as N-95respirators and surgical gloves and other life-sav-ing medical materiel. While this list is not compre-hensive, it is representative of the itemscontained in the SNS.

The SNS is positioned in undisclosed locationsthroughout the United States and is configuredto provide a flexible response strategy. Includedin the stockpile are a dozen 12-hour Push Pack-ages, which contain over 50 tons of pharmaceu-ticals and medical materiel. These assets arepre-configured in deployable containers andstrategically located to enable rapid delivery tothe site of a national emergency within 12 hoursof the federal decision to deploy.

The majority of the SNS formulary is maintained inmanaged inventory. Like the 12-hour Push Pack-ages, these assets are also strategically locatedaround the nation. They provide the ability to con-figure and deliver significant quantities of pharma-ceuticals and medical materiel as an initial responseif the nature of the public health emergency is welldefined, or as follow-on to a “push package” deliv-ery. Delivery of assets from managed inventoryare planned to begin arriving within 24 to 36 hoursafter the federal decision to deploy them. Quanti-ties in the SNS change based on national planning

guidance and prioritization, modeling scenarios,and standard inventory management procedures.

According to the Office of the Assistant Secretaryfor Preparedness and Response (ASPR), some ofthe contents of the national stockpile include:

n Enough smallpox vaccine to protect 300 mil-lion people, or every man, woman, and childin America;51

nOver 41 million regimens of countermeasuresagainst anthrax;52

n Therapeutic anthrax antitoxins to treat symp-tomatic patients;53

n 17 million anthrax vaccine (AVA) doses;54

n Countermeasures to address radiation expo-sure including 475,000 combined doses ofCalcium-DTPA (Diethylenetriamine pentaac-etate) and Zinc-DTPA;55 and

n 4.8 million bottles of pediatric formulation ofpotassium iodide (KI) for use in the event of arelease of radioiodines.56

The SNS also has a supply of countermeasuresthat could be used during an influenza pandemic.In fact, during the 2009 H1N1 pandemic flu re-sponse, the U.S. government distributed both an-tivirals and supplies from the SNS to state andlocal health departments. As of June 17, 2010,the total quantity of antiviral drugs in the stockpilewas 68 million treatment courses.57 The pediatricformulations of antivirals had also been replen-ished and increased. It is unclear what plansCDC has to replenish the supplies, including N95respirators and surgical masks, which were de-ployed during the H1N1 pandemic. HHS is con-ducting a review of all hazards requirements forthese ancillary supplies which will result in recom-mendations that include replenishment plans.

THE STRATEGIC NATIONAL STOCKPILE (SNS)

3. Biosurveillance — Compatability with CDC’s National Electronic DiseaseSurveillance System (NEDSS)

As of 2009, 44 states and Washington, D.C. re-ported using a disease surveillance system thatis compatible with CDC’s National ElectronicDisease Surveillance System. In 2004, only 18states reported having a disease surveillance sys-

tem that was NEDSS-compliant. NEDSS pro-motes standards-based, electronic reporting ofinfectious diseases for more rapid, accurate, andintegrated information.

4. Vaccinating Seniors for the Seasonal Flu

In 2009, 47 states and Washington, D.C. increasedvaccination rates for seniors. In 2006, only 38states had increased rates from the year before.The ability to mass vaccinate the population orsegments of the population is a key preparednessbenchmark. According to CDC, often five to 20percent of Americans contract the seasonal flueach year. Seasonal flu is preventable with a vac-cine, yet millions of Americans still needlessly getthe flu each year. The flu is often seen as a nui-sance, but it is actually very serious. Between1976 and 2007, flu-related deaths in the UnitedStates have ranged from a low of 3,000 to a highof 49,000 Americans each year.58 Even for peo-ple who get sick, they need to take sick leave from

work, possibly costing them pay and costing em-ployers in lost productivity. The flu contributes tomore than $10 billion in lost productivity and di-rect medical expenses and another $16 billion inlost potential earnings each year.59 Seniors areamong the highest risk groups for complicationsfrom the flu, so there is extra focus each year totry to vaccinate all seniors.

Seniors are particularly vulnerable for develop-ing pneumonia as a complication of the flu.HHS has set a goal of vaccinating 90 percent ofseniors against pneumonia. As of 2009, onlythree states did not maintain rates of vaccinat-ing seniors against pneumonia.

5. Medical Reserve Corps Readiness

The Medical Reserve Corps (MRC) is a nationalnetwork of community-based groups which en-gage civilian volunteers to strengthen publichealth, emergency response and community re-silience. MRC volunteers include professionalsfrom fields such as public health, medicine, andnursing, as well as non-health professionals whowork on administration, logistics, communica-tions and other support tasks.

The MRC network is supported by the Office ofthe Civilian Volunteer Medical Reserve Corps(OCVMRC), which is run out of the Office ofthe U.S. Surgeon General in coordination withASPR. As of October 4, 2010 there were 210,180volunteers enrolled in 940 MRC units in all 50states, D.C., Guam, Palau, Puerto Rico, and theU.S. Virgin Islands.

It is recognized that local governmental servicesmay be quickly overtaxed in a major public healthemergency, and that MRC volunteers could helpdeliver essential medical care and other services.For example, Homeland Security Presidential Di-rective 21 (HSPD-21), emphasizes the need forstate and local jurisdictions to have a cadre oftrained volunteers who can come to the aid oftheir fellow community members. This presi-dential directive envisions a country “where local

civil leaders, citizens, and families are educatedregarding threats and are empowered to mitigatetheir own risk, where they are practiced in re-sponding to events, where they have social net-works to fall back upon, and where they havefamiliarity with local public health and medicalsystems.”60 Groups such as MRC fulfill this visionand “will significantly attenuate the requirementfor additional assistance.”61

As of November 2010, every state now meets thefollowing three criteria (in 2009, only 41 statesand Washington, D.C. met these criteria):

n The presence of a state-level MRC Coordinator.

s All states have been encouraged to appointan MRC State Coordinator to provide rec-ommendations to OCVMRC about new(and continued) MRC unit registrations,and to provide technical assistance and sup-port to their local MRC units. The appoint-ment of an MRC State Coordinator shows alevel of commitment from the state to theMRC. In some states, the same individualserves a dual role as the MRC State Coordi-nator and coordinator for the EmergencySystem for Advance Registration of Volun-teer Health Professionals (ESAR-VHP).

31

n The majority of MRC units in a state are incompliance with the National Incident Man-agement System (NIMS) guidelines, or work-ing towards compliance.

s NIMS provides a consistent nationwidemechanism for federal, state, tribal, andlocal governments, and private sector andnongovernmental organizations to effec-tively work together to prepare for, respondto, and recover from emergency incidents.

sOCVMRC has provided the following guid-ance to MRC units regarding NIMS (availableat http://www.medicalreservecorps.gov/NIMSGuidance): “all MRC units shouldadopt NIMS and an ICS response structure,and have a NIMS/ICS training plan that uti-lizes a tiered approach to meeting NIMScompliance requirements. All MRC leadersand members must be trained in ICS-100: AnIntroduction to ICS, or equivalent and IS-700:NIMS, An Introduction or equivalent, andhave received certificates of completion forthese courses.”

n The majority of MRC units in a state are inte-grated with the state ESAR-VHP or workingtowards integration.

s The MRC and ESAR-VHP are national ini-tiatives of HHS created to improve the na-tion’s ability to prepare for and respond topublic health and medical emergencies.While MRC units are made up of individu-als from local communities who supportpublic health activities year-round, and aretrained to respond in times of emergency,the ESAR-VHP system is primarily a meansof registering and verifying the credentialsof volunteer health professionals in ad-vance of an emergency. HHS encouragesintegration so as to strengthen the local-state-federal coordination of volunteers inthe event of a public health emergency.

The local MRC units are a crucial part of our na-tion’s public health emergency response work-force. These men and women serve theircommunities throughout the year and are readywhen needed if an emergency, such as H1N1 ora natural disaster, strikes. Ensuring a robustMRC capability provides communities with alocal safety net that can be activated in times ofneed which increases public health resiliencyand helps to further states, and our nation’s na-tional health security.

32

MRC units participate in local activities on a reg-ular basis, and are encouraged to report onthose activities at least once per quarter. Activi-ties are classified into the following four cate-gories: administrative, preparedness/training,public health, and emergency response.

Since nearly every state now has a coordinator inplace, for future analyses, TFAH will work withOCVMRC to assess the MRC units within eachstate on their participation in and reporting of ac-tivities. This is an important mark of prepared-ness because ongoing activities are an indicatorof a unit’s overall engagement of volunteers andresilience. Since most jurisdictions will not havean emergency to respond to, an MRC unit’s sup-port of local public health activities as well aspreparedness and training of their volunteers

serves as an indicator that the community hasengaged volunteers who support preparedness.State leaders can encourage, support, promote,and work with the local MRC units in their stateson a variety of activities.

An assessment performed in Fall 2010 byOCVMRC showed that for FY 2010 (October 1,2009 to September 30, 2010) only 33 percent ofall MRC units reported on their MRC profile atleast one activity per each quarter. Further, only10 states reported that the majority of MRCunits in that state participated in at least one ac-tivity per quarter.

Data for this analysis will cover the FY2011 report-ing period (October 1, 2010 to September 30,2011) and will be provided by OCVMRC to TFAH.

FUTURE MRC ANALYSIS

Federal Policy Issues andRecommendations

Over the past decade, the country has made great strides in preparing forpublic health emergencies.

However, there are still major, fundamental gapsthat leave Americans unnecessarily vulnerableto threats of disease, disasters, and bioterrorism.

The current economic climate makes it harderthan ever to continue progress and threatensthe improvements that have already been made.Even with limited resources, we must addresssome key issues, otherwise the country will re-main at high-risk.

TFAH has identified some top concerns thatmust be addressed moving forward, including:

A. Providing resources to truly modernize pub-lic health systems — including a real-time dis-ease detection and tracking system;

B. Ensuring there are a sufficient number of ad-equately trained public health experts — in-

cluding epidemiologists, physicians, nurses,and other workers — to respond to all threatsto the public’s health, including the prioritiesestablished in the PAHPA;

C. Improving research, development, and avail-ability of vaccines and medications;

D. Increasing the ability of the public health andhealth care systems to quickly expand beyondnormal services during a major emergency; and

E. Working with communities to cope with andrecover from emergencies — particularlymore vulnerable members of communities,such as children, the uninsured or underin-sured, the elderly, people with underlyinghealth conditions, racial and ethnic minori-ties, and lower-income individuals.

33

In 2011, Congress may consider reauthorizationof PAHPA, which became law in December 2006.This would provide an opportunity to update thestatute to more adequately address ongoing chal-lenges that public health preparedness faces.

The PAHPA legislation helped to greatlystrengthen the nation’s preparedness and responseplanning — and helped the country plan ahead andbe better prepared for emergencies like the H1N1flu pandemic and Gulf Coast oil spill.

In 2010, members of the Institute of Medicine’sForum on Medical and Public Health Prepared-ness for Catastrophic Events identified a numberof priority issues that should be considered aspart of PAHPA reauthorization discussions.TFAH recommends that these issues be treatedas top priorities:

1) Sustaining and strengthening state and localpreparedness through federal grants anddefining benchmarks or measures of pre-paredness and response;

2) Data collection and research;

3) Improving preparedness and response for vul-nerable populations;

4) Leveraging the health care industry tostrengthen preparedness and response;

5) Medical countermeasures;

6) Modernization of the National Disaster Med-ical System (NDMS); and

7) Improving regional and community resilience.

TFAH asked Dr. Robert Kadlec and Lynne Kidder,who co-chair the forum, to provide a commen-tary about these priority issues.

REAUTHORIZATION OF THE PANDEMIC AND ALL-HAZARDS PREPARENDSS ACT (PAHPA)

2SECT ION

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Priorities for Reauthorization of the Pandemic and All-HazardsPreparedness ActBy Robert Kadlec and Lynne Kidder

EXPERT PERSPECTIVE

Since the 109th Congress enacted the Pandemicand All-Hazards Preparedness Act (PAHPA) in

late 2006, we have seen many of the bill’s provisionshave a direct impact on the federal, state and localresponses to large-scale medical and public healthdisasters — including most recently, the 2009 H1N1pandemic, the response to the 2010 earthquake inHaiti, and the health effects of the Deepwater BPOil Spill. Many of the outcomes from the originallegislation have strengthened the medical and pub-lic health community, and the nation’s resilience atlarge; however, many challenges remain.

The 2006 PAHPA authorized HHS to appoint theAssistant Secretary for Preparedness and Response;provided new authorities for a number of programs,including the advanced development and acquisitionof medical countermeasures; and called for the es-tablishment of a quadrennial National Health Secu-rity Strategy. How do we build on this foundation toenable continued progress? As the 112th Congresstakes on the responsibility of reauthorizing PAHPA,it will become extremely important that the fullspectrum of the public health community inform theon-going discussions related to that legislation. Webelieve medical and public health stakeholders mustidentify a set of key principles, goals, and core ca-pabilities that can guide the PAHPA reauthorization.

At a recent meeting of the Institute of Medicine’sForum on Medical and Public Health Preparednessfor Catastrophic Events, its members discussed aspectrum broad range of issues that will be im-portant to consider during PAHPA reauthorization.Seven core capabilities emerged as worthy of pri-ority consideration: 1) Sustaining and strengtheningstate and local preparedness through federalgrants; 2) Defining benchmarks or measures ofpreparedness and response and data collection andresearch; 3) Improving preparedness and responsefor vulnerable populations; 4) Leveraging thehealth care industry to strengthen preparednessand response; 5) Medical countermeasures; 6)Modernization of NDMS; and 7) Improving re-gional and community resilience.

Sustaining and strengthening state and localpreparedness through federal grants

National preparedness and response is largely de-pendent on the ability of states and localities to ef-fectively prepare for and manage the response todisasters. This capability requires training, exercising,and resources. We need to improve current fundingmechanisms by considering alternative funding for-mulas, multi-year grant cycles, greater flexibility incarryover and use of funds, improved streamlining offederal resources during disasters, and whether toprovide states and localities the authority to utilize ordraw from other federal grant dollars when re-sponding to a public health emergency. In addition,during non-Stafford Act public health emergencies,there is a need for alternative funding mechanisms.

Defining benchmarks or measures forpreparedness and response: data collectionand research

Disaster management is not static, but an evolvingcapability that requires real time situational aware-ness to inform decisions. Furthermore, as theDeepwater BP Oil Spill and destruction of the TwinTowers in New York have shown, many disasterscarry long term health consequences that may notbe apparent at the time of the incident. Therefore,it is important to begin to collect data from the timean incident occurs — not 100, 200, or 300 dayslater. We need to create a research infrastructurethat fits into response plans, without becoming aburden to responders. Scientific protocols shouldbe in place and ready to be activated when a disas-ter occurs, with the understanding that the re-search infrastructure must be flexible enough toadapt to unique or changing circumstances.

Improving preparedness and response forvulnerable populations

Planning for vulnerable populations must be a centralcomponent of disaster planning and response at alllevels of government — not an afterthought. Weneed to clarify the authorities and responsibilities of

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federal, state, and local governments to better facili-tate the care and potential evacuation of vulnerablepopulations. There should be greater focus on tech-nologies capable of tracking individuals during anemergency, and public shelters need to better inte-grate the needs of persons with disabilities. Childrenand youth in particular have unique requirements andmust become a national priority.

Leveraging the private health care industryto strengthen preparedness and response

Government alone does not have the resourcesor expertise to prepare and respond to a signifi-cant public health disaster. Rather, the most pre-pared communities are those that work inpartnership with the entire community — bothpublic and private sectors — to ensure a resilientdisaster response system. Medical and publichealth preparedness must be considered a com-ponent of national security, as well. Partnershipswith private industry — such as pharmacies, hos-pitals, EMS and other critical infrastructure, needto be part of medical and public health prepared-ness and response planning. Legal and regulatoryframeworks need to facilitate, not discourage, thiskind of capacity-building collaboration so criticalto disaster response.

Medical countermeasures

Research, development, and dispensing of MCMshould remain a national priority. We need to cre-ate benchmarks and new tools to ensure statesand localities have the capability to deliver and ad-minister MCM within a defined timeframes; im-prove guidance pertaining to the Shelf-LifeExtension Program for medical countermeasures;continue our work to develop alternative and en-hanced dispensing modalities, including homestock piling; and create a federal registry to beused in coordination with other biosurveillancetools, to track and monitor medical countermea-sure distribution and dispensing. And finally, weneed to provide for emergency use authorizationsof non-FDA approved MCMs.

Modernization of NDMS

The National Disaster Medical System (NDMS)provides medical care to victims and respondersduring a domestic disaster by supplementing re-sponse capabilities and assisting state and local au-thorities. While NDMS has a solid track record ofservice, the program could be strengthened

through the establishment of regional centers ofexcellence and by providing core standardizedtraining for all providers and response entities. Im-proved partnerships with the private sector andimproved logistical systems to track personnel andsupplies would also enhance response capabilitiesand coordination. An important adjunct to NDMSis the pivotal role played by Emergency MedicalServices, whose capabilities and contributionsshould be recognized as an essential part of ournational system.

Improving regional resilience

Community resilience is dependent not only onthe capabilities of its local citizens and institutions,but also on the preparedness and resources ofneighboring communities. Likewise, regional re-silience is fundamental in managing any large-scalepublic health disaster of national or even global sig-nificance. Research should continue to establishcore standards and metrics of readiness, response,and recovery. Regional disaster plans should be in-clusive and regularly exercised, along with associ-ated training programs. Regional centers shouldalso facilitate information sharing among health sys-tems and other critical infrastructure.

Conclusion

The reauthorization of PAHPA provides the med-ical and public health community the opportunity todebate and define the core capabilities that will en-sure that our neighbors, communities, and the na-tion are capable of responding to large-scale medicalor public health threats. These capabilities need notbe codified, but rather should help inform PAPHAreauthorization so as to provide the tools and guid-ance for states and local communities to achieve ahigher level of preparedness and resilience.

Dr. Robert Kadlec is a Vice President in the Global Public Sectorof PRTM. He previously served as Special Assistant to the Presi-dent for Homeland Security. He also serves as co-chair of the In-stitute of Medicine’s Forum on Medical and Public HealthPreparedness for Catastrophic Events

Ms. Lynne Kidder is a Senior Advisor at the Center for Excellencein Disaster Management and Humanitarian Assistance, a DoDorganization reporting to U.S. Pacific Command. She also servesas co-chair of the Institute of Medicine’s Forum on Medical andPublic Health Preparedness for Catastrophic Events

The responsibility for the content of this commentary rests with theauthors and does not necessarily represent the views of the Instituteof Medicine, its staff, its committees, or its convening activities.

While the available funds to improve public healthpreparedness over the last decade have supportedmajor improvements — in recent years, the fund-ing levels have been insufficient to truly modern-ize and upgrade many public health functions.

Over the years, the funding has decreased —due to federal cuts to the grants for state andlocal preparedness and state and local cuts tocore infrastructure.

In order to bring public health into the 21st cen-tury and to improve the boots-on-the-groundreadiness, TFAH recommends that:

1. Infrastructure funds authorized by the newhealth reform legislation should be appropri-ated and leveraged to modernize biosurveil-lance, the public health workforce, and othercore systems; and

2. Cuts to the state and local preparednessgrants must be restored to levels adequate tomeet current public health preparednessneeds, including special focus on building thepublic health workforce, and greater flexibil-ity is needed to get funds out quickly to statesand locals during emergencies.

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A. FUNDING AND MODERNIZING PUBLIC HEALTH PREPAREDNESS

Despite attempts to improve preparedness —funding has not been at an adequate level to up-grade some core systems — and until these out-dated systems are modernized, responses toemergencies will be behind the times.

Departments around the country are operatingwith outdated technologies, workforce and train-ing shortages, and limited laboratory capacity.

As a priority example, the lack of real-time, co-ordinated surveillance is one of the most trou-bling and ongoing gaps in our core systems.While technologies exist to greatly improve thecollection, reporting, and timeliness of data —resources have not been devoted to an overhaul.Instead, health departments around the coun-try have a patchwork of different systems and re-porting methods — which slow and hamper theintelligence public health officials can use totrack and control disease outbreaks or bioter-rorism events. CDC should also be able to per-form in-depth epidemiologic assessments.

Looking for resources in the current economicclimate to upgrade systems is more challengingthan usual. However, the Prevention and PublicHealth Fund, created in the Affordable Care Act(ACA), provides a new potential opportunity forincreased funds to improve infrastructure. Overthe next 10 years, $15 billion will be available to

support a broad range of public health pro-grams. In FY 2010, the Obama Administrationcommitted $70 million in one-time funding forPublic Health Infrastructure.62 Congress andthe Administration should make a multi-yearcommitment of a defined portion of the fund toimproving Public Health Infrastructure.

TFAH recommends that the ACA funds devoted topublic health infrastructure be coordinated with thePublic Health Emergency Preparedness (PHEP)grants to leverage a meaningful modernization ofthe core capacities of state and local health depart-ments. This would have a positive impact on ourpublic health system across all threats and all publichealth problems, and would specifically improveour nation’s preparedness capability by including:

n A real-time surveillance system with uniform na-tional standards that is compatible with emerg-ing Health Information Technology (HIT) andElectronic Health Records (EHR) standards;

n Laboratories with state-of-the-art, interoperabletechnology and enough trained experts;

n Coordinated, efficient ability to distributevaccines, medications, and equipment to thepublic; and

n A dedicated workforce with the expertise tomanage information and new technologies.

1. Health Reform and Modernizing Biosurveillance and Infrastructure

Federal Funding for State and Local Preparedness, Hospital Preparedness, and State and Local Pandemic Preparedness

PHEP Actual Levels - FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 TOTAL 2009 report. Upgrading State & Local Capacity $1,038,858,000 $918,454,000 $919,148,000 $823,099,000 $766,660,000 $746,039,000 $746,596,000 $761,100,000 $6,719,954,000 HPP Actual Levels - 2009 report FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 Hospital Preparedness $498,000,000 $514,943,000 $487,098,000 $473,882,000 $474,030,000 $423,399,000 $393,585,000 $426,000,000 $3,690,937,000 Pandemic Influenza Supplemental Funding FY2006 FY2007 FY2008 FY2009

$325,000,000 $250,000,000 $24,000,000 $1,444,000,000 $2,043,000,000Subtotal $1,536,858,000 $1,433,397,000 $1,406,246,000 $1,621,981,000 $1,490,690,000 $1,193,438,000 $2,584,181,000 $1,187,100,000 Total Pandemic & All Hazards Funding for S&L and HPP $11,266,791,000

The H1N1 pandemic flu demonstrated ongoingbudget and funds distribution challenges foremergency health preparedness.

The federal dollars that CDC uses to fund thestate and local PHEP cooperative agreements,the Centers for Public Health Preparedness, theAdvanced Practice Centers, and all other stateand local capacity have declined nearly 27 per-cent since FY 2005 when adjusted for inflation.The President’s FY 2011 budget proposal in-cluded $757.8 million for upgrading state andlocal capacity, a decline of less than one percentfrom FY 2010’s $761.1 million.63

In addition to using new funds from ACA andrestoring the cut funds, federal funding for pre-paredness should be better harmonized across de-partments and funding streams to ensure funds arebeing used as effectively as possible. Right now, fed-eral funding for public health preparedness is frag-mented with several agencies and departmentsresponsible for various grant programs, includingCDC, ASPR, and DHS. Each agency has its ownfunding requirements and objectives, which makesit challenging for state and local health departmentsto develop comprehensive preparedness plans.

Additional recommendations for the PHEP andfor future supplemental emergency funds include:

n Putting mechanisms in place to get funds tostates and for states to get funds to local de-partments and for contracting to be able tohappen more quickly during emergencies;

n Considering enhanced flexibility to allow stateand local health departments to waive somecategorical requirements during times ofemergencies -- so all public health staff can beused to respond during crises;

n Ensuring maintenance of effort requirementsare upheld and that states are required tomaintain their funding levels; and

nCreating multi-year funding to allow more re-sources and time for states to meet requirements.

2. Restore Funding for State and Local Preparedness Grants and IncreaseFlexibility and Speed of Funds to States During Emergencies

$0

$200,000,000

$400,000,000

$600,000,000

$800,000,000

$1,000,000,000

$1,200,000,000

CDC’s State and Local Capacity ASPR’s Hospital Preparedness Program

CDC’s Upgrading State and Local Capacity and ASPR’s Hospital Preparedness Program Funding, FY 2003-FY 2010

FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010

Fed Funding for State & Local Preparedness, Hospital Preparedness, & Pandemic Preparedness

PHEP Actual Levels 2010 +/- 2005 % change % change FY 2011 2011 % change 2009 report. (unadjusted for inflation) (adjusted for inflation) President’s Budget +/- 2010

Upgrading State & Local Capacity ($158,048,000) -17% -26.95% 757,793,000 -$3,307,000 -0.43% HPP Actual Levels - 2009 report 2010 +/- 2005 Hospital Preparedness ($61,098,000) -13% -22.85% 426,000,000 $0 0.00%

Pandemic Influenza Supplemental Funding

Subtotal ($219,146,000) -16% -25.53%

*Note: CDC’s State andLocal Capacity includesfunds for: PHEP Coopera-tive Agreements, Centersfor Public Health Pre-paredness, Advanced Prac-tice Centers, and all otherstate and local capacity.ASPR’s Hospital Prepared-ness Program line includesactual grant awards tostates and ESAR-VHPfunds. This chart repre-sents actual funds, not ad-justed for inflation.Source: 1) Upgrading Stateand Local Capacity fromCDC’s FY 2011 BudgetJustification document.64 2)Hospital PreparednessProgram (HPP) fundingfrom HHS’s FY2011 PublicHealth and Social ServicesEmergency Fund BudgetJustification document.65

t

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CDC Funding Source: FY 2010: http://www.cdc.gov/fmo/topic/Budget%20In-formation/appropriations_budget_form_pdf/FY2011_CDC_CJ_Final.pdf, p. 281Source: FY 2009:http://www.cdc.gov/fmo/topic/Budget%20Information/appro-priations_budget_form_pdf/FY2010_CDC_CJ_ Final.pdf, p. 366Source: FY 2007 and FY 2008 numbers fromhttp://www.cdc.gov/fmo/PDFs/FY09_CDC_CJ_Final.pdf, p.371; FY 2004 and 2005 confirmed on p. 375.Note: Upgrading State & Local Capacity includes funds for:PHEP Cooperative Agreement, Centers for Public Health Pre-

paredness, Advanced Practice Centers, and All Other State andLocal Capacity.HPP FundingSource: FY 2010:http://dhhs.gov/asfr/ob/docbudget/2011phssef.pdf, p. 32.Source: FY 2009: http://www.hhs.gov/asrt/ob/docbudget/2010phssef.pdf, p. 8.Source: FY 2007-2009 HHS FY 2009 Justification of Estimatesfor Appropriations Committees, http://www.hhs.gov/bud-get/09budget/budgetfy09cj.pdf, p. 290.; FY2004-2008 p. 304.Note:HPP budget authority includes funding for both HospitalPreparedness and ESAR-VHP

B. ENSURING SUFFICIENT NUMBER OF ADEQUATELY TRAINEDPUBLIC HEALTH EXPERTS

The public health workforce is in crisis. Thereare not enough professionals, particularlytrained experts, to adequately protect Ameri-cans during health emergencies.

n As of 2008, the United States had an esti-mated 50,000 fewer public health workersthan it did 20 years ago. In 2008 and 2009,approximately 23,000 local public health jobswere cut and additional jobs were lost at thestate level;66 and

n One-third of the public health workforce willbe eligible to retire within five years.67

Public health needs to attract a new generationof professionals to serve core functions — butthis is complicated by the fact that actual jobslots are being cut, which makes it harder to re-cruit new individuals to enter the field.

The ACA provides some new opportunities to at-tract the next generation of public health profes-sionals — but it does not necessarily adequatelyaddress the number of needed positions. TFAHrecommends that serious efforts be made to re-cruit and train new workers, but also to evaluatethe actual staffing needs of state and local healthdepartments to perform basic preparedness func-tions, and that, where necessary, jobs be createdor recreated to match the need.

TFAH recommends that some of the infrastruc-ture funding provided in the Prevention and Pub-lic Health Fund be directed at protecting existingpositions and recruiting and training new publichealth workers. In addition, TFAH recommendsthe workforce-related provisions of the ACA beimplemented effectively and strategically to en-hance the public health workforce as much aspossible. Some of these key provisions include:

n The Public Health Workforce Loan Repay-ment Program which would provide loan re-payment assistance for individuals who agreeto serve full-time in a federal, state, local ortribal public health agency for at least threeyears. In FY 2010, $195 million was author-

ized to be appropriated for this program, andsuch sums as necessary for FY 2011-2015.

n The Training for Mid-Career Public and Al-lied Health Professionals Program would au-thorize the U.S. Secretary of HHS to makegrants or enter into contracts to award schol-arships to mid-career public health and alliedhealth professionals to enroll in degree orprofessional training programs. $60 millionwas authorized for these programs in FY 2010and such sums as necessary for FY 2011-2015.

n The Fellowship Training in Public Health au-thorizes funding for fellowship training in ap-plied public health epidemiology, public healthlaboratory science, public health informatics,and expansion of the epidemic intelligenceservice in order to address documented work-force shortages in state and local health de-partments. For each of fiscal years 2010 through2013, $5 million was authorized for epidemiol-ogy fellowship training programs, $5 million forlaboratory fellowship training programs; $5 mil-lion for the Public Health Informatics Fellow-ship Program; and $24,500,000 for expandingthe Epidemic Intelligence Service;

n Grants to Promote the Community HealthWorkforce (CDC) authorizes the Director ofCDC to award grants to promote positive healthbehaviors and outcomes for populations inmedically underserved communities throughthe use of community health workers; and

n Epidemiology-Laboratory (Epi-Lab) CapacityGrants which authorize the U.S. Secretary ofHHS (subject to the availability of appropria-tions) to establish an Epidemiology and Labo-ratory Capacity Grant Program to award grantsto eligible entities to assist public health agen-cies in improving surveillance for and responseto infectious diseases and other conditions ofpublic health importance. $190 million was au-thorized for each year of fiscal years 2010-2013.$20 million from the ACA Prevention Fund hasalready been used for Epi-Lab Capacity Grants.

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C. RESEARCH AND DEVELOPMENT OF MEDICAL COUNTERMEASURES

Research and development of vaccines and medi-cines to help protect Americans from new diseasesand bioterrorism threats remains problematic.

Project BioShield and BARDA were created toincentivize and speed the creation of new MCM.These have been important developments,which have led to advancements, including therapid development of a vaccine in response tothe H1N1 pandemic flu outbreak in 2009.

However, there are many challenges to creatingmedical breakthroughs, and the bureaucracy anda perceived limited profitability in developingcountermeasures constrain progress. Few privateentities have invested in the medical counter-measure market. But, development and manu-facturing of MCM is vital to national security.

TFAH recommends strategic rethinking to spurthe creation of MCM– to help better align pri-vate and national security interests. The WhiteHouse recently released such a plan — a newstrategy that would address key priorities to cre-ate incentives for private industry while protect-ing the public’s interest, including: 1) Enhancing regulatory innovation, science,

and capacity; 2) Improving domestic manufacturing capacity; 3) Providing core advanced development and

manufacturing services to development part-ners;

4) Creating novel ways for the enterprise towork with partners;

5) Developing financial incentives; 6) Addressing roadblocks from concept devel-

opment to advanced development; and 7) Improving management and administration

within the enterprise.

The MCM review provided a series of recom-mendations including:

n Establish Centers for Innovation in AdvancedDevelopment and Manufacturing: HHSwould invest in flexible manufacturing, wherea single facility could produce platforms for avariety of health threats, and create advanceddevelopment partnerships between the gov-ernment, industry, and academia to leverageeach group’s assets.

n Improve Regulatory Science: The plan callsfor investment in FDA’s scientific capacity tooversee medical countermeasures, to mod-ernize and allow for increased efficiency inthe regulatory review process.

n Create an MCM Strategic Investor (MCMSI):The proposal asks for statutory authority tocreate an independent strategic investmentfirm, similar to a venture capital firm, to bringtogether government and private investmentin biotechnology that meets emerging publichealth needs yet still has commercial uses.

n Expand Translation of Product Concepts: Oneidea included in this category would buildEarly Development teams that would act as“sherpas,” to provide strategic guidance to part-ner companies and academic institutions asthey work with federal programs, to help movepromising concepts through the process.

n Shore Up Federal Leadership: The review rec-ommends an MCM development leader atHHS, better agency coordination, and a multi-year planning process.

Although some of the recommendations — in-cluding the proposal for an independent strate-gic investment firm — will require Congressionalauthorization, many of the recommendationscan be implemented without seeking additionalauthorities. The review noted that both the pub-lic and private sector will be needed to trulytransform the MCM enterprise. At the August19, 2010 release of the report, senior Obama ad-ministration officials committed $1.9 billion tothe plan, most of which would be from funds leftover from the response to the H1N1 flu pan-demic.68 The money would fund:

n $170 million to improve FDA regulation ofthe drug-development process;

n $678 million for the development of new, flex-ible countermeasures manufacturing facilities;

n $33 million to accelerate pharmaceutical de-velopment processes at the National Instituteof Allergy and Infectious Diseases;

n $822 million for efforts related to pandemicinfluenza vaccine development; and

n $200 million for the creation of the inde-pendent strategic investment firm.

The plan is intended to connect and buildaround existing MCM programs, such asBARDA’s investment in advanced developmentand NIH’s grants for initial research. The strat-egy has tremendous potential to modernizeAmerica’s countermeasure enterprise by takinga long-term approach to increase innovation, re-search, and development. But success will be de-pendent upon industry buy-in, strong White

39

House and HHS leadership, and champions onCapitol Hill. The White House should begin aneducation campaign of policymakers and pro-vide as much detail as possible about its imple-mentation strategy, including a multiyear

professional judgment budget. Implementationplans should also include end-to-end details,from initial investment through distribution anddispensing of the final product.

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The 2009 H1N1 influenza pandemic was awake-up call that the United States does nothave the infrastructure and capacity to produceMCM in a rapid manner. H1N1 also made peo-ple realize that pandemics, emerging infectiousdiseases, and drug-resistant bacteria are part ofthe same threat posed by bioterror attacks.

In August 2010, the President’s Council of Advi-sors on Science and Technology (PCAST) issued areport with recommendations to enhance the na-tion’s ability to produce influenza vaccine in atimelier manner.69 The report recognized the ef-forts put forth by U.S. public health officials toconfront the 2009/2010 H1N1 pandemic. How-ever, according to the report, “their efforts were

impeded by unanticipated delays that arose inmanufacturing what was supposed to be the mostpowerful tool for preventing widespread morbid-ity and mortality: a vaccine designed to protectagainst the 2009 H1N1 virus.” Although theUnited States was ultimately able to produce andprocure enough H1N1 vaccine to protect half thepopulation, this process took 38 weeks, and itwould have taken an additional 10 weeks to pro-duce enough supply to cover the entire nation.“Protecting the nation from an influenza pandemicthus requires tightening the schedule for makingvaccine substantially,” the report notes, addingthat “in a serious pandemic, saving weeks couldtranslate into saving tens of thousands of lives.”

PANDEMIC FLU VACCINE MANUFACTURING CAPACITY

Since 2005, Project BioShield has led to a num-ber of advancements, including:

n Development and acquisition of the currentlylicensed anthrax vaccine, new smallpox MVAvaccine, two anthrax antitoxins, botulinum an-titoxin, DTPA and KI chelating agents forrad/nuc, and Prussian Blue.

BARDA has led to a number of advances, including:

nMore than 25 product candidates in develop-ment, including next generation anthrax vac-cines and antitoxins, next generation botulinumantitoxins, smallpox vaccines and antiviral drugs,broad spectrum antibiotics, different types oftherapeutics to treat illnesses associated withacute radiation syndrome, and biodosimetrydevices to measure exposure to radiation.These radiation drugs and broad spectrum an-tibiotics are also multi-purpose products forrad/nuc and biothreats as well as oncology andcommunity-acquired infectious pneumonia.

n Development, manufacturing, and acquisitionof licensed H5N1 and H1N1 vaccines, as wellas development of new cell- and recombi-nant-based influenza vaccines that provideplatform technologies for many other prod-ucts; antigen-sparing vaccines using new adju-vants; multiple cell- and antigen-sparingvaccine, which were licensed and used in Eu-rope during the 2009 H1N1 pandemic; andnew influenza antiviral drugs, which wereused under Emergency Use Authorizationduring the 2009 H1N1 pandemic.

n Building domestic manufacturing surge capac-ity since 2007 to retrofit or build new facilitiesthat produced vaccine during the 2009 H1N1pandemic. A new cell-based vaccine manufac-turing facility in North Carolina can producenot only influenza vaccines, but, in an emer-gency, can also produce vaccines or biologicalsagainst known and unknown emerging infec-tious diseases at very large commercial scale.

SOME KEY PROJECT BIOSHIELD AND BARDA ACCOMPLISHMENTS

D. SURGE CAPACITYIn the event of a severe health emergency, thehealth care system would be stretched beyondnormal limits. Patients would quickly fill emer-gency rooms and doctors’ offices, exceed the ex-isting number of available hospital beds, andcause a surge in demand for critical medicinesand equipment.

The challenge of how to equip hospitals and trainhealth care staff to handle the large influx of crit-ically injured or ill patients who show up for treat-ment after or during a public health emergencyremains the single, most challenging issue forpublic health and medical preparedness.70

In public health emergencies, such as a new dis-ease outbreak, a bioterror attack, or catastrophicnatural disaster, U.S. hospitals and health carefacilities are on the front lines providing triageand medical treatment to individuals. In thebest of times, however, most emergency roomsand intensive care units (ICUs) must confrontbed shortages and staffing issues; in a mass ca-sualty event -- particularly a pandemic influenzaor mass bioterror attack -- the situation couldquickly spiral out of control.

ASPR at HHS is currently examining the Hospi-tal Preparedness Program (HPP) to assesswhether it is the best model for preparing thehealth care system for a disaster and how it canbest focus on health system preparedness.TFAH supports these efforts by ASPR.

As it currently exists, HPP may not be the bestmodel because it is a relatively small and discre-tionary funding stream, which may lead hospitalsto lack the motivation or incentive to participatein the program. In FY 2010, HPP received $426million, a nearly 23 percent decline since FY 2005when adjusted for inflation. The President’s FY2011 budget proposal flat funds the program.71

Regardless, the HPP should be expanded andenhanced by:

n Increasing funding: HPP is a federal grantprogram intended to enhance the ability ofhospital and health care systems to preparefor and respond to bioterrorism and otherhealth emergencies. The funding for theHPP program is limited and does not cover

large-scale emergency capabilities. HPP fund-ing goes to state health departments where itis divided up between statewide health carepreparedness initiatives, sub-state regional ini-tiatives, and individual hospitals. Some hos-pitals receive as little as $10,000 annuallyalthough they may also benefit indirectly fromregional and statewide programs;

n Encouraging state and local officials to ex-pand inclusion of non-hospital health caresettings -- including ambulatory care and doc-tors’ offices -- in response plans and processes;

n Improving regional and community coordi-nation, so cross-state and private-public re-sources can be leveraged;

n Improving crisis standards of care and plan-ning development;

n Increasing support to alternate care sites thatare needed during mass emergencies, includ-ing coordination, resource, and licensing andconcerns; and

n Providing incentives for recruiting a surgeworkforce, so providers are ready in times ofemergency, including creating incentives forprivate and public health workers to participate,and reaching out to a range of staff, includingadministrative staff, medical technicians, EMS,public safety workers, and medical and nursingstudents in addition to doctors and nurses. Is-sues of liability, licensing, and accreditationshould all be addressed ahead of an emergency.

Issues around financing emergency prepared-ness care also must be further addressed, partic-ularly ensuring payment concerns do not keeppeople who are uninsured or underinsured fromseeking care, especially in the event of an infec-tious disease outbreak when they could spreadthe disease to others. In addition, providers mustbe compensated for care to the uninsured or un-derinsured, ensuring that payment concerns donot keep people from receiving care, includingnecessary vaccines and antiviral medications.

TFAH asked Eric Toner, MD, from the Centeron Biosecurity to provide a commentary outlin-ing key issues for surge capacity planning.

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42

Hospitals Better Prepared for Common Disasters but National Strategy for CatastrophicEvents NeededBy Eric Toner, MD

EXPERT PERSPECTIVE

Over the last three years, under contract to the office ofthe Assistant Secretary for Preparedness and Response

(ASPR) in the Department of Health and Human Services(HHS), the Center for Biosecurity of UPMC conducted a na-tionwide study of the state of hospital preparedness, how it haschanged since 2001, and to what extent that change was dueto ASPR’s Hospital Preparedness Program (HPP).72

The HPP was created in 2002 after the anthrax attack of Octo-ber 2001 to better prepare U.S. hospitals for bioterrorism andsince then the program has provided approximately $400 mil-lion/year to the states and major cities, most of which waspassed through to the hospitals.

We found that in many ways hospitals are in fact much better pre-pared than they were a decade ago and that much of the improve-ment can be attributed the HPP, but not only the HPP. Two otherfactors coincided with this improvement; the Joint Commissiongreatly strengthened its emergency management standards in Jan-uary of 2001, and after 9/11 and the anthrax letters, many hospi-tals began to perceive the threat of disasters as being much moreimminent. So, in fact, there was a convergence of factors thatpushed hospitals to be better prepared; the threat perceptionprovided motivation, the Joint Commission standards providedthe “what to do”, and the HPP provided the means to do it.

Specifically we found that most individual hospitals had designatedemergency management coordinators, improved emergency op-erations plans, implemented incident command structures, im-proved communications, trained staff, and improved drills andexercises. But the most significant finding was that, in every loca-tion we talked to, cooperation among hospitals and between hos-pitals and public health and emergency management agencies hadgreatly improved. And every location had created, or was creat-ing, some sort of health care coalition to facilitate preparedness.

In some locations, these coalitions were quite evolved; in oth-ers they were still nascent. In the best of them, the coalitionsplayed a significant role in coordinating emergency responseamong the hospitals. We found several examples wherein thecoalitions had been instrumental in improving the response toactual emergencies—the Minnesota bridge collapse and theVirginia Tech shootings are just two examples. In both cases,systems, technologies, and protocols created as a result of theHPP were judged to have made for a more coordinated re-sponse that saved lives. Much work remains to be done in

most locations to be adequately prepared for common disas-ters like these but programs are in place that, over time andwith sustained funding, should gradually lead to a good level ofpreparedness for this scale of event.

On the other hand, in contrast to these relatively small scaleevents, we found a significant gap in preparedness for cata-strophic health events (CHE).73 By this we mean the kind ofevents that could result in many thousands of sick or injured.This includes large scale bioterrorism, a nuclear detonation, ora major earthquake. We found few locations had well thoughtout plans for how they would respond to the health care de-mands of an event of this scale. And there was no nationalstrategy that would lead to adequate health care preparednessfor a CHE. So, in recommending future directions for the HPPwe focused on health care response to CHEs.

So what could we do in response to a CHE? Really there areonly three options: 1) move stuff in—deployable resources likeDMAT teams; 2) move patients out—to other cities; or 3) alterthe kind of care provided. The problem is that we havenowhere near enough deployable resources, or transportationassets in our current plans for this number of patients, and wehave only just begun a national dialogue on altering standards ofcare in a crisis. We believe that we need to greatly improve ourcapabilities in all three of these realms.

The good news, however, is that despite very real limitations inmedical surge capacity in any one city or region, the country asa whole has an enormous health care capacity. The problem isgetting the patients and the medical resources in the sameplace in time to be of use.

We have recommended some steps that we believe would movethe U.S. in the direction of being able to respond more effectivelyto a CHE. They include, among other things, rethinking the waywe do patient transportation in a CHE—this probably meansusing non-medical vehicles without highly trained attendants; cre-ating fully evolved health care coalitions in every city and linkingthem together to create a flexible web of coalitions that can pro-vide mutual assistance and burden share; advancing the develop-ment of coordinated, fair, ethical, and legal approaches to crisisstandards of care so we can do the most good for the greatestnumber; and creating a national framework for health care re-sponse to CHEs to guide states, and local entities in developingtheir own plans for medical and public health response.

E. COMMUNITY RESILIENCEEnsuring communities can cope and recoverfrom emergencies is another significant chal-lenge in emergency health preparedness.

More vulnerable members of communities -- in-cluding children, the uninsured and underin-sured, the elderly, people with underlying healthconditions, and racial and ethnic minorities --face special challenges that need to be plannedfor prior to emergencies happening.

Building community resilience is one of the twooverarching goals identified by HHS in the re-lease of the draft Biennial Implementation Planfor the National Health Security Strategy. It callsfor fostering informed, empowered individualsand communities.

TFAH recommends that greater priority and ef-fort be placed on preparing communities foremergencies. This includes providing clear, hon-est, straightforward guidance to the public -- andfor health officials to develop standing relation-ships with the community, so when emergenciesarise, they will be trusted and understood. To besuccessful, members of the community must beengaged in emergency planning efforts.

Community relationships can be developed andmaintained through ongoing public health ef-forts and programs, such as obesity preventionand tobacco prevention initiatives, and the Vac-cine for Children program outreach. In fact,Communities Putting Prevention to Work grants,which were distributed as part of the America Re-covery and Reinvestment Act of 2009, supportedthe building of community coalitions to addressobesity and tobacco, and the Community Trans-formation Grants authorized in the ACA will also

bring together community coalitions to addresspublic health problems. These grants could beconsidered as long-term investments by also serv-ing the purpose of building community resilienceand improving public health department rela-tionships with underserved communities. Out-reach to individuals with underlying healthproblems serves a dual purpose since they areoften particularly vulnerable during emergencies,and people dependent on prescription drugs ormedical treatments encounter unique challengesduring emergencies. Addressing mental healthissues must also be a priority for disaster responseand recovery efforts.

To be effective in reaching diverse communities,it is also important to ensure information is pro-vided in channels beyond the Internet, such asradio and racial and ethnic publications and tel-evision, and in languages other than English.Furthermore, translations must be idiomaticrather than word-for-word and materials must betailored to specific cultural perspectives andshould be from a trusted source, such as reli-gious and community leaders.

To highlight key considerations for some vul-nerable, special needs, and at-risk communities,TFAH has included and supports:

n Recommendations from National Commis-sion on Children and Disasters; and

n Recommendations outlined in a commentaryfrom Nadia Siddiqui, Dennis Andrulis, andJonathan Purtle for building a National Strat-egy for Advancing Preparedness Programsand Policies for Racially and Ethnically Di-verse Communities.

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In October 2010, the National Commission on Children andDisasters released a report to the President and Congress onthe state of children during disasters. The report finds chronicgaps in disaster preparedness for children since Hurricane Kat-rina and calls for a national strategy to protect children notonly during an emergency, but also before and after.

The Commission broke down their recommendations into 11main categories. Some key recommendations include:

n Disaster Management and Recoverys Distinguish and comprehensively integrate the needs ofchildren across all inter- and intra-governmental disastermanagement activities and operations.

s The President should accelerate the development and im-plementation of the National Disaster Recovery Frameworkwith an explicit emphasis on addressing the immediate andlong-term physical and mental health, educational, housing,and human services recovery needs of children.

n Mental Healths HHS should lead efforts to integrate mental and behav-ioral health for children into public health, medical, andother relevant disaster management activities.

s DHS/FEMA and the Substance Abuse and Mental HealthServices Administration (SAMHSA) should strengthen theCrisis Counseling Assistance and Training Program to bet-ter meet the mental health needs of children and families.

n Child Physical Health and Traumas Congress, HHS, and DHS/FEMA should ensure availabil-ity of and access to pediatric MCM at the federal, state,and local levels for chemical, biological, radiological, nu-clear, and explosive threats.

s HHS should ensure that health professionals who maytreat children during a disaster have adequate pediatricdisaster clinical training.

s The Environmental Protection Agency (EPA) should en-gage state and local health officials and non-governmentalexperts to develop and promote national guidance andbest practices on re-occupancy of homes, schools, childcare, and other child congregate care facilities in disaster-impacted areas.

n Emergency Medical Services and Pediatric Transports The President and Congress should clearly designate andappropriately resource a lead federal agency for emer-gency medical services with primary responsibility for thecoordination of grant programs, research, policy, andstandards development and implementation.

s Improve the capability of emergency medical services totransport pediatric patients and provide comprehensive pre-hospital pediatric care during daily operations and disasters.

n Disaster Care Managements Disaster case management programs should be appro-priately resourced and should provide consistent holisticservices that achieve tangible, positive outcomes for chil-dren and families affected by the disaster.

n Child Care and Early Educations Congress and HHS should improve disaster prepared-ness capabilities for child care.

s Congress and federal agencies should improve capacityto provide child care services in the immediate aftermathof and recovery from a disaster.

n Elementary and Secondary Educations Congress and federal agencies should improve the pre-paredness of schools and school districts by providing ad-ditional support to states.

s Ensure that school systems recovering from disasters areprovided immediate resources to reopen and restore thelearning environment in a timely manner and providesupport for displaced students at their host schools.

n Child Welfare and Juvenile Justices State and local child welfare agencies, state and local ju-venile justice agencies, including residential treatment,correctional, and detention facilities, and HHS and De-partment of Justice dealing with juvenile, dependency,and other childhood court matters should all be ade-quately prepared for disasters.

n Sheltering Standards, Services, and Suppliess Government agencies and non-governmental organiza-tions should provide a safe and secure mass care shelterenvironment for children, including access to essentialservices and supplies.

n Housings Prioritize the needs of families with children, especiallyfamilies with children who have disabilities or chronichealth, mental health, or educational needs, within disas-ter housing assistance programs.

n Evacuation

s Congress and federal agencies should provide sufficientfunding to develop and deploy a national sharing capabil-ity to quickly and effectively reunite displaced childrenwith their families, guardians, and caregivers when sepa-rated by a disaster.

s Disaster plans at all levels of government must specifi-cally address the evacuation and transportation needs ofchildren with disabilities and chronic health needs, in co-ordination with child congregate care facilities such asschools, child care, and health care facilities.

NATIONAL COMMISSION ON CHILDREN AND DISASTERS RECOMMENDATIONS74

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Building a National Strategy for AdvancingPreparedness Programs and Policies for Raciallyand Ethnically Diverse CommunitiesNadia Siddiqui, MPH; Dennis Andrulis, PhD, MPH; and Jonathan Purtle, MPH, MSc

EXPERT PERSPECTIVE

Racially and ethnically diverse populations often experi-ence higher rates of injury, disease and death from disas-

ters and other public health emergencies.75 While this unequalimpact is clearly linked to community poverty and underlyingsocioeconomic inequalities, longstanding inattention to theprofound influence of race, ethnicity and language—intimatelyrelated to, but extending far beyond emergency events—con-tribute significantly to this gap. As a result, failure to learnabout and consider cultural beliefs and norms, limited Englishproficiency, legacies of distrust in government, and historic lackof access to health care, may greatly affect these communities’understanding of, participation in and adherence to prepared-ness recommendations and directives that can make the differ-ence between life, disability and death.

While the legacy of Hurricane Katrina prompted attention tothis national priority, other recent events reinforce patterns ofinequity. For example, the Southern California Wildfires of2007 had severe adverse health effects on Hispanic and Latinofarm workers, migrant families and immigrants, who in manycases did not evacuate firestorms due to fear of detention ordeportation by Border Patrol and lack of culturally and linguisti-cally tailored communication on where, when and how toevacuate.76 The 2009 H1N1 Pandemic catastrophically af-fected American Indians and Alaska Natives, who were foundto have a three to eight times higher rate of hospitalization andmortality associated with the infection across at least 12states.77 And in the wake of the BP Oil Spill in the Gulf of Mex-ico, large scores of Vietnamese fishing communities were ad-versely affected, their response and recovery made difficult bycultural misunderstandings and language barriers that did notaccount for intra-cultural and dialectal differences.78

These legacies strongly reinforce the important and complexrole that race, ethnicity, culture and language often play in influ-encing emergency preparedness, response and health out-comes. At the same time, they point to the need and urgencyfor national policies to build infrastructure, programs andstrategies that ultimately eliminate inequities.

In recognition of this priority, the U.S. Department of Healthand Human Services’ Office of Minority Health supported aunique initiative, known as the National Consensus Panel onEmergency Preparedness and Cultural Diversity, to develop andissue “guidance to national, state, territorial, tribal and local

agencies and organizations on the development of effectivestrategies to advance emergency preparedness and eliminatedisparities for racial and ethnic communities.” Created in 2006,the Panel is comprised of nearly three dozen experts from lead-ing federal, state and local/community based public and privateorganizations, representing a broad spectrum of perspectivesincluding public health, emergency managers and responders,hospitals and health care, risk communication, faith-based andneighborhood organizations, and diverse racial and ethnicgroups. A complete list of National Consensus Panel membersis available at http://www.diversitypreparedness.org/NCP/92/.

In 2008, the Panel released a National Consensus Statementand eight Guiding Principles, representing the nation’s first, andonly, blueprint on advancing preparedness for diverse popula-tions. Built on the foundation of creating informed, empow-ered and resilient communities, a theme central to the U.S.Department of Health and Human Services’ National HealthSecurity Strategy, the consensus statement stresses that coor-dination in working with diverse communities is key to success,and concludes that their active involvement and engagement isessential to their understanding, participation in and adherenceto public health preparedness and response actions. Core tosuccess in the long term is commitment and support at all lev-els for developing sustainable programs and services that buildin mutual accountability. (An abbreviated version of the state-ment can be found in the Institute of Medicine’s 2009 Reportentitled, Guidance for Establishing Crisis Standards of Care forUse in Disaster Situations.)

Accompanying the consensus statement are eight guiding prin-ciples that provide a roadmap of actions and practical strategiesfor incorporating diverse communities into preparedness andresponse. Examples of featured principles include: identifyingdiverse community risks, needs and assets; creating drills andexercises that incorporate specific scenarios around diversity,race, culture, language and trust; building capacity for culturallyand linguistically appropriate services and programs; and utiliz-ing tools and measures to evaluate cultural and linguistic appro-priateness of programs.

The consensus statement, guiding principles and Panel’s spe-cific recommendations around operationalizing the principlesserved as the foundation for developing a toolkit to offer guid-ance to public health and emergency management agencies as

46

EXPERT PERSPECTIVE CONTINUED

well as community-based organizations on prac-tical strategies, promising models and resourcesfor improving programs, plans and practices inmeeting the needs of racially and ethnically di-verse communities. In addition, the Panel’s workoffers important guidance and added depth anddimension on application of the toolkit and iden-tified priorities for pandemic influenza planningand response in diverse communities, coveringissues of public awareness, data and evidence,governance, community engagement, outreachand delivery networks. The complete toolkit willbe available by Winter, 2011. For further infor-mation or to request the toolkit please contactNadia Siddiqui at nsiddiqui@texashealthinsti-tute.org.

Finally, recent Panel discussions have stressed theneed to identify and develop sustainable fundingmechanisms for building community and organi-zational capacity for advancing emergency pre-paredness in diverse communities. Recognizingthat investments in public health preparednessare declining at federal, state and local levels, thePanel recommends turning to the recent PatientProtection and Affordable Care Act (ACA) of2010 for opportunities to frame diversity and pre-paredness priorities within the broader healthcare and community health context. For exam-ple, through the Centers for Disease Control andPrevention, ACA appropriates $100 million incompetitive Community Transformation Grants

(CTGs) between 2010-2014.79 These grants areavailable to state and local governmental agenciesand community-based organizations for the im-plementation, evaluation, and dissemination ofevidence-based community preventive health ac-tivities to, among other priorities, “address healthdisparities”. As such, CTGs offer one vehicle foragencies and organizations to address prepared-ness and response for diverse populations—broadly through enhancing community resilienceas well as for distinct events such as seasonal andpandemic influenza. Other funding opportunitiesto address preparedness for diverse populationsmay be embedded in provisions focused onworkforce diversity, cultural competence trainingand community health workers.

The work of the Panel generally and in the con-text of health care reform offers new opportu-nities for bridging an important divide in planningfor and responding to racially and ethnically di-verse communities and, in so doing, improvingthe health and well-being of all populations. Itsdedication and continued contributions are tes-taments to the need for maintaining a nationalfocus on this critical priority.

Nadia Siddiqui, MPH, is Senior Health Policy Analyst at theTexas Health Institute. Dennis Andrulis, PhD, MPH is SeniorResearch Scientist at the Texas Health Institute and AssociateProfessor at the University of Texas School of Public Health.Jonathan Purtle, MPH, MSc, is Program Manager at the DrexelUniversity School of Public Health’s Center for Public HealthReadiness & Communication.

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APPENDIX A: CDC AND ASPR PREPAREDNESS GRANTS BY STATEALL-HAZARDS PREPAREDNESS FUNDING BY SOURCE AND YEARFY 2009 FY 2010 % Change

State CDC ASPR Total State CDC ASPR Total Alabama $9,984,931 $5,528,753 $15,513,684 Alabama $10,048,584 $5,959,171 $16,007,755 3.09%Alaska $5,015,000 $1,232,661 $6,247,661 Alaska $5,165,000 $1,295,371 $6,460,371 3.29%Arizona $13,658,394 $7,242,486 $20,900,880 Arizona $14,047,671 $7,819,583 $21,867,254 4.42%Arkansas $7,279,503 $3,573,514 $10,853,017 Arkansas $7,393,805 $3,836,580 $11,230,385 3.36%California $49,341,755 $29,486,456 $78,828,211 California $49,301,738 $31,967,442 $81,269,180 3.00%Colorado $10,637,403 $5,697,522 $16,334,925 Colorado $10,875,195 $6,142,385 $17,017,580 4.01%Connecticut $8,704,406 $4,332,291 $13,036,697 Connecticut $8,719,806 $4,660,301 $13,380,107 2.57%Delaware $5,000,000 $1,433,223 $6,433,223 Delaware $5,150,000 $1,513,099 $6,663,099 3.45%D.C. $6,461,359 $1,589,577 $8,050,936 D.C. $6,616,482 $1,682,835 $8,299,317 2.99%Florida $32,906,612 $20,280,168 $53,186,780 Florida $33,481,834 $21,973,177 $55,455,011 4.09%Georgia $18,146,190 $10,738,888 $28,885,078 Georgia $18,481,819 $11,615,246 $30,097,065 4.03%Hawaii $5,144,507 $1,905,612 $7,050,119 Hawaii $5,249,782 $2,025,920 $7,275,702 3.10%Idaho $5,330,380 $2,103,488 $7,433,868 Idaho $5,495,096 $2,240,733 $7,735,829 3.90%Illinois $19,985,919 $11,422,845 $31,408,764 Illinois $19,496,622 $12,357,745 $31,854,367 1.40%Indiana $12,979,201 $7,403,442 $20,382,643 Indiana $12,995,857 $7,994,316 $20,990,173 2.89%Iowa $7,540,433 $3,760,725 $11,301,158 Iowa $7,565,448 $4,039,814 $11,605,262 2.62%Kansas $7,446,545 $3,522,344 $10,968,889 Kansas $7,530,021 $3,781,030 $11,311,051 3.03%Kentucky $9,510,505 $5,099,081 $14,609,586 Kentucky $9,455,848 $5,492,721 $14,948,569 2.27%Louisiana $9,756,363 $5,188,408 $14,944,771 Louisiana $9,999,458 $5,589,694 $15,589,152 4.13%Maine $5,183,337 $1,945,059 $7,128,396 Maine $5,259,067 $2,068,743 $7,327,810 2.72%Maryland $12,690,042 $6,640,448 $19,330,490 Maryland $12,720,551 $7,166,017 $19,886,568 2.80%Massachusetts $14,323,704 $7,538,670 $21,862,374 Massachusetts $15,229,770 $8,141,119 $23,370,889 6.45%Michigan $20,123,542 $11,538,958 $31,662,500 Michigan $20,143,034 $12,483,796 $32,626,830 2.96%Minnesota $12,055,280 $6,149,904 $18,205,184 Minnesota $12,911,644 $6,633,486 $19,545,130 6.86%Mississippi $7,467,891 $3,682,495 $11,150,386 Mississippi $7,527,286 $3,954,888 $11,482,174 2.89%Missouri $12,475,814 $6,888,644 $19,364,458 Missouri $12,572,343 $7,435,455 $20,007,798 3.22%Montana $5,019,036 $1,532,896 $6,551,932 Montana $5,166,198 $1,621,303 $6,787,501 3.47%Nebraska $5,774,382 $2,433,560 $8,207,942 Nebraska $5,876,388 $2,599,056 $8,475,444 3.16%Nevada $7,292,961 $3,228,706 $10,521,667 Nevada $7,511,623 $3,462,259 $10,973,882 4.12%New Hampshire $5,244,492 $1,937,756 $7,182,248 New Hampshire $5,349,356 $2,060,815 $7,410,171 3.08%New Jersey $18,247,856 $10,039,764 $28,287,620 New Jersey $18,015,661 $10,856,284 $28,871,945 2.02%New Mexico $6,853,141 $2,637,233 $9,490,374 New Mexico $7,643,606 $2,820,161 $10,463,767 9.30%New York $22,171,004 $12,628,147 $34,799,151 New York $22,932,149 $13,666,210 $36,598,359 4.92%North Carolina $16,224,492 $10,184,038 $26,408,530 North Carolina $16,552,440 $11,012,906 $27,565,346 4.20%North Dakota $5,023,393 $1,195,281 $6,218,674 North Dakota $5,021,860 $1,254,791 $6,276,651 0.92%Ohio $21,312,180 $13,050,486 $34,362,666 Ohio $20,947,527 $14,124,698 $35,072,225 2.02%Oklahoma $8,536,905 $4,413,646 $12,950,551 Oklahoma $8,487,239 $4,748,620 $13,235,859 2.16%Oregon $8,884,916 $4,546,549 $13,431,465 Oregon $8,871,324 $4,892,898 $13,764,222 2.42%Pennsylvania $22,975,362 $14,103,046 $37,078,408 Pennsylvania $22,808,671 $15,267,347 $38,076,018 2.62%Rhode Island $5,000,000 $1,667,365 $6,667,365 Rhode Island $5,150,000 $1,767,281 $6,917,281 3.61%South Carolina $10,097,336 $5,225,017 $15,322,353 South Carolina $11,034,653 $5,629,437 $16,664,090 8.05%South Dakota $5,000,000 $1,354,980 $6,354,980 South Dakota $5,150,000 $1,428,159 $6,578,159 3.39%Tennessee $12,495,537 $7,103,056 $19,598,593 Tennessee $12,711,428 $7,668,219 $20,379,647 3.83%Texas $42,816,952 $26,204,300 $69,021,252 Texas $43,194,539 $28,404,362 $71,598,901 3.60%Utah $7,018,990 $3,288,335 $10,307,325 Utah $7,328,511 $3,526,992 $10,855,503 5.05%Vermont $5,042,969 $1,182,205 $6,225,174 Vermont $5,193,078 $1,240,595 $6,433,673 3.24%Virginia $16,613,973 $8,857,019 $25,470,992 Virginia $17,063,098 $9,572,306 $26,635,404 4.37%Washington $13,561,976 $7,493,408 $21,055,384 Washington $13,731,541 $8,091,982 $21,823,523 3.52%West Virginia $5,839,235 $2,488,384 $8,327,619 West Virginia $5,898,188 $2,658,572 $8,556,760 2.68%Wisconsin $12,177,579 $6,575,694 $18,753,273 Wisconsin $13,276,438 $7,095,720 $20,372,158 7.95%Wyoming $5,000,000 $1,063,125 $6,063,125 Wyoming $5,000,000 $1,111,323 $6,111,323 0.79%

CDC Total ASPR Total Grand Total CDC Total ASPR* Total Grand Total Grand Total FY 09** FY 09** FY 09** FY 10** FY 10** FY 10** Percent Change

FY 09 - FY 10$623,373,683 $330,359,658 $953,733,341 $633,349,277 $356,452,963 $989,802,240 3.64%

* Note that state CDC total funding include funding for Cities Readiness Initiative funding, Level 1 chemical laboratory funding, and EWIDS funding although not everystate 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, andNew York City, U.S. Territories, such as Puerto Rico and Guam, and Freely Associated States of the Pacific, such as the Marshall Islands. Source: FY2010 Funding 1) CDC. Public Health Emergency Preparedness Cooperative Agreement Budget Period 10 Extension (FY 2010) Funding.<http://www.bt.cdc.gov/cdcpreparedness/coopagreement/10/Revised_PHEP_BP10_Extension_Funding_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.) FY2009 Funding 1) CDC. Cooperative Agreement Guidance for PublicHealth Emergency Preparedness Program Announcement AA154 - FY 2009 (Budget Period 10). Atlanta, GA: U.S. Department of Health and Human Services, 2009,p. 24-26. <http://www.bt.cdc.gov/cotper/coopagreement/10/FinalPHEP_BP10_Guidance_5-01-09.pdf> (accessed September 11, 2009). 2) HHS/ASPR. FY09 Hospi-tal Preparedness Program Funding Opportunity Announcement. Washington, D.C.: HHS/ASPR/OPEO/DNHPP, August 2009, p. 84-85.

COMMUNITY RESILIENCY -- CHILDREN AND PREPAREDNESS INDICATORIndicator 7 focuses only on the first criteria inthe Save the Children National Report Card onProtecting Children in Disasters

2010 National Report Card on Protecting Chil-dren in Disasters Criteria

This document provides analysis of the defini-tions and applications of the four minimumstandards for emergency preparedness in Savethe Children’s National Report Card on Pro-tecting Children in Disasters. Many states havepolicies in place that relate to disaster pre-paredness. Whether these policies meet the Re-port Card’s standards depends upon theircontent and application.

In the Report Card, a state is not judged to meeta particular standard unless (1) the substance ofthe state’s policy meets the minimum require-ments of the standard; (2) the policy is man-

TFAH conducted an analysis of state spendingon public health for the last budget cycle, fiscalyear 2009-2010. For those states that only reporttheir budgets in biennium cycles, the 2009-2011period (or the 2008-2010 and 2009-2010 for Vir-ginia and Wyoming respectively) was used, andthe percent change was calculated from the lastbiennium, 2007-2009 (or 2008-2010 and 2009-2010 for Virginia and Wyoming respectively).

This analysis was conducted from August to Oc-tober of 2010 using publicly available budgetdocuments through state government web sites.Based on what was made publicly available,budget documents used included either execu-tive budget document that listed actual expen-ditures, estimated expenditures, or finalappropriations; appropriations bills enacted bythe state’s legislature; or documents from leg-islative analysis offices.

“Public health” is defined broadly to include allhealth spending with the exception of Medicaid,CHIP, or comparable health coverage programsfor low-income residents. Federal funds, mentalhealth funds, addiction or substance abuse-re-lated funds, WIC funds, services related to de-velopmental disabilities or severely disabledpersons, and state-sponsored pharmaceuticalprograms also were not included in order tomake the state-by-state comparison more accu-rate since many states receive federal money forthese particular programs. In a few cases, statebudget documents did not allow these pro-grams, or other similar human services, to bedisaggregated; these exceptions are noted. Formost states, all state funding, regardless of gen-eral revenue or other state funds (e.g. dedicatedrevenue, fee revenue, etc.), was used. In some

cases, only general revenue funds were used inorder to separate out federal funds; these ex-ceptions are also noted.

Because each state allocates and reports its budgetin a unique way, comparisons across states are dif-ficult. This methodology may include programsthat, in some cases, the state may consider a pub-lic health function, but the methodology used wasselected to maximize the ability to be consistentacross states. As a result, there may be programsor items states may wish to be considered “publichealth” that may not be included in order tomaintain the comparative value of the data.

Finally, to improve the comparability of thebudget data between FY 2008-2009 and FY 2009-2010 (or between biennium), TFAH adjustedthe FY 2009-2010 numbers for inflation (using a0.9841 conversion factor based on the U.S.Dept. of Labor Bureau of Labor Statistics; Con-sumer Price Index Inflation Calculator athttp://www.bls.gov/cpi/).

After compiling the results from this online re-view of state budget documents, TFAH coordi-nated with the Association of State andTerritorial Health Officials (ASTHO) to con-firm the findings with each state health official.ASTHO sent out emails on November 4, 2010and state health officials were asked to confirmor correct the data with TFAH staff by Novem-ber 16, 2010. ASTHO followed up via email withthose state health officials who did not respondby the November 16, 2010 deadline. In the end,seven states and the District of Columbia did notrespond by December 1, 2010 when the reportwent to print. These states were assumed to bein accordance with the findings.

APPENDIX B: METHODOLOGY FOR SELECT INDICATORS

State Public Health Budget Methodology

48

dated; and (3) all licensed or regulated childcare — or in the case of the 4th criteria — all K-12 schools are subjected to the policy. Substan-tive descriptions of the standards are listedbelow. A rule is considered mandated if it is (1)in statute (2) in regulation or (3) is provided bythe relevant agency as mandatory guidance.Mandatory guidance includes forms, templates,and technical assistance that are provided to alllicensed or regulated child care facilities and arerequired to be completed or implemented.

The final requirement is that all licensed or reg-ulated child care — and all K-12 schools in re-gard to the 4th criteria: An Evacuation Plan forSchools — be implicated by these requirements.Many states not receiving credit have policies inplace but do not make those policies applicableto all facilities. For example, a state might havea full multihazard written plan requirement butapply it only to center-based child care, exclud-ing homecare facilities. Despite having a regu-lation in place, the state would not receive creditfor the first criteria: A Plan for Evacuating Chil-dren in Child Care.

Criteria 1: A Plan for Evacuating Children inChild CareThe state must require all licensed or regulatedchild care facilities to have a written multi-haz-ard plan for evacuating and safely moving chil-dren to an alternate relocation site. Amulti-hazard plan must cover manmade and nat-ural emergencies and address evacuation, shel-

ter-in-place, and lock-down situations. A statemay have more than one classification for li-censed or regulated child care, but the standardmust apply to all facilities equally.

Criteria 2: Reunifying Families after a DisasterThe state must require all licensed or regulatedchild care facilities to have a written plan foremergency notification of parents and reunifi-cation of families following an emergency.Again, a state may have more than one classifi-cation for licensed or regulated child care, butthe standard must apply to all facilities equally.

Criteria 3: Children with Special NeedsThe state must require all licensed or regulatedchild care facilities to have a written plan that ac-counts for children with special needs. This stan-dard is not met by policies that addressaccommodations for special needs children inchild care settings, but instead those that directemergency plans to specifically meet the needs ofall special needs children. Again, the requirementmust apply to all licensed or regulated child care.

Criteria 4: An Evacuation Plan for K-12 SchoolsThe state must require all K-12 schools to have amulti-hazard emergency preparedness plan. Amulti-hazard plan must cover manmade and nat-ural emergencies and address evacuation, shelter-in-place, and lock-down situations. Mandating fireor tornado drills alone is considered incompleteand therefore does not meet the standard. Again,it should apply to all K-12 schools.

49

1 McNichol E., et al. States Continue to Feel Recession’s Im-pact. Washington, D.C.: Center on Budget and PolicyPriorities, October 2010. http://www.cbpp.org/files/9-8-08sfp.pdf (accessed November 15, 2010).

2 National Association of County & City Health Officials.Local Health Department Job Losses and Program Cuts: Find-ings from January/February 2010 Survey. Washington,D.C.: National Association of County & City Health Offi-cials, May 2010. http://www.naccho.org/topics/infra-structure/lhdbudget/index.cfm (accessed November15, 2010).

3 Adjusting for inflation. Analysis by Trust for Amer-ica’s Health. See Section II, Part A, number 2 of thisreport.

4 Association of the Schools of Public Health. Con-fronting the Public Health Workforce Crisis: ASPH State-ment on the Public Health Workforce. Washington, D.C.:Association of Schools of Public Health, 2008.

5 Association of State and Territorial Health Officials.2007 State Public Health Workforce Survey Results. Ar-lington, VA: Association of State and TerritorialHealth Officials, 2007.

6 U.S. Centers for Disease Prevention and Control. Pub-lic Health Preparedness: Strengthening the Nation’s EmergencyResponse State by State. Atlanta, GA: CDC, 2010, p. 163.

7 Monke J. Agroterrorism: Threats and Preparedness. Wash-ington, D.C.: Congressional Research Service, 2004.

8 Blackburn BG, et al. “Surveillance for WaterborneDisease Outbreaks Associated with Drinking Water —United States, 2001-2002.” Morbidity and MortalityWeekly 53, (SS08), 23-45, October 22, 2004.

9 Ellis K. “One Health Initiative Will Unite Veterinary,Human Medicine: Experts Urge Collaboration BetweenVeterinarians, Physicians in Wake Of Emerging Zoo noticDiseases, Potential Epidemics.” Infectious Disease News.February 2008. http://www.infectiousdiseasenews.com/200802/veterinary.asp (accessed July 15, 2008).

10 Institute of Medicine (IOM). The Future of the Public’sHealth in the 21st Century. Washington, D.C.: NationalAcademies Press, 2002.

11 National Health Security Strategy of the United States ofAmerica. Washington, D.C.: U.S. Department ofHealth and Human Services, 2009, p.3.

12 Ibid, p.2.13 Ibid, p. 3.14 Ibid, p. 1.15 Draft Biennial Implementation Plan for the National Health

Security Strategy of the United States of America. U.S. De-partment of Health and Human Services, July 19, 2010.

Endnotes

16 Congressional Budget Office Cost Estimate, Novem-ber 19, 2004. “H.R. 4634: Terrorism InsuranceBackstop Extension Act of 2004”; Kunreuther,Howard and Michel-Kerjan Erwann, 2004. “Dealingwith Extreme Events: New Challenges for TerrorismRisk Coverage in the U.S.,” Working Paper.

17 Ibid.18 Caruso D. “WTC workers agree to $625 million set-

tlement for toxic dust exposure.” Associated Press.November 19, 2010.

19 Lengel A. “Little Progress In FBI Probe of AnthraxAttacks”. The Washington Post. September 16, 2005.http://www.washingtonpost.com/wp-dyn/con-tent/article/2005/09/15/AR2005091502456_pf.html. (accessed November 18, 2010).

20 National Institute for Occupational Safety and Health.“NIOSH Respiratory Diseases Research Program: Evi-dence Package for the National Academies’ Review2006-2007 -- 6.2 Anthrax.” http://www.cdc.gov/niosh/nas/RDRP/ch6.2.htm. (accessed November16, 2010.)http://www.cdc.gov/niosh/nas/RDRP/ch6.2.htm. (accessed November 16, 2010.)

21 Lipton E. “U.S. Lists Possible Terror Attacks andLikely Toll.” New York Times, March 15, 2005.

22 Towers Perrin, 2004. “Workers’ Compensation Ter-rorism Reinsurance Pool Feasibility Study,” March.

23 Ibid. 24 Roberts K. “U.S. lawmakers differ in terror insur-

ance approach,” Reuters News, March 17, 2005. 25 Hartwig RP. 2003-Year End Results. New York: Insur-

ance Information Institute, 2003.http://www.iii.org/media/industry/finan-cials/2003yearend/ (accessed November 18, 2010).

26 U.S. Central Intelligence Agency. The World Factbook:The United States. Washington, D.C.: U.S. Central In-telligence Agency. https://www.cia.gov/library/publications/the-world-factbook/geos/us.html (ac-cessed July 20, 2010).

27 Estimates based on: Bureau of Labor Statistics. Occu-pational Outlook Handbook, 2010-11, Agricultural Work-ers, Other http://www.bls.gov/oco/ocos349.htm(accessed July 20, 2010) and Food Preparation andServing Related http://www.bls.gov/oco/ocos162.htm; http://www.bls.gov/oco/ ocos331.htm#out-look; http://www.bls.gov/oco/ocos 330.htm#emply(accessed July 20, 2010); and Current Population Sur-vey, U.S. Department of Labor, U.S. Bureau of LaborStatistics. “Labor Force Statistics from the CurrentPopulation Survey -- Table 13. Employed Persons byIndustry and Sex, 2007 and 2008 Annual Averages.”http://www.bls.gov/cps/wlftable 13.htm (accessedJuly 20, 2010).

28 Campbell D. “The Foot and Mouth Outbreak, 2001:Lessons Not Yet Learned,” ESRC: BRASS WorkingPaper, 2001.

29 Ekboir JM. “Potential impact of foot-and-mouth dis-ease in California: the role and contribution of ani-mal health surveillance and monitoring services.”University of California, Davis, Agricultural IssuesCenter, 1999.

30 The National Creutzfeldt-Jakob Disease SurveillanceUnit, data. http://www.cjd.ed.ac.uk/figures.htm

31 CIDRAP, University of Minnesota, 2003. “Overviewof Agricultural Biosecurity,” Working Paper, March.

32 Israel cuts back orange exports by about 40% follow-ing discovery of poisoned oranges.” New York TimesAbstracts, February 10, 1978.

33 World Horticulture Trade and US Export Opportunities: Situ-ation and Outlook for Citrus. Washington, D.C.: UnitedStates Department of Agriculture, September 2004.

34 US Citrus Exports Economic and Market Research ReportNumber Ex-04-12. Florida Department of Citrus,February 17, 2005.

35 Mitchell, M., et al. “The Impact of External Partieson Brand-Name Capital: The 1982 Tylenol Poison-ings and Subsequent Cases.” October 1989. 27; 4:601-618.

36 World Health Organization, data.http://www.who.int/csr/sars/country/table2004_04_21/en/ (accessed November 19, 2010).

37 Bio Economic Research Associates. SARS and theNew Economics of Biosecurity. 2003.

38 CIDRAP. “Overview of Agricultural Biosecurity.”Working Paper, University of Minnesota, March 2003.

39 Trust for America’s Health. “Pandemic Flu and thePotential for U.S. Economic Recession.” March 2007.

40 Watson, T. “Oil Spill Kills Jobs, Shrinks Incomesand Hurts Industry.” USA Today. August 5, 2010.http://www.usatoday.com/money/economy/2010-08-04-oil-spill-economic-impact_N.htm (accessedNovember 19, 2010).

41 Institute of Medicine (IOM). The Future of the Public’sHealth in the 21st Century. Washington, D.C.: NationalAcademies Press, 2002.

42 Lav I. and McNichol E. “Fiscal Year Brings No ReliefFrom Unprecedented State Budget Problems.”Center on Budget and Policy Priorities, September2009. http://www.cbpp.org/cms/index.cfm?fa=view&id=711. (accessed September 14, 2009).

43 Johnson N, Oliff P, and Williams E. “An Update onState Budget Cuts: At Least 46 States Have ImposedCuts That Hurt Vulnerable Residents and the Econ-omy.” Center on Budget and Policy Priorities, Au-gust 4, 2010. http://www.cbpp.org/files/3-13-08sfp.pdf (accessed August 10, 2010).

44 U.S. Centers for Disease Control and Prevention. “Syn-dromic Surveillance: an Applied Approach to Out-break Detection.” http://www.cdc.gov/ncphi/disss/nndss/syndromic.htm (accessed November 19, 2009).

45 Buehler JW, Sonricker A, Paladani M, Soper P, andMostashari F. “Syndromic Surveillance Practice inthe United States: Findings from a Survey of State,Territorial, and Selected Local Health Departments.”Advances in Disease Surveillance 6, no. 3 (2008): 1-20.

46 U.S. Centers for Disease Prevention and Control.Public Health Preparedness: Strengthening the Nation’sEmergency Response State by State. Atlanta, GA: CDC,2010, p. 163.

47 Save the Children. A National Report Card on Protect-ing Children during Disasters. Washington, D.C.: Savethe Children, 2010.

48 U.S. Centers for Disease Control and Prevention.“The Laboratory Response Network: Partners in Pre-paredness -- History.” http://www.bt.cdc.gov/lrn/.(accessed November 18, 2010).

49 Association of Public Health Laboratories. “PublicHealth Laboratories: Diminishing Resources in anEra of Evolving Threats.” June 2010.http://www.aphl.org/aphlprograms/ep/ahr/Docu-ments/DiminishingResourcesEvolvingThreats.pdf(accessed December 6, 2010).

50 Association of Public Health Laboratories. “Labora-tories Must Be Able to Transmit Test and ResultData Electronically.” Fact Sheet 2009.http://www.aphl.org/policy/facts/Documents/LIMSFactSheet2009.pdf (access December 6, 2010).

50

51

51 Parker GW. HHS Update on the Advanced Developmentand Procurement of Medical Countermeasures, Statement be-fore the Committee on Homeland Security, Subcommittee onEmerging Threats, Cybersecurity, and Science & Technology,U.S. House of Representatives. Washington, D.C.:U.S. Department of Health and Human Services,2007, http://www.hhs.gov/asl/testify/2007/04/t20070418b.html (accessed September 12, 2007).

52 Ibid.53 Ibid.54 U.S. Department of Health and Human Services.

Fiscal Year 2010 Public Health and Social Services Emer-gency Fund Justification of Estimates for AppropriationsCommittees. Washington, D.C., U.S. DHHS, 2009.http://www.hhs.gov/asrt/ob/docbudget/2010phssef.pdf, p. 53. (accessed October 6, 2009).

55 Ibid.56 Ibid.57 U.S. Centers for Disease Control and Prevention.

“Q&A Sheet.” July 29, 2010.58 U.S. Centers for Disease Control and Prevention. “Es-

timates of Deaths Associated with Seasonal Influenza --United States, 1976-2007.” MMWR. August 27, 2010/ 59(33);1057-1062. http://www.cdc.gov/mmwr/pre-view/mmwrhtml/mm5933a1.htm?s_cid=mm5933a1_e%0d%0a (accessed August 31, 2010).

59 Li C, and Freedman M. “Seasonal Influenza: AnOverview.” J Sch Nurs. 2009 Feb;25 Suppl 1:4S-12S.

60 Homeland Security Council. Homeland Security Presi-dential Directive/HSPD 21: Public Health and Medical Pre-paredness. Washington, D.C.: The White House, 2007.

61 Ibid.62 HealthReform.gov. “Affordable Care Act: Laying the

Foundation for Prevention.” http://www.healthre-form.gov/newsroom/acaprevention.html (accessedOctober 14, 2010).

63 U.S. Department of Health and Human Services.Fiscal Year 2011 Centers for Disease Control and Preven-tion Justification of Estimates for Appropriations Commit-tees. Washington, D.C., U.S. DHHS, 2010, p. 281.http://www.cdc.gov/fmo/topic/Budget%20Infor-mation/appropriations_budget_form_pdf/FY2011_CDC_CJ_Final.pdf. (accessed October 14, 2010).

64 Ibid.65 Ibid.66 Association of Schools of Public Health. “Con-

fronting the Public Health Workforce Crisis: ASPHStatement on the Public Health Workforce.” 2008.http://www.asph.org/document.cfm?page=1038(accessed December 2, 2010).

67 Association of State and Territorial Health Officials.“2007 State Public Health Workforce Survey Results.”2007. http://biotech.law.lsu.edu/cdc/astho/Work-forceReport.pdf (accessed December 2, 2010).

68 Korade M. “$1.9 Billion Put Toward Countermea-sures for Bioterrorism, Pandemics.” CongressionalQuarterly, August 19, 2010.

69 President’s Council of Advisors on Science andTechnology. Report to the President on Reengineering theInfluenza Vaccine Production Enterprise to Meet the Chal-lenges of Pandemic Influenza. Washington, D.C.: TheWhite House, August 2010.

70 Agency for Healthcare Research and Quality. Ad-dressing Surge Capacity in a Mass Casualty Event.Bioterrorism and Health System Preparedness, Issue BriefNo. 9. U.S. Department of Health and Human Serv-ices. http://www.ahrq.gov/news/ulp/btbriefs/bt-brief9.htm (accessed October 22, 2008).

71 U.S. Department of Health and Human Services. Fis-cal Year 2011 Public Health and Social Services EmergencyFund Justification of Estimates for Appropriations Commit-tees. Washington, D.C., U.S. DHHS, 2010, p. 32.http://dhhs.gov/asfr/ob/docbudget/2011phssef.pdf. (accessed October 14, 2010).

72 See Hospitals Rising to the Challenge: The First Five Yearsof the U.S. Hospital Preparedness Program and PrioritiesGoing Forward (Evaluation Report, March 2009).Eric Toner, MD, Principal Investigator; RichardWaldhorn, MD, Co-Principal Investigator.http://www.upmc-biosecurity.org/website/re-sources/publications/2009/2009-04-16-hppreport.html (accessed December 2, 2010). Fri,24 Apr 2009 16:16:23 GMThttp://www.upmc-biose-curity.org/website/resources/publica-tions/2009/2009-04-16-hppreport.html

73 See The Next Challenge in Healthcare Preparedness: Cata-strophic Health Events (January 2010). Eric Toner, MD,Principal Investigator; Richard Waldhorn, MD, Co-Principal Investigator. http://www.upmc-biosecu-rity.org/website/resources/publications/2010/2010-01-29-prepreport.html (accessed December 2, 2010).

74 National Commission on Children and Disasters.2010 Report to the President and Congress. AHRQ Publi-cation No. 10-M037. Rockville, MD: Agency forHealthcare Research and Quality. October 2010.http://www.ahrq.gov/prep/nccdreport/ncc-dreport.pdf (accessed November 17, 2010).

75 Pastor M, et al., In the Wake of the Storm: Environment,Disaster, and Race after Katrina, New York: RussellSage Foundation (2006); A. Fothergill, E.G. Maestasand J.D. Darlington, “Race, Ethnicity and Disastersin the United States: A Review of the Literature, Dis-asters 23, no.2 (1999).

76 Nunez-Alvarez A, Martinez K, Ramos M, andGastelum F. San Diego Firestorm 2007 Report: Fire Im-pact on Farmworkers and Migrant Communities in NorthCounty, 2007. National Latino Research Center, Cali-fornia State University, San Marcos.http://www2.csusm.edu/nlrc/publications/Re-ports/NLRC%20Wildfires%20Report%202007%20Rev.pdf. (accessed October 18, 2010).

77 Centers for Disease Control and Prevention.“Deaths Related to 2009 Pandemic Influenza A(H1N1) Among American Indian/Alaska Natives—12 States,” 2009. Morbidity and Mortality Weekly Report,December 11, 2009 / 58(48); 1341-1344.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5848a1.htm. (accessed October 18, 2010).

78 Ravitz J. “Vietnamese Fishermen in Gulf Fight toNot Get Lost in Translation.” CNN, June 25, 2010.http://www.cnn.com/2010/US/06/24/viet-namese.fishermen.gulf.coast/index.html?hpt=C1.(accessed October 18, 2010).

79 Andrulis DP, Siddiqui NJ, Purtle JP, and Duchon, L.Patient Protection and Affordable Care Act of 2010: Ad-vancing Health Equity for Racially and Ethnically DiversePopulations, July 2010. Washington, D.C.: Joint Centerfor Political and Economic Studies. http://www.joint-center.org/hpi/sites/all/files/PatientProtection_PREP_0.pdf. (accessed October 18, 2010).

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