Department of Health and Human Services Centers for Disease Control and Prevention Agency for Toxic

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Department of Health and Human ServicesCenters
for Disease Control and PreventionAgency for
Toxic Substances and Disease Registry
NGA Regional Bioterrorism WorkshopCDC
Perspectives
Glen Koops, M.P.H. Associate Director for Field
Services Office of Terrorism Preparedness and
Emergency Response May, 13-14, 2004 San
Francisco, California

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Outline

• Strategic Overview
• Enhancing State Capacity
• State Activities
• Evaluation
• Workforce Issues
• Funding

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• Strategy

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All-Hazards Approach
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Dimensions of Public Health Readiness

1,000s 100,000s
Global
Command and control vital to assure containment
Activate community-wide mass care system manage
the dead
Manage high volume of data and information
Number of Cases
Deliver mass intervention call up reserve
workforce
Level of Effort
Resources
Communicate to stakeholders and public enhance
surveillance reporting
Report Mobilize Response Investigate
Prophylaxis
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Assess Diagnose Isolate Treat Manage
Local
Time
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Strategy DETECTION

• Early detection/warning is critical to allow for
  early intervention.
• The sooner we know the sooner we can intervene!

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Strategy DETECTION
Current State
Law Enforcement
Environmental (BioWatch)
DoD VA
Border States
Pharmacy Data
Schools
Public
Employers
Media
Cargo/ Imports
Laboratory
Immigration
Clinicians
First Responders
International
Vital Records
Veterinary
Quarantine Stations
Hospitals
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Strategy DETECTION
Key Services Efforts Detection
Desired State
DoD VA
Law Enforcement
Environmental (BioWatch)
Pharmacy Data
Border States
Public
Schools
Employers
Media
Cargo/ Imports
Laboratory
Immigration
Clinicians
First Responders
Hospitals
Veterinary
Vital Records
International
Quarantine Stations
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Strategy DETECTION

• Improving Connectivity for Diagnosis and
  Detection
• 24x7 Clinical Information Hotline Media and
  public outreach
• Clinician outreach and communication
  Blended-media educational programs
• Epi-X (2-way communication network) Other
  critical channels and audiences
• Health alerting MMWR Dispatch

• Quarantine Stations
• New York Chicago Miami Atlanta
• Los Angeles San Francisco Seattle
  Honolulu

• CDC Laboratories
• Biological Antimicrobial resistance assays
  Continuity of Operations Plan (COOP) Throughout
  Capacity, BSL-4 containment lab, scientific depth
• Chemical Rapid Toxic Screen (150 agents)
  Blood and Urine Samples State Labs

• Improving Laboratory Diagnosis and Detection
  Capabilities
• Smallpox Tularemia
• Anthrax Radiation
• - Plague
• Botulinum Toxin
• Chemicals in blood and urine

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Strategy DETECTION

• Laboratory Response Network (LRN)

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Strategy CONTAINMENT

• Strategic National Stockpile (SNS)
• Repository of antibiotics, chemical antidotes,
  antitoxins, life-support medications, IV
  administration, etc.
• Twelve, strategically located, 12-hour push
  packages
• Tailored Vendor Management Inventory (VMI)
• VMI deployable within 24 to 36 hours
• Technical Advisory and Response Unit (TARU)
  support

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Strategy CONTAINMENT

• Directors Emergency Operations Center (DEOC)
• 7,000 square feet 85 workstations 24x7 staff
  state-of-the-art communication technologies
• Emergency Communications System (ECS)
• Concept of Operations based on ICS Model
• Continuity of Operations Plan (COOP)
• Deployable Emergency Response Assets

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Strategy CONTAINMENT

• Environmental Microbiology
• Water safety research
• Detection and survival of select bacterial
  agents research
• Research on remediation of environments and
  facilities
• Exotic bacterial data collection with respect
  to the environment
• Development of lab sampling methods and
  processes
• Studies on the effect of common disinfectants
  on these agents

• Smallpox Readiness
• Vaccination of the medical frontline
  (healthcare, public health, etc.)
• Pending licensed vaccine (for those who insist)
• Early detection capacity
• Rapid control and containment plans
• Vaccination of population within 10 days

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• CDC Efforts to
• Enhance State Capacity

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CDC Efforts to Enhance State Capacity

• Cooperative Agreement for 62 state, major city
  and territory health departments expands
  epidemiology and surveillance capacity to detect,
  investigate, and mitigate health threats. (2
  billion invested to date)
• 31 Centers for Public Health Preparedness
  assisting state and local public health emergency
  preparedness by improving the quantity and
  quality of the public health and healthcare
  response workforce.
• Increasing the number of state and local public
  health professionals (1,886) who use Epi-X to
  share intelligence regarding outbreaks and other
  emerging health events including those suggestive
  of bioterrorism.
• Rapid assessment of surveillance capacities in 8
  priority cities.
• Forensic Epidemiology training sessions for
  public health and law enforcement professionals.

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• State Activities

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State Activites Progress Report

• Statutes and ordinances, timelines and
  assessments - updated
• 24x7 system to receive and evaluate urgent
  disease reports
• in place 49/50 have systems in place
• Epidemiologic capacity enhanced
• Information technology to assure rapid detection
  and reporting improving (i.e. BioWatch)
• Effective working relationships between clinical
  and higher-level laboratories
• Ongoing education and training of front-line
  public health and healthcare responders to assure
  recognition of the early signs and symptoms of
  unusual health events

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State Activities -- Progress Report

• State and Local Cooperative Agreement Program
• 90 of states have response plans for
  anthrax(78 exercised)
• 100 for smallpox (86 exercised)
• 90 for plague (76 exercised)
• 85 for botulinum toxin (46 exercised)
• 92 for RDD/Nuclear events (91 exercised)
• 75 for Nerve Agents (70 exercised)
• 25/50 completed their state-wide response plans
• 50/50 completed their interim SNS plans work
  needed!

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• Site visits by senior CDC management to
• Florida
• Nebraska
• New Hampshire
• New York State
• Texas
• Washington State

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• Florida
• Developed critical institutional partnerships
  that will enable long-term readiness that is not
  dependent on current leaders
• Investment in electronic disease mgmt system that
  will link disease detection-laboratory
  diagnosis-outbreak investigation-analysis.
• Trained 500 lab staff in procedures for
  handling/transfer of critical agents
• Conducted 4 exercises in collaboration with FBI ,
  HAZMAT, state/local law enforcement and
  fire/rescue
• Emphasis on strong corrective action process
  following exercises
• Vaccinated 4,000 persons who will implement mass
  smallpox vaccination, investigate cases and
  manage patients.

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• New York State
• Contracts with local health depts have clear
  deliverables that cover all aspects of
  preparedness and response
• Protocols for isolation and quarantine
• Packaging/transport of lab samples
• Processes for rapid diagnoses and agent
  confirmation
• Plans to ensure rapid control and containment
• Training of staff and reserve staff as events
  scale up
• Plan linkage with state and regional plans
• Partnerships with State Medical Society, Nurses
  Assoc, Healthcare Association, Community Health
  Center Assoc, Hospital Assoc, etc.
• Developed sophisticated electronic communicable
  disease reporting and laboratory information
  systems
• Can test for critical agents Variola major,
  vaccinia, tularemia, bot toxin, ricin toxin,
  brucellosis, glanders, Q fever

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• Texas
• Partnerships include 12 Metropolitan Medical
  Response Systems, 22 councils of Governments,
  US-Mexico Border Health Commissions, FBI and
  state/local law enforcement
• 3-member epidemiologic response teams assigned in
  each of the 8 regions
• Relationships with 138 labs
• Trained 60 Texas Medical Rangers a reserve
  corps of the Texas State Guard through the
  Center for Public Health Preparedness and
  Biomedical Research at UT-HSC in San Antonio.
  Plan to train a total of 1000
• Conducted exercises to test ability to receive
  and distribute the SNS
• Pre-event smallpox preparedness program
  vaccinated over 4,000 hospital and public health
  staff

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• Washington
• Assessed all local health jurisdictions and
  hospitals to determine emergency preparedness and
  response capacity
• Expanded public health workforce at the district
  level
• A new emergency response planners in each of the
  9 districts
• 9 new learning specialists to coordinate and
  evaluate preparedness training
• 17 new epidemiology response and surveillance
  coordinators
• Critical preparedness capacities are included in
  the comprehensive public health improvement
  planning process result is performance-based
  and outcome-driven planning

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• EVALUATION

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• Project to Define Performance Goals and
  Indicators . . .
• Define what good looks like
• Culmination year of work
• Input from SMEs, Academics, Public Health
  Partners, other stakeholders
• Validated information with extensive literature
  search

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• Project to Define Performance Goals and
  Indicators . . .
• Performance Goals based on preparedness
  principles
• Systems are connected pieces
• Planning should be supported by evidence
• Focus is State support of a local response

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• Project to Define Performance Goals and
  Indicators . . .
• Evidence based approach focuses on areas that the
  literature indicates that there are problems

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• Project to Define Performance Goals and
  Indicators . .
• Result
• 42 Performance Goals
• 47 Indicators

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• Example
• Performance Goal 2
• Internal Agency Staff Awareness of Public Health
  Role and of Other Community Responder Roles

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Example Measure 2 Percent of a random sample
of Public Health Agency staff that have response
roles can

• Describe their job functions during a response
  AND the description matches the employees role
  and responsibilities as written in the Agencys
  plan and the jurisdictions plan
• Show documentation of training jointly with
  response partners whom they are likely to
  interact with as they carry out disaster role
  functions
• Describe the role and responsibilities of
  response partners whom they are likely to
  interact with as they carry out disaster role
  function
• Identify by name and/or job title whom they
  report to in a disaster
• Demonstrate the correct use of equipment used in
  their emergency job function (e.g., conferencing
  equipment, blackberries, blast faxing, two-way
  radios)

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Next steps

• Field Test to provide input on validity,
  reliability, and feasibility
• Oklahoma
• Florida
• Washington
• Massachussets
• Chicago

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Next steps

• Determine appropriate method/resources needed to
  test progress to goal
• Random testing (who, how often)?
• Self-reporting?

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Exercises

• System to design and proctor exercises
• Conduct performance-based, interactive exercises
• Develop system to identify, collect and analyze
  information about exercises
• Develop recommendations for change

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Exercises

• CDC is working with various agencies to provide
  opportunities to exercise public health systems
• NCEH
• ODP
• Performance Goals

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Exercises

• National Center for Environmental Health
• Scenario and exercise development, implementation
  and evaluation
• 16 grantees annually
• Including injects that will measure performance
  goals
• Including activities that test Incident Command
  principles

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Exercises

• Office of Domestic Preparedness
• Will test every grantee (DHS) yearly
• Working with NCEH to assure PH components are
  tested with traditional first responder activities

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• Workforce

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Workforce Activities
Detection Reporting
Response Containment
Recovery
Preparedness

• Contact tracking
• Education
• Quarantine
• Response Coordination
• Communicating with Clinicians, Public Health
  the General Public
• Developing Interventions Therapies

• Planning
• Exercising
• Partnering
• Training
• System Building
• Testing

• Surveillance
• Clinician Training
• Laboratory Diagnostics
• Electronic reporting systems

• Monitoring community mental health
• Applying Lessons learned to continuously improve
  Response Containment

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• Background
• State and Local authorities concern over their
  ability to recruit, hire, train, and retain
  qualified personnel to rapidly build public
  health preparedness systems
• Assignment of CDC staff has been a successful
  model for CDC to assist state and local agencies
  with program planning and implementation

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• New CDC Initiative (Public Health Readiness Field
  Program to increase CDC field presence to . . .
• 1. Rapidly enhance preparedness of state, local
  and territorial public health agencies
• 2. Improve CDCs ability to respond to terrorism
  and other urgent health threats
• 3. Address the long-range need for public health
  leaders at federal, state and local levels

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• Ideas we are exploring . . .
• Multidisciplinary and multi-level assignments
• Strong training component Preparedness Boot
  Camp
• Assignments within State/Territorial and Local
  public health agencies
• Foster the dual use concept
• Mitigate the silo-effect of categorical programs
  at federal, state, and local levels
• Cross-train all CDC assignees so that all have a
  Readiness Role
• Pilot Project to out-place Senior Management
  Officials to improve coordination of Disease
  Prevention/Health Promotion/Community Protections
  grants, cooperative agreements and other CDC
  activities
• Emphasize BT while also support an all-hazards
  approach
• Make a dent in long range public health work
  force needs

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• FUNDING

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Funding
FY04 Appropriation by Budget Line (1.16
Billion) (compared with 1.54 Billion in FY03)
The appropriation amount of 1.16 billion does
not include the rescission and indirect costs.
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Funding
FY04 Funding Upgrading State and Local Capacity

• Bioterrorism Cooperative Agreement 872 Million
• Centers for Public Health Preparedness 29.4
  Million
• Advanced Practice Centers 5.5 Million
• Technical Assistance and Oversight 17.9
  Million
• Epidemic Intelligence Exchange (Epi-X) - 1.8
  Million
• Cooperative Agreement Technical Assistance
  13.8 Million
• Public Health Field Readiness Program 2.2
  Million
• Health Alerting 9.4 Million

Total 934.4 Million
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Funding

• Funding Concerns
• 80 unobligated reported on FSRs (11/1/03)
• Draw-down lag
• Supplanting
• Allocation formula change?