Public Health - State, Local, Federal
Baseline Activities
DISSUADE DENY DETECT DEFEND Cross-Cutting
Root Causes Establish Norms Encourage norms Enforce norms Info Materiel Equipment Access People Capabilities Plans Agents Disease Source Protection Incident Management (IM) Plans IM Capabilities/ Resources Counter- measures Remediation
                                         
Communities S/L/F Public Health         * CDC regulates select agents for use in laboratories, but this is a new area.             * Historically, US public health has focused on early detection of a biological threat rather than on consequence management of positive signals.
* Data sharing and reporting policies are being pursued with much more urgency.
* DHS and DHHS authority to compel S/L to perform disease surveillance or collect health intelligence remains unclear, especially if not due to Federal investment.
* BioSense and BioWatch assume that consequence management is in place to respond to a positive signal.  This is not the case.  No systems answer the question, "what happens when we see something happening?"
* Biowatch (DHS/CDC) has placed environmental sensors in 30 major metro areas.  Monitored by the health department and contract staff, as well as EPA employees. 
* US Postal Service and Private Mail Facility Bio-Detection Systems (BDS) are in several postal facilities to detect anthrax spores.  Some private industries have them too.  Little guidance from USPS on how local PH would get involved.
* Major technological and operational challenges for detection and post-detection response		 * DHS and DHHS authority to compel S/L to perform disease surveillance or collect health intelligence remains unclear, especially if not due to Federal investment.
* BioSense and BioWatch assume that consequence management is in place to respond to a positive signal.  This is not the case.  No systems answer the question, "what happens when we see something happening?"
* There has been significant investment in etection technologies
* Data sharing and reporting policies are being pursued with much more urgency.
* In many areas, private healthcare systems are not required to be connected to the government - this connection may even be discouraged
* Federal investment in disease detection is recent and focused on technological challenges of detection.
* Government role up to now has been to report health statistics; not monitor real-time information or coordinate detection systems
* Laboratory Response Network (LRN) is CDC-sponsored and links S/L laboratories to share data and request reagents.
* BioSense (CDC) links local health facility clinical data w/ local PH surveillance data to detect disease outbreaks.  One goal is to create a national disease intelligence center in the CDC to constantly monitor data.
* Local or State-Based syndromic surveillance systems - many local PH departments have them, but specifics on monitoring and effectiveness is beyond scope of paper
* Federal Quarantine stations exist through CDC at airports and harbords, but links to S/L have not been articulated, and capacity for disease detection is unclear.
* Major technological and operational challenges for detection and post-detection response
   * Health Resources and Service Administration (HRSA) provides preparedness resources to hospitals
* DHS and DHHS provide most money to states and localities for PH preparedness and response		 * L/S/Fed pub health agencies have spent much time planing for post-release intervention, treatment, and messaging.  A number of federal programs exist to assist local PH (focused on urban areas and directed through CDC). 
* Mass prophylaxis distribution and mass vaccination plans have been major efforts.
* Accepted need for PH and DHS to cooperate on natural disasters, large scale infectious disease outbreaks; other than that, major challenge is to integrate PH and HLS programs.
* Some limited, focused planning between public health and private health care entities
* Weak relations and continuing opposition to public health partnerships w/ national security agencies, the military, and "traditional" first responders.  PH receives "need to know" information but rarely brought into HLS briefings, HSC updates, or other national-level health intelligence communications.
* Very little information shared regarding bioterrorism between S/L/Fed agencies. 
* Agency for Healthcare Research and Quality (AHRQ) researches effective healthcare practices
* CDC has no official regulatory authority; cannot compel S/L health departments to take specific PH actions
* DHHS and its Office of Emergency Preparedness (OEP) operate most agencies mentioned here and support infrastructure of regional emergency coordinators and medical materiel.
* Agencies operate independently of DHS, EPA, Dept of Agriculture and DOD.  Very little integration of PH with military intelligence.
* Justification for federal initiatives is often not given clearly and based on abstract notions of threat.
* Many tabletop scenarios and drills at all levels.  Growing number of PH exercise developers.  Increased work on best practices.
* NACCHO's Project Public health Ready is one that uses peer-developed preparedness criteria to recognize readiness and excellence in planning, training, adn demonstration.  It's the only national program to recognize PH preparedness activities nationawide.
* Several programs exist to develop preparedness metrics.  Four major efforts:  Project Public health Ready, DHS efforts through its Target Capabilities Listing and National Preparedness Goal, CDC Health Protection Goals, and CDC S/L PH Preparedness Performance Metrics.  These are all in progress but no definitive set of measures has been used to assess preparedness nationwide.
 * Local PH departments are a "safety net" or "provider of last resort"
* CDC is technically advisory; cannot order quarantine (only S/L can do this).
* Centers for Medicaid and Medicare Services (CMS) reimburse healthcare providers for certain procedures in certain populations
* Core business of public health is PH nursing and enivronmental health services, not BTR
* DOD is engaged in planning for domestic PH emergencies (a new area for the military), but use of DOD resources adds level of complexity to S/L planning.
* A clear handoff of an escalating event from local->state->regional->national response is not likely.  There is not enough operating knowledge of available local resources, nor is there likely to be clear signals that more resources are necessary, nor adequate situational awareness to deploy resources effectively and as needed.
* More resources need to be invested in S/L intervention planning and communication, training, and coordination among emergency management, PH, and medical care sectors.
* No ISAC for health intelligence or info-sharing with PH and healthcare.  Few HLS intel analysts with PH training.
* CDC has a Health Alert Network and Epidemic Intelligence Exchange (Epi-X) system, but these do not convey secret or classified information.
 * Failed plan to vaccinate HCW against smallpox:  unresolved liability issues, poor information about side effects, perception of likelihood of attack, low trust of DHS.  Program was waged without appropriate buy-in from the PH and medical communities.
* Difficult cooperation for nongovernmental entities during an emergency - excess capacity is not rewarded in day-to-day system.
* CDC maintains SNS but S/L are tasked to develop dispensing plans once requested.
* FDA regulates and approves food, drugs, medical devices
* Much time spent at all levels developing mass prophylaxis distribution and vaccination plans, including to workplaces and private residences.
* Project BioShield stimulated industry research, but few of these resources assure that PH and medical professionals are available to administer the countermeasures.
 * Conflicting information on remediation of sites during Anthrax attacks led to massive distrust of government response and lack of federal credibility.   *Much work remains to be done in all categories of "defend"
                                     
Hospital/Medical                                      
                                     
Law Enforcement                                       
                                     
Emergency Management/ Fire                                      
                                     
Biotech Industry                                      
                                     
Science Community                                      
                                     
Military/Defense                                      
                                     
Arms Control                                      
                                     
Federal Government                                      
                                     
Federal Legislative Bodies                                      
                                     
International Public Health                                      
                                     
International Organizations                                      
                                     
KEY: SOURCES :
  BASELINE ACTIVITIES 1.  Libbey, Patrick.  Public Health Preparedness at the Local, State, and Federal Level.
 
 
 
  GAPS