december 2012 ready or not report

7/30/2019 December 2012 Ready or Not report

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2012

Issue RepoRt

December 2012

Preventing ePidemics.

Protecting PeoPle.

Ready or Not?pRotectIng the publIcs health FRomDIseases, DIsasteRs,

anD bIoteRRoRIsm


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tFah boaRD oF DIRectoRs

Gail Christopher, DN

President o the Board, TFAH

Vice PresidentProgram Strategy

WK Kellogg Foundation

Cynthia M. Harris, PhD, DABT

Vice President o the Board, TFAHDirector and Proessor

Institute o Public Health,

Florida A&M University

Theodore Spencer

Secretary o the Board, TFAH

Senior Advocate, Climate Center

Natural Resources Deense Council

Robert T. Harris, MD

Treasurer o the Board, TFAH

Former Chie Medical Ocer and Senior Vice

President or Healthcare

BlueCross BlueShield o North Carolina

David Fleming, MD

Director o Public Health

Seattle King County, Washington

Arthur Garson, Jr., MD, MPH

Director, Center or Health Policy, University

Proessor, And Proessor o Public Health Services

University o Virginia

John Gates, JD

Founder, Operator and Manager

Nashoba Brook Bakery

Alonzo Plough, MA, MPH, PhD

Director, Emergency Preparedness and Response

Program

Los Angeles County Department o Public

Health

Eduardo Sanchez, MD, MPH

Chie Medical Ocer

Blue Cross Blue Shield o Texas

Jane Silver, MPH

President

Irene Diamond Fund

RepoRt authoRs

Jerey Levi, PhD.

Executive Director

Trust or Americas Health and

Associate Proessor in the Department o

Health Policy

The George Washington University Schoolo Public Health and Health Services

Laura M. Segal, MA

Director o Public Aairs

Trust or Americas Health

Dara Alpert Lieberman, MPP

Senior Government Relations Manager


Kendra May, MPH

Albert Lang

Communications Manager


Rebecca St. Laurent, JD

Health Policy Research Manager


peeR ReVIeWeRs

TFAH and thanks reviewers or their time, ex-

pertise and insights. The opinions expressed in

the report do not necessarily represent the views

o these individuals or their organizations.

Gerrit Bakker

Senior Director, Preparedness Planning andResponse

Association o State the Territorial

Health Ocials

James S. Blumenstock

Chie Program Ocer, Public Health Practice

Association o State and Territorial

Health Ocials

Leah McCall Devlin, DDS, MPH

Former State Health Director o the Department

o Health and Human Services in North Caro-

lina, and Gillings Visiting Proessor

University o North Carolina Gillings

School o Public Health

Jonathan Fielding, MD, MPH

Director and Chie Health Ocer

Los Angeles County Department o

Public Health

Irwin Redlener, MD

Clinical Proessor o Population and Family Health

Columbia University, Mailman School o

Public Health and

Director

National Center or Disaster PreparednessSenior Sta

Center or Biosecurity

University o Pittsburgh Medical Center

This report is supported by a grant rom the

Robert Wood Johnson Foundation. The

opinions expressed in this report are those o the

authors and do not necessarily refect the views

o the oundation.

acKnoWleDgements

trustforAmericAs HeAltHisanon-profit, non-partisanorganizationdedicatedtosavinglivesby

protectingthehealthofeverycommunityandworkingtomakediseasepreventionanationalpriority.

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iri, vii www.rwj.r. Fw Fdi twir www.rwj.r/wir r Fk www.rwj.r/k.


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Introduction

S

eptember 11, 2001 and the anthrax tragedies were a wake-up call to the

country. One o the things that caught the country o-guard was how limited

public health emergency preparedness was in the United States.

Since then, there have been ongoing remindersabout why it is essential to maintain the ability torespond to health needs during major incidents,like Superstorm Sandy or the H1N1 pandemic fuoutbreak. But what has become equally evident isthe number o health threats in the realm that wecan anticipate but we are not suciently preparedto address as a nation. In addition to extremeweather events and oodborne illnesses like Salmo-nellaandE.coli, we have suered a deadly rise o

West Nile virus, a ungal meningitis outbreak and aresurgence o old diseases we thought were largelyconqueredlike whooping cough and tuberculo-sisall in an era o growing antibiotic resistance.

In addition, we have learned lessons about theneed to coordinate eorts and partners acrossa range o sectors or preparedness to be eec-tive. Preparedness requires public health o-cials, health care providers (including hospitals,primary care providers and institutional care a-cilities), police, reghters, EMS and other emer-gency personnel, the intelligence community,

poison control centers, business, transportation,human services, housing ocials, elected o-cials, community and aith-based groups, schoolsand a host o other groups to work together, com-municate and build common goals and strategies.

The importance o being prepared or catastro-phes cannot be diminished, but, as a country,we have not paid sucient attention to the ev-eryday threats that public health departmentsand health care providers ace repeatedly.

The good news is that considerable progresshas been made to eectively prepare or and

respond to public health emergencies o alltypes and sizes and much o what it takes toprepare or bioterrorism or major disasters isalso essential to respond to ongoing everydayhealth emergencies. The bad news is that theaccomplishments achieved over the past decadeto improve public health preparedness or allhazards are now being undermined due to se-vere budget cuts and lack o prioritization.

Since 2001, investments have led to major ac-complishments in preparedness planning andcoordination; public health laboratories; vaccinemanuacturing; the Strategic National Stock-pile; pharmaceutical and medical equipmentdistribution and administration; surveillance;communications; legal and liability protections;increasing and upgrading sta; and surge ca-pacity. However, major areas o vulnerabilityhave also persisted, particularly in biosurveil-

lance, providing mass care during emergencies,maintaining a stable medical countermeasure(MCM) strategy and helping communities learnhow to become more resilient and to cope withand recover rom emergencies.

Instead o building on the achievements andtackling the continuing concerns, the progresso the past 10 years is now at risk due to actorsincluding:

nOutdated Congressional Authority: Reautho-rization o the Pandemic and All-Hazards Pre-paredness Act o 2006 (PAPHA) [previously

known as the Public Health Security and Bio-terrorism Act o 2002] has languished in Con-gress or over a year;

nFederal Budget Cuts: Ater September 11th,it was widely recognized that there was nosystematic support or state and local com-munities to prepare or public health emer-gencies, and Congress acted quickly to llthat gap. These are the only unds dedicatedto help state and local health departmentswith the ability to prepare and respond to arange o health emergencies, including bio-

terror attacks, natural disasters, oodborneillnesses and emerging inectious diseases.From scal years (FY) 2005 to 2012, however,there has been more than a 38 percent cutto these ederal unds rom the U.S. Centersor Disease Control and Prevention (CDC)used to support state and local preparedness(adjusted or infation), and additional cutsare expected.

3


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nState Budget Cuts: 29 states have cut their publichealth budgets rom FY 2010-11 to FY 2011-12.Budgets in 23 states decreased or two or moreyears in a row, and budgets in 14 states decreasedor three or more years in a row. According toa survey by the Association o State and Territo-rial Health Ocials (ASTHO), 48 state healthagencies (SHAs) reported experiencing budget

cuts since 2008.1 According to the Center onBudget and Policy Priorities (CBPP), states haveexperienced overall budgetary shortalls o $540billion combined rom FY 2009 to FY 2012 and31 states have projected or closed budget gapstotaling $55 billion in FY 2013.2, 3

nJob and Program Cuts: State and local healthdepartments have cut more than 45,700 jobsacross the country since 2008.4 During 201157 percent o all local health departmentsreduced or eliminated at least one programEmergency preparedness was the hardeshitwith 23 percent o local health departments reporting a reduction.5

Every American deserves basic health protectionsand to live in a sae community. It is essential tomaintain basic, core preparedness and responsecapabilities to protect us rom unthinkable catastrophes and those we live with everyday.

Ready oR Not 2012

The Trust or Americas Health (TFAH) issuesthe Ready or Not?report annually to provide thepublic and policymakers with an independent

analysis about progress and vulnerabilities inthe nations public health preparedness. Thereport assesses the level o preparedness instates, evaluates the ederal governments roleand perormance, and oers recommendationsor improving emergency preparedness.

This report also aims to oster greater account-ability or how eectively taxpayer dollars areused to improve the nations readiness orhealth emergencies. Without transparency, itis hard or the policymakers to assess how wellprepared we are or the range o threats our

nation aces.

The report:

nInorms policymakers about the status o pub-lic health preparedness in the United States;

nProvides greater transparency or publichealth preparedness programs;

nEncourages greater accountability or thespending o preparedness unds; and

nRecommends ways to help the nation movetoward a strategic, capabilities-based system

able to respond eectively to health threatsposed by diseases, disasters and bioterrorism.

The 2012 edition o the Ready or Not? reportocuses on reviewing state and ederal publichealth emergency preparedness.

The report eatures indicators that provide acomposite snapshot o key areas o preparedness.The indicators are based on a range o prepared-ness concerns, refecting a broad denition o all-hazards emergency health preparedness. Manyo the indicators refect proxy measures or areaswhere direct measures are not available.

Scores are not intended to serve as a refection onperormance o specic state or local health departments, since they refect a much broader con

text, including resources, policy environmentsand health status o a community, and refecmany actors that are oten beyond the direct control o these departments. Rather, this report iintended to help identiy where sucient actionhas been taken to support adequate public healthpreparedness and where and how states could improve or overcome obstacles to an all-hazards approach to public health preparedness.

Over the course o 10 years, the set o indicatorseatured in the report has evolved to refect recenpriorities and concerns, and some indicators have

been retired when a large majority o states haveconsistently achieved the specic measure. TheReady or Not?report has documented signicanaccomplishments o states. For instance, all statehave developed preparedness plans and pandemicfu plans; nearly every state has shown signicantadvances in the ability to rapidly test or biologicaland chemical threats; all states and WashingtonD.C. have met CDCs evaluation standard or plansto receive and distribute supplies rom the Strategic National Stockpile; nearly every state now uses adisease surveillance system that is compatible withthe CDCs system and can send and/or receive

electronic health inormation with health careproviders; and all states and Washington, D.C. metthree key criteria or the Medical Reserve Corps.

The contents o the report include:

nSection 1: An examination o state-by-state public health preparedness, in which states are evaluated on 10 key preparedness indicators, basedon input and review rom public health experts

nSection 2: An examination o national policyissues and recommendations or improvingall-hazards and pandemic preparedness.

4


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5

Ready oR Not? 2012: Key FInDIngs

n 29 di r i r Fy2010-11 Fy 2011-12;

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n o i rr rrd

dr i i lrr R nwrkr ci tr (lRn-c) i ir a 10, 2011 a 9, 2012.


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7

State-by-State Public HealthPreparedness Indicators

and ScoresAll Americans have the right to expect undamental health protections duringpublic health emergencies, no matter where they live.To help assess health emergency preparedness,this section o the Ready or Not?report examinesa series o 10 indicators o preparedness in eachstate that, taken collectively, oer a compositesnapshot o strengths and vulnerabilities.

While ederal, state and local health departmentsand private health providers, particularly hospitals,all have roles to play in public health prepared-ness, states have primary legal jurisdiction andresponsibility or the health o their citizens.6 Inaddition, the ederal government provides und-ing or preparedness to states. Since the terroristattacks o September 11, 2001, the U.S. Depart-ment o Health and Human Services (HHS) hasprovided $9 billion in preparedness unding tostates and some major cities through CDCs PublicHealth Emergency Preparedness (PHEP) coop-

erative agreements and more than $4.6 billion tohelp improve the ability o hospitals and states toprovide medical care during emergencies throughthe Hospital Preparedness Program (HPP). In2012, these two major preparedness grant pro-grams were aligned to improve coordination andleverage resources. In addition, there are eorts atthe ederal level to continue to improve coordina-tion o preparedness programs across the FederalEmergency Management Agency (FEMA).

States dier in how they structure, deliver andund public health services, and dierent stateshave dierent strengths and vulnerabilities incapabilities. States with multiple, high-densityurban areas may unction very dierently thanthose with ewer residents spread across smallercities and towns.

1S e c T i o n

FeDeRal, state anD local publIc health JuRIsDIctIons

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This report was developed to provide taxpay-ers and policymakers with inormation abouthow well-prepared their states and communi-ties are or dierent types o health threats.The American people deserve to know howprepared their states and communities are ordierent types o health threats, particularlywhen their taxpayer dollars are being spent tosupport preparedness eorts. Currently, theAmerican public is not equipped with enoughinormation to monitor and hold public o-cials accountable or whether their communi-ties are adequately prepared.

Limited data is made publicly available to mea-sure public health preparedness. In act, de-spite nearly a decade o ederal public healthpreparedness unding to states and localities,reliable, valid perormance measures to evalu-ate emergency preparedness are not yet ullydeveloped, despite numerous commissions andstudies that were unded to create them.11, 12, 13

In September 2012, CDC issued its ourth report on states preparedness, Public Health Preparedness: 2012 State-By-State Report on LaboratoryEmergency Operations Coordination, and EmergencyPublic Inormation and Warning Capabilities, a ollow-up to their 2008 and 2012 reports on statespreparedness.14 The report diers rom theReady or Not?report in that it only reports ondata collected by CDC.

Following up on Congress expressed desire orCDC to continue to report state-by-state data, the

CDCs reports have been a step orward in improving accountability and transparencyallowingAmericans to see how their tax dollars are beingused to better protect their amilies and communities rom a range o health threats. However, the2012 report provided little detail about the ndings and measurement, and was limited to available data related to three o the 15 public healthpreparedness capabilities identied by CDC as thebasis or state and local preparedness.

8

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The Ready or Not? report compiles indicatorsbased on the best publicly available data or datareceived rom surveying states directly. Eachstate receives a score based on 10 key indica-tors. States receive one point or achieving an

indicator or zero points i they do not achievethe indicator. Zero is the lowest possible overallscore, and 10 is the highest. (For more inorma-tion, please see Appendix D: Data and Methodologyor State Indicators.)

9

DC

WA

NV

AZ

CO

NE

ND

MN

WI

IL

KY VA

NY

HI

MDDC

DENJ

NH

VT

MA

RICT

NC

LA

AR

MS AL

SD

KS MO

TN

GA

SC

FL

IN OH

WV

PA

ME

MIIA

OK

TX

NM

ORID

MT

WY

UT

AK

CA

8(5 stats)

7(10 stats)

6(15 stats)

5(13 stats& D.c.)

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10

STATe PrePAreDneSS ScoreS

Stats

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11

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The measures refect a broad deniton o all-hazards preparedness, including disease con-trol, response to manmade and natural disastersand bioterrorism. They also encompass a rangeo capabilities, policies and outcomes. Also, the2012 indicators refect an increasing emphasison the intersection o public health and healthcare services and cross-sector preparedness.

Low scores are not intended to lead to puni-tive actions. In act, scores are not intendedto serve as a refection on perormance o spe-cic state or local health departments, sincethey refect a much broader context, includ-ing resources, policy environments and healthstatus o a community, and refect many ac-tors that are oten beyond the direct controlo these departments. Rather, this report isintended to help identiy where sucient ac-tion has been taken to support adequate pub-lic health preparedness and where and how

states could improve or overcome obstacles toan all-hazards approach to public health pre-paredness. In addition, providing inormationabout which states have particular strengths al-lows others to know which states to turn to orbest practices and models to guide their ownpreparedness eorts.

The indicators in this report were selectedbased on:

n Refection o a undamental, systemic publichealth need;

n Consultation with key experts about areas important to serving basic public health emergency needs; and

n The availability o state level data which wereable to be veried through independentmeans or in consultation with states.

Based on only being able to use available, veriabledata, TFAH is only able to assess states compara-tively where there are data available or all 50 statesand DC. It is important to note that many statehave taken action and developed strengths inother areas o preparedness or may be in the process o increasing certain capabilities not refectedin this report that may be important or that state

Data rom these indicators were drawn rom a range

o publicly available sources, including CDC, a survey conducted by the Association o Public HealthLaboratories (APHL), Save the Children, KaiserFamily Foundation, Center or Climate and EnergySolutions, Emergency Management AccreditationProgram (EMAP), the National Council o StateBoards o Nursing, states public documents andinterviews with government ocials.

12

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13

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14

pResIDentIal polIcy DIRectIVe-8 anD natIonal health secuRItystRategy upDates

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5. t i dvd rr drd vr di , , ri d rriri iii.

I Dr 2009, hhs rd nih sri sr (nhss) v-iz r iiiz qid wi iif iid. tr i i di irii.19 I m 2012, hhs rd nhss Ii p, wi dri dird i rdr rijiv nhss, d idif riri

ii ivii, idi riird, wrd idivid d iid dvi d iii wrkrdd r i ri.20


15/80

a. 2012 Ready oR Not?state-by-state InDIcatoRs

15

idats What th idats masu

1. Fudg ctt Did ii r ir di r i rr r Fy 2010-2011 Fy 2011-12?

ti idir, djd r ii, dr i d ii d i rr, wir irrr dd dq rd ri.

2. rsps radss W i d idi (wii i 60 i) i r qik r iid i 2011?

t ii k dii kr qik ii r i i rii qik d iv dir rrd r wr r dd.

3. itus Dsas ctl ad

Vaats Did hhs vii 90 r 19- 35--d i wi ?

t ii rr vi i, riridr, i ir r r w w iv r d r vii i. t d r i ii i ifd dri i rii w i i r r d r r w i i

vid i w r i-iiv d.

4. itus Dsas ctl D rqir mdiid vr wi - r firi dr 65?

eii r r vii r r r i i r vi ari qik dri w dir d di rk. eiii - rmdiid firi i rir ir i

ari id w-i d vr i r qi .

5. ext Wath evt Ppadss D rr v i di ?

ci di id idi drdi d i r i idrid w wr r d r.

6. cuty rsly D d id id-r iii v i-zrd wri vi dri ?

hvi d i i r d idr d r vr i i ririr dri ri.

7. egy maagt h rdid emap?

ardii i ir r r i drdd ii i iii. s v rdid r emap vr, r-rviwd

r v k ri dr d rizd r i drd.

8. Halth Syst Ppadss D rii i nr lir c?

mi- ir ri i r r ii rir ir i ri, w i iir rri rid di d

vr r r jridii i r.

9. Pul Halth Laats Stag ad

Sug capaty D i rr rr vi fi wrk fv, 12-r d r i i wk i r ii dirk, v iz a h1n1,r a 10, 2011 a 9, 2012?

pi r r i didii i dri w r r rk d i iir v i i dri ri.

10. Pul Halth Laats ci

tr prrd Did i rr rr vi ird riid ir lrr R nwrkr ci tr (lRn-c) i iir a 10, 2011 a 9, 2012?

t ii v i d qik

i r i ir rd iv i r.


16/80

1. inDicATor: PUbLic HeALTH FUnDinG commiTmenT STATePUbLic HeALTH bUDGeTS

FinDinG: 29 stats ut udg pul halth FY 2010-11 t FY 2011-12.

Surc: Rsrch tFaH puic vi s ug cumns n inrviws wih hh n ug cis in h ss.

N: Fris dircr Hh n Surgn Gnr Jhn H. armsrng, Md, FaCS, FCCP n in his rviw ug mris h

Fri dprmn Hh hs h, n cninus hv, h rsurcs ncssr ccmpish cr puic hh uncins in Fri.

16

21 stats ad D.c. asd atadlvl udg pul halth svs FY 2010-11 t FY 2011-12

29 stats DecreASeD udg pul

halth svs FY 2010-11 t FY 2011-12

Stat ad pt as (adjustd fat)

Stat ad pt das (adjustd fat)

a (4.4%) ariz (-10.2%)âk (4.2%)2 ark (-2.1%)ciri (1.5%) crd (-3.9%)^ci (3.9%)2 Frid (-15.5%)2

Dwr (29.4%)2 Iii (-2.5%)^D.c. (15.6%) K (-6.0%)4, ^gri (1.2%) Kk (-2.9%)*hwii (0.1%)2 lii (-19.3%)Id (14.4%) mi (-7.7%)2, *Idi (32.9%) mrd (-1.3%)2,Îw (10.2%) mii (-18.4%)3

m (0.7%) miri (-2.8%)^mi (16.7%)2, 4 m (-21.0%)*miiii (0.1%)2 nrk (-2.5%)*nw yrk (5.3%) nvd (-5.1%)4^nr cri (2.1%)2 nw hir (-17.4%)*nth Dakta (21.9%)3 nw Jr (-1.3%)ôk (6.9%)1 nw mi (-9.1%)^s cri (0.2%) oi (-8.7%)

Vr (10.5%) og (-17.1%)^Wii (7.0%) pvi (-6.7%)2 ,^

Wyg (0.5%) Rd Id (-5.6%)^s Dk (-5.6%)4, *t (-3.5%)t (-7.3%)*

u (-9.5%)^Vga (-4.3%)3, ^Washgt (-0.2%)3, *W Virii (-6.3%) *

notes:

bii d r bolded.

1 m i i rvi rr, but not Medicaid or CHIP.

2 gr d .

3 bd d k r rrii ii.

4 s did rd d k tFah rdid wi astho w or 26, 2012. s wr iv

i nvr 16, 2012 fr r rr iri. t did r d wr d

i rd wi fdi.

* bd drd r d r i rw

^ bd drd r ird r i rw


17/80

This indicator, adjusted or infation, illustratesa states commitment and ability to provideunding or public health programs that sup-port the inrastructureincluding workorceneeded to adequately respond to emergencies.

Every state allocates and reports its budget indierent ways. States also vary widely in the

budget details they provide. This makes com-parisons across states dicult. For this analysis,TFAH examined state budgets and appropria-tions bills or the agency, department, or divi-sion in charge o public health services or FY2010-11 and FY 2011-12, using a denition asconsistent as possible across the two years, basedon how each state reports data. TFAH denedpublic health services broadly, including moststate-level health unding.

Based on this analysis, 29 states made cuts intheir public health budgets. Twenty-three statescut their budget or two or more years in a row,14 or three or more years in a row.

Public health unding is discretionary spend-ing in most states and, thereore, is at high riskor signicant cuts during economic down-turns. While ew states allocate unds directlyor public health preparedness, state and localunding is essential or supporting public health

inrastructure and core capacities o health de-partments. It is notable that several states thatreceived points or this indicator may not haveactually increased their spending on publichealth programs. The ways some states reporttheir budgets, or instance, by including ederalunding in the totals or including public healthdollars within health care spending totals, make

it very dicult to determine public health asa separate item.

Few states allocate unds directly or bioterror-ism and public health preparedness as part otheir public health budgets. Instead, most relyon ederal unds to support these activities. Theinrastructure o other public health programs(e.g. environmental health, immunization ser-vices, etc), however, also supports their underly-ing preparedness capabilities.

While this indicator examines whether statespublic health budgets increased or decreased,it does not assess i the unding is adequate tocover public health needs in the states. Thisalso does not take into account ongoing hospi-tal needs and unding.

For additional inormation on the methodologyo the budget analysis, please see Appendix D:Methodology or Select State Indicators.

17


18/80

Surc: U.S. Cnrs r diss Cnr n Prvnin21

2. inDicATor: reSPonSe reADineSS emerGencY oPerATionScoorDinATion cAPAbiLiTY

FinDinG: 47 stats ad Washgt, D.c. dstatd th alty t ty ad datly

assl (wth th gal t 60 uts) pul halth sta t su a quk sps t

a dt 2011.

18

47 stats ad Washgt, D.c. td adassld pul halth sta t su quksps t a dt 2011 (1 pt).

3 stats dd t ty ad assl pul

halth sta t su quk sps t a

dt 2011 (0 pts).a (18 i) ci (70 i)ak (58 i) hwii (221 i)ariz (43 i) nw yrk (72 i)ark (48 i)ciri (6 i)crd (10 i)Dwr (44 i)D.c. (30 i)Frid (53 i)gri (23 i)Id (5 i)Iii (25 i)Idi (23 i)Iw (55 i)K (56 i)Kk (14 i)lii (25 i)mi (26 i)mrd (18 i)m (22 i)mii (41 i)mi (45 i)miiii (11 i)miri (39 i)m (16 i)

nrk (45 i)nvd (14 i)nw hir (46 i)nw Jr (32 i)nw mi (32 i)nr cri (44 i)nr Dk (15 i)oi (56 i)ok (16 i)or (49 i)pvi (36 i)Rd Id (10 i)s cri (49 i)

s Dk (30 i)t (59 i)t (59 i)u (10 i)

Vr (30 i)Virii (26 i)Wi (8 i)W Virii (5 i)Wii (8 i)Wi (20 i)


19/80

This indicator examines which states were ableto assemble key decision-makers to lead andmanage a response within a goal time o 60 min-utes or less, which was set by CDC. In 2011, 47states met the 60-minute goal. Overall, stateswere able to assemble sta in a median time o30 minutes. The ability to assemble key deci-sion makers quickly is essential or public health

agencies to assess an emergency situation sothey can quickly and eectively direct resourcesand personnel where they are needed.

This indicator is based on one o the measureseatured in the Public Health Preparedness: 2012State-By-State Report on Laboratory, Emergency Op-erations Coordination, and Emergency Public Inor-mation and Warning Capabilitiesreport, issued byCDC in September 2012.22 The report ocuseson data collected by CDC.

In addition to the perormance measure ad-dressing the ability to assemble public healthsta, the CDC report also provided data on ad-ditional measures supporting the emergencyoperations coordination capability, includingnding that:

n 47 states and Washington, D.C. successully de-veloped approved incident action plans (IAPs),which describe the strategy and objectives or anincidents operational period and are approvedby the incident commander. The incidents canbe real or based on exercises. In 2011, morethan hal o IAPs were developed in respond toan executed or planned exercise, while natural

disasters accounted or the rest o the IAPs. Sev-enty-seven percent o CDCs grantees partneredwith other public or private agencies as part otheir response activities. The IAPs are livingdocuments to brie and be disseminated to pub-lic health response sta to help inorm aboutpast, present, and uture steps in responding todisasters or emergencies.

n Every state and Washington, D.C. completedan ater action report and improvementplan (AAR/IP). These plans are used to as-sess what worked well during an exercise or

real incident and what can be improved. Byevaluating the states response and identiy-ing gaps and areas that need improvement,state health departments can improve theirpreparedness and response operations.

19


20/80

3. inDicATor: inFecTioUS DiSeASe conTroL AnD VAccinATionS PerTUSSiS VAccinATionS

FinDinG: oly tw stats t th HHS gal vaatg 90 pt 19- t 35-th-lds

agast whpg ugh.

Surc: Mrii n Mri Wk Rpr (MMWR)23

20

2 stats t th HHS gal vaatg90 pt 19 t 35 th lds agastwhpg ugh (1 pt).

48 stats ad Washgt, D.c. dd noT t

th HHS gal vaatg 90 pt 19

t 35 th lds agast whpg ugh (0pts).hwii (90.6%) a (87.5%)nrk (92.3%) ak (77.4%)

ariz (86.0%)ark (84.5%)ciri (87.7%)crd (81.0%)ci (88.8%)Dwr (83.7%)D.c. (87.4%)Frid (84.6%)gri (87.5%)Id (79.0%)Iii (84.0%)Idi (82.2%)Iw (85.7%)K (87.6%)Kk (87.2%)lii (84.2%)mi (88.9%)mrd (89.5%)m (88.4%)mii (81.7%)mi (86.7%)miiii (80.8%)miri (80.8%)m (76.8%)nvd (75.2%)nw hir (84.6%)nw Jr (86.7%)nw mi (86.7%)nw yrk (82.6%)nr cri (81.3%)nr Dk (89.7%)oi (85.2%)ok (84.1%)or (76.6%)pvi (85.8%)Rd Id (84.5%)

s cri (79.5%)s Dk (75.8%)t (81.9%)t (82.7%)u (82.0%)

Vr (88.2%)Virii (84.4%)Wi (85.5%)W Virii (78.4%)Wii (88.4%)Wi (75.5%)


21/80

This indicator examines which states meet thenational goals or the number o children ages19 to 35 months old who have been vaccinatedagainst pertussis (whooping cough). Only twostatesHawaii and Nebraskamet the goal setby HHS in the Health People 201024 and HealthyPeople 202025 o vaccinating 90 percent o chil-dren ages 19 to 35 months against pertussis.

Nebraska had the highest rate o vaccinationsat 92.3 percent, while Nevada had the lowest at75.2 percent. Nine states had rates below 80percent. The national average in 2011 was 84.6percent. Meeting vaccination rate goals servesas a marker or the ability to protect the popula-tion rom inectious diseases, and a part o thisrole involves the ability to eectively communi-cate about the importance, saety and ecacyo vaccinations.

The ability to regularly vaccinate the public, par-ticularly children, is as an important measure

or how well the system can eectively reach andencourage vaccinations among the public. Thisneed or this capability is amplied during atime o crisis, when it is oten necessary to reachand encourage mass segments or the whole pop-ulation o a community to get vaccinated againsta new threat on a time-sensitive schedule.

Pertussis, commonly known as whooping cough,is a highly contagious bacterial respiratory in-

ection that can be atal in inants, who are tooyoung to complete the entire vaccination series.Early symptoms mirror those o a cold, but in-ection progresses into a severe cough that canaect breathing. The best way to prevent per-tussis is through the DTaP (diphtheria, tetanusand pertussis) vaccine.26

In 2012, the majority o states saw increases inthe number o pertussis cases, as compared with2011. As o November, over 36,000 cases and16 deaths (most in inants younger than threemonths) were reported to CDC. Rates have alsoincreased in children ages 7 to 10, and in ado-lescents ages 13 and 14.27 Observational studiessuggest these outbreaks in children and adoles-cents may be a result o early waning o immunitydue to reormulated vaccine in 1997.28 However,some experts believe that reduced vaccinationrates may also be a contributing actor. Severalstates allow parents to reuse vaccination or

their children based on personal or philosophi-cal reasons, and many o those states, includingWisconsin and Washington have seen the larg-est spikes in incidence. Compared to 2011, thenumber o cases this year has increased ouroldin Wisconsin and sixold in Washington.29, 30

States with an incidence o pertussis the same orhigher than the national incidence (as o Novem-ber 23, 2012), which is 11.6/100,000 persons.31

The Section 317 Immunization Program, whichsupports grants to states or vaccinating underin-sured children and adults, has received additionalunding in recent years through the Preventionand Public Health Fund and American Recoveryand Reinvestment Act. However, a large shortallremains. Appropriations have not kept up withthe cost increase o additional vaccine recommen-dations according to CDC. A FY 2012 CDC report

to Congress outlined that the 317 program needsabout $914 million to ully achieve its mission,about $350 million above the Presidents FY2013request.32 Meanwhile, National Association oCounty and City Health Ocials (NACCHO) re-ports that 19 percent o local health departmentshave cut immunization programs,33 while nearly athird o state and territories have reduced vaccineprograms as a result o budget cuts.34

21

*on sm sus Minns prussis css hv n rpr hrugh NNdSS r 2012. this ws ccss rm h

Minns dprmn Hh wsi.

Wii 93.4 nw mi 31.0 ariz 13.5

mi 78.1* ak 28.6 Iii 13.5Vr 66.1 nr Dk 25.6 Id 13.1

Wi 64.3 or 22.1 pvi 12.9

Iw 47.5 K 21.9 miri 12.3

mi 45.6 nw hir 15.7 - -

m 44.3 crd 15.2 - -

u 40.9 nw yrk 14.5 - -


22/80

4. inDicATor: inFecTion conTroL meDicAiD coVerAGe oF FLUSHoTS WiTH no co-PAY

FinDinG: 37 stats qu mdad t v fu shts adults ud th ag 65 wth

-pay.

Surc: Kisr Cmmissin n Mici n h Uninsur35

* d n cvr fu shs vn wih c-ps. **disric Cumi, Hwii n Wiscnsin i n pricip in h surv. Wiscnsin cnrm

h n rquir c-p vi crrspnnc wih tFaH; Hwiis nin mris u ns inic h rquir c-p. 36

22

37 stats qu mdad vag fushts wth -pay as udth ag 65 (1 pt).

13 stats ad Washgt, D.c. d noT qumdad vag fu shts wth -pay as ud th ag 65 (0 pts).

a akark arizci ciriDwr crdId D.c.**Iii Frid*Idi gri*Iw hwii**K miriKk mlii okmi pvimrd um Viriimiimimiiiinrknvdnw hirnw Jrnw minw yrknr crinr DkoiorRd Ids cris Dktt

VrWiW ViriiWii**Wi


23/80

This indicator examined which states Medic-aid programs cover fu shots without co-pays orother cost-sharing. While 46 states cover thevaccine under Medicaid, only 37 states haveeliminated co-pays and other cost-sharing orthese vaccinations.37 Eliminating co-pays orMedicaid beneciaries is particularly impor-tant since these Americans include many o the

lowest-income and most vulnerable in terms oquality o health. Requiring co-pays are a strongdisincentive and can oten make the shots eco-nomically out-o-reach or many Americans.

Establishing a cultural norm o annual fu vacci-nations ensures the country has a strong mecha-nism in place to be better able to vaccinate allAmericans quickly during a new pandemic orunexpected disease outbreak.

The Advisory Committee on ImmunizationsPractices (ACIP) recommends yearly infuenzavaccines or all individuals 6 months and older.Recent studies estimate that vaccine rates mayneed to be as high as 85 percent to 90 percentto establish herd immunity.38, 39 The seasonal fuvaccine protects against three dierent virusesand is the best way to avoid contracting the virus.The higher the number o people who are vac-cinated, the lower the likelihood a carrier willcome in contact with an unvaccinated person.During the 2011-2012 fu season, only around 42percent o Americans were vaccinated.40

The Aordable Care Act (ACA) requires newgroup and individual health plans to provide

the vaccines recommended by ACIP prior toSeptember 2009 with no cost-sharing, i pro-vided by an in-network provider. (For recom-mendations ater September 2009, the no-costsharing requirement takes eect one year ol-lowing the date o the recommendation.)41However, the legislation did not eliminate cost-sharing requirements under Medicaid. In an

eort to encourage states to adopt the require-ments in their Medicaid plans, under the ACA,states can earn a one-percentage point increasein their ederal matching rate starting January1, 2013 i they eliminate cost-sharing or the 10immunizations recommended by ACIP.

Flu takes a toll on the country each year. Dur-

ing the seasonal outbreak time, an average o5 percent to 20 percent o the U.S. populationgets the viral respiratory inection infuenza,leading to more than 200,000 hospitalizations.Flu strains vary rom year to year and can bemild or severecausing 3,000 to 49,000 deathsrom 1976 to 2006. Certain populations are athigher risk or complications rom infuenza, in-cluding children, the elderly, pregnant women,and those with certain health conditions likeasthma or heart disease.42

In addition to its health eects, fu has a seriousimpact in terms o health care and worker absen-teeism costs. Seasonal fu can oten result in ahal day to ve days o work missed, which aectsboth the individual and his or her employer. An-nually, the fu leads to approximately $10.4 billionin direct costs or hospitalizations and outpatientvisits, and $76.7 million in indirect costs.43

Approximately hal o Americans do not havepaid sick leave rom their employers, whichmeans they risk not getting paid or possibly los-ing their jobs i they stay home rom work be-cause they get sick or must care or sick amilymembers. A signicant percentage o service

workers, such as waiters or cashiers, who comein to direct contact with a range o customers orconsumers, do not have paid sick leave.

By preventing hospitalizations, infuenza im-munizations can save $80 per year, per personvaccinated.44

23


24/80

5. inDicATor: eXTreme WeATHer eVenTS PrePAreDneSS

FinDinG: 15 stats utly hav lat hag adaptat plas that a pltd.

Surc: Cnr r Cim n enrg Suins45

*Pns in prgrss

This indicator examines which states have com-

plete climate adaptation plans, which includeunderstanding and planning or changinghealth considerations based on new weatherpatterns and threats. According to the Centeror Climate and Emergency Solutions, 15 statescurrently have complete climate adaptationplans, and our additional states have plans inprogress. Depending on the regions specicneeds, adaptation plans can ocus on a varietyo issues, to include sea-level rise and associatedfooding, drought mitigation and water insecu-

rity, hurricanes and other severe weather, and

extreme heat events.46 All 15 states with adaptation plans include public health concerns.

According to the U.S. Environmental Protection Agency (EPA), as the environment changespeople will be at a higher risk or a range ohealth threats.47 As temperatures and sea levels rise, many o the current U.S. environmental health challengessuch as natural disastersand inectious diseases that avor warmer climatesare expected to increase and become

24

15 stats utly hav lat hagadaptat plas that a pltd (1 pt).

35 stats ad Washgt D.c. d tutly hav plt lat hagadaptat plas (0 pts).

ak aciri arizci arkFrid crdmi Dwr*mrd D.c.m grinw hir hwiinw yrk Iwor Idpvi Iii

Vr IdiVirii KWi KkWii lii

miimi*miiiimirimnrknvdnw Jr*nw minr crinr Dkoiok

Rd Id*s cris Dkttu

W ViriiWi


25/80

more severe. In 2012 alone, the United Stateshas endured a nationwide drought, a West Nilevirus outbreak, a historic derecho (severe wind-storm), and two devastating hurricanes. Thissummers extreme heat caused roads to bucklein Wisconsin, a railroad bridge to collapse in Il-linois due to warped train tracks, and a nuclearpower plant to shutdown due to not-so-cool cool-

ing seawater.48 And in October, a hurricane, anoreaster, and the jet stream collided to cre-ate a once-in-a-century extreme weather event.Superstorm Sandy cast its ury across a span o1.8 million square miles,49 leaving Lower Man-hattan underwater, the New Jersey coast dam-aged and millions across the eastern seaboardwithout powersome or weeks. Early estimatesindicate the damage caused by Sandy could cost$50 billion, making it the second costliest stormater Hurricane Katrina.50 In November 2012,the Pacic Northwest also aced severe stormchallenges with record rainall and fooding.51

Some major health concerns related to extremeweather changes include:

n Temperature Eects: Severe heat waves areprojected to intensiy, which can increaseheat-related deaths and sickness.

n Air Quality Changes: Worsening regional ozonepollution, with associated risks o respiratory in-ections, aggravation o asthma, increased aller-gic airway disease and premature death.

n More Extreme Weather Events: Storm im-

pacts, particularly hurricanes and tropicalstorms, are likely to be more severeincreas-ing the risk o injury, fooding, and adversewater quality eects due to runo. Otherareas will suer rom reduced precipitationleading to droughts and wildres.

n Climate-Sensitive Diseases: Certain vector-,ood- and water-borne diseases are expectedto increase and spread as temperature andweather patterns allow these pathogens toexpand into new geographic regions.

Communities across the United States will expe-

rience the negative health eects associated withclimate change in dierent ways, or instance:

n Urban Communities: Urban neighborhoods,particularly low-income areas, are especiallyvulnerable to natural disasters, such as foodsand heat waves.

n Rural Communities: Rural communities maybe threatened by increased ood insecuritydue to geographical shits in crop-growingconditions and yield changes in those crops;

reduced water resources; food and stormdamage; and increased rates o climate-sensi-tive health outcomes.52

n Coastal and Low-Lying Areas: Climate changecould lead to a rise in sea levels, a rise in sur-ace-sea temperatures, and an intensicationo hurricanes and tropical stormsthreaten-

ing residents o coastal or low-lying areas.n Mountain Regions: The melting o moun-

tain glaciers and changes in snowpack andseasonal timing o snow melt can aect resh-water runo. I the temperature warms athigher altitudes, some vector-borne patho-gens could take advantage o new habitats.53

n Polar Regions (Alaska): While Alaskancommunities could see a reduction in cold-weather-related injuries and death, meltingpolar ice also puts indigenous communitiesat risk as they have to travel urther or ood

hunting into treacherous, shiting ice and wa-ters. This warming could be accompanied bythe spread o disease into what were tradition-ally cooler climates.54

Public health departments are uniquely posi-tioned to help communities prepare or the ad-verse eects o climate change given their rolein building healthy communities. Public healthworkers are trained to develop communicationcampaigns that both inorm and educate thepublic about health threats and can use theseskills to educate the public about climate change

prevention and preparedness. Public health de-partments are also on the rontlines when thereis an emergency, whether its a natural disasteror an inectious disease outbreak. These typeso emergency preparedness and response skillswill be invaluable as extreme weather events be-come more common.

To help prepare or the health impact o ex-treme weather incidents and climate change,CDCs Climate-Ready States and Cities Initiativehas awarded $7.25 million in grants to 16 statesand 2 cities to build resilience to the health im-pacts o climate change, with plans to award upto $19.25 million by 2016. CDC will assist award-ees in developing and using models to moreaccurately anticipate health impacts, monitorhealth eects, and identiy the most vulnerableareas in their region. Awardees include depart-ments o health in Arizona, Caliornia, Florida,Illinois, Maine, Maryland, Massachusetts, Michi-gan, Minnesota, New Hampshire, New York City,New York State, North Carolina, Oregon, RhodeIsland, San Francisco, Vermont and Wisconsin.55

25


26/80

This indicator examines whether a state has alaw or regulation mandating all licensed child-care acilities to have a multi-hazard writtenevacuation and relocation plan or moving kidsto a sae location during multiple types o disas-ters. The plans must go beyond the provisionso a basic re drill. According to the 2012 IsAmerica Prepared To Protect Our Most VulnerableChildren in Emergencies?report by Save the Chil-dren, 30 states and Washington, D.C. have sucha mandate in place. 57 This is an increase rom25 states and Washington, D.C. in 2010, and 20states and Washington, D.C. in 2009.

This indicator refects only one o our measuresin the Save the Children report. The other mea-

sures in the report included whether a state: 1)requires all K-12 schools to have a disaster planthat accounts or multiple types o hazards itscommunity may encounter (e.g., earthquakeswildres, gun violence); 2) regulates child careacilities to have a written plan that accounts orany special assistance an inant, toddler, a childon crutches, or a child with physical or cognitivedisabilities may require (e.g., moving cribs onwheels or children in wheelchairs); and 3) requires all regulated child care acilities to havea written plan to notiy parents o an emergencyand reunite parents with their kids.

Only 17 states met all our criteria. Five state(Idaho, Iowa, Kansas, Michigan and Montana)

6. inDicATor: commUniTY reSiLiencY cHiLDren AnD PrePAreDneSS

FinDinG: 30 stats ad Washgt, D.c. adat all lsd hld-a alts t hav a

ult-hazad wtt vauat ad lat pla.

Surc: Sv h Chirn56

26

30 stats ad Washgt, D.c. adat alllsd hld-a alts t hav a ult-hazad wtt vauat ad lat pla

(1 pt).

20 stats d noT adat all lsd hld-a alts t hav a ult-hazad wttvauat ad lat pla (0 pts).

a arizak crdark Fridciri grici IdDwr IiiDiri ci Idihwii IwKk Klii mimrd miim mi

miiii mmiri nrknvd nw Jr nw hir ornw mi Rd Idnw yrk s crinr cri s Dknr Dk toiokpvitu

VrViriiWiW ViriiWiiWi


27/80

met none o the indicators. Failing to plan orthese worst-case scenarios puts children andadolescents at increased risk o injury.

Planning to care or 67 million children inAmerican schools and child-care settings dur-ing a public health emergency presents com-plex considerations and challenges. Children

are not small adults and special consideration

needs to be given to complicated issues rang-ing rom child-appropriate doses o medicationsand vaccines, to caring or children i schoolsand child care acilities are closed or extendedperiods. Parents and other caregivers may alsobecome sick or injured during a disaster, com-plicating their ability to care or children.

27

saVe the chIlDRens IS aMeRICa PRePaRed to PRoteCt oUR MoSt VUlNeRable CHIldReN INeMeRGeNCIeS?RepoRt

I sv cidr Rr crd, i jdd rir drd (1) i ii rqir drd; (2)

i i dd; d (3) id r rd idr iiir i 4 riri K12 r jd i. a r i idrd -

dd i i i (1) i ; (2) i ri; r (3) i rvidd rv dr id. mdr id- id r, d i i rrvidd id r rd id-r iii d rrqird d r id.

Fr ddii iri d sv cidr rr, adi e.

n 42 rqir K12 v dir r i zrd i i r (.., rqk, widfr, vi):

a, ak, ariz, ark, ciri, crd,ci, Dwr, Frid*, gri, hwii, Iii,

Idi, Kk, lii, mi, mrd, m,mi, miiii, nrk, nvd, nw hir,nw Jr, nw mi, nw yrk, nr cri,oi, ok, or, pvi, Rd Id, scri, s Dk, t, t, u, Vr,

Virii, Wi, W Virii, d Wii.

n 23 d Wi, D.c. rqir rd idr iii v wri r i i i, ddr, id r, r id wi i r iiv diiii rqir(.., vi ri w r idr i wir):

a, ak, ark, ciri, ci, Diri

ci, hwii, Kk, lii, mrd,m, miiii, miri, nw hir,nw mi, nw yrk, nr cri, Rd Id,t, Vr, Wi, W Virii,

Wii, d Wi.

n 32 d Wi, D.c. rqir rd idr iii v wri i r r d ri r wi ir kid: a,

ark, ciri, crd, ci, Dwr,Diri ci, Frid*, hwii, Idi, Kk,lii, mrd, m, mi, miiii,miri, nw hir, nw mi, nw yrk,

oi, ok, pvi, s cri, t,t, u, Vr, Virii, Wi, W Virii,Wii d Wi

*Rguins r unr rvisin n r h prps rgu-

ins ws rviw n m criri.

suRVey: most schools not ReaDy to ResponD to panDemIc oRotheR outbReaKs

Rrr s. li uivri rvdr 2,000 r r 26

ir rdi rd dirr ii di rk. t rv d

, di 2009 h1n1 di: wri dir ddrddi rrd; ird vki r riv qi; 1.5 r v dii k-id; d idr r rid i rirr -

i r i ird .tr-qrr r rrd rivd iz vi, w r d i. td d rviw dd ir di d rdi- wi dir rdr. I rd rii i -i rvi rr i i rdi ii di rk.58


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28

EXPERT COMMENTARY

School Nurses: The Front Line oEmergency Response or Many Childrenb Shir Schnz, ed, RN, aRNP, dircr Nursing eucin, Nin assciin Sch Nurss

n Chrisin tuck, MS, bSN, RN, NCSN, Hh Srvics dircr, Smn Sch disric, tpk, KS

S r r r i ri ridr . Fi-w ii idrd vr d, d idi r wrk r ii , ki r fr ri rr d d i r.

nr v di d kwd idi r ii, iii rivd r di rvi (ems)r, i d ir-

vi ems r d w wi r rvidr. s r rvid frrdr d r-i r i ii ii ri, id-i irrri, i d rdii v.

t r r wii r idifd r i id:

n Pvt/mtgat o-i d idifi zrd r r drd i r r ii.

n Ppadss s r rv -i i ii d i wi r rrd d r idr, idi wi i d.

n rsps t r i kwd- i r r r, idi ri, r-

izi d rdii fr id r, d dir i d

r vii r, idrd d, iki di d i rr. t r i vi irii ii dri d r rii.

n rvy t r iiw d, r, d iid i rr rr i r dir.59

y i riz i, r r qifd rvid ri-i r w ri wi i. tir rir r i v

rvid ri d idi fr id r d d . s r r dr fr id . t d ri id ii d r ri r iiid dr ri i r rrriv. t r ir i r-i r r d ivvd i

rii r r r

i i v dir

t r rdi -i iri r vri r dv r . er r rqir rdii wi diir-

r, , d r i fr rdr.

ni ir r, v k dr rdd d rr r ri, idi d-

v r drdr r r d riiii.hwvr, d idri rdr dri d ki.

Wi r i r r iv d i r rid rr i.

s ri i i rri, wi id difi i -ii d rdii wi fr rdr,

It is the position o the National

Association o School Nurses (NASN)

that school nurses provide leadership in

all phases o emergency preparedness

and management and are a vital part o

the school team that develops emergency

response procedures or the school

setting, using an all-hazards approach.


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29

k qi, rii r , w i ririi rd di d

wi ivii r r .

I ddii, v wi r ri k r-ri, iid i r di , r k irrii w qi d diri d fr rdr. mwidvi, iii d rii i r i rdi qik, -rri, d fi wi ri dd did riv rr

i d i i rvidi ri vir.

Fr , r r idi rrd w vid dri

2009 h1n1 di. s i rdri d di r i d ri rd . t r i r i d kwd rd idi, r-

vi r, rvi, rri d -i wi i i.60

t ddr i rd r i i diri, i irdd r idi diri ii wi d

vr dir r d r s hd sri prr, ciizcr/mdi Rrv cr r dii dird diri. Dr edi, h d h srvi, der m d rr id-

i r r diri, frrdr, d i rr ri

r, dv ri r ddr-i r, d r r i

diri i i r. eiv - ri rqir rii,rri d i i ri iiz . t r rii, ni aii s nr rd

s er tri trii (sett)rr (://www..r/ciied-

i/livciiediprr/sett),wi rvid r wi kw-d, ki, d rr rr dr Fir-aid i r v rri i .

s r d wi r - i r rd d wii r d r vi , -i r, d r dri r v.t r i vi ri wi kwd i d id d i , d idifif ri d r d d, idi drir v.

m diri k r f rriv r i d r, rr fr (sRo), r

d r. t r i rii i d r r i r rrd d dr vi r dvr r rdr r i, i -zrd r.

School nurses respond to emergencies and

disasters that can range rom one student

or adult who is injured on the playground

to the mass illness situations seen with theH1N1 pandemic u. School nurses deal

with weather-related emergencies, and

the nature o these emergencies oten

depends on geographic location. They

can range rom hurricanes, tornadoes,

tsunamis and ooding to snow and ice

storms. I students are required to be

sheltered in school or long periods o time

this creates issues or students with chronic

health conditions, including diabetes,

asthma, and allergies/anaphylaxis.

Dramatic large scale emergencies occur in

the school as well as many well publicized

violent events, such as school shootings

that create serious saety and injury

issues. Schools can also be vulnerable to

explosions and fres. In addition, schools

located near nuclear power plants have

their own concerns about potential

accidents and emergencies.


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7. inDicATor: emerGencY mAnAGemenT emerGencYmAnAGemenT AccreDiTATion

Fdg: 29 stats ad Washgt, D.c. hav adtd y th egy maagt

Adtat Pga (emAP).

Surc: emrgnc Mngmn accriin Prgrm61

This indicator examines which states have beenaccredited by the Emergency Management Ac-creditation Program. So ar, 29 states, Washing-ton, D.C. and 13 additional jurisdictions havemet the EMAP standards.

EMAP62 was created ollowing a 1997 NationalEmergency Management Association-hosted ses-sion on the need or standards and assessmentswithin emergency management. The resultingEmergency Management Standard was devel-oped with input rom stakeholders rom nationalemergency management agencies, as well as stateand local government. Emergency manage-ment, as dened by EMAP, encompasses all or-ganizations with emergency or disaster unctionsin a jurisdiction, which may include prevention,mitigation, preparedness, response and recovery.

EMAP is a voluntary, peer reviewed process thagives programs the opportunity to demonstrateand be recognized or meeting national standards. The standards do not uniquely apply topublic health, but ocus on the overall emer

gency response preparedness capabilities in anarea. The evaluations do specically includewhether responsibility or public health and arange o other sectors is assigned, public healththreat surveillance and creating public communication plans that act to protect the publicshealth. Since this is a voluntary program, statethat are not accredited may have chosen not toparticipate in the program rather than it beinga refection on their state o preparedness.

The EMAP voluntary accreditation or all emergency preparedness is an important mechanism

30

29 stats ad Washgt, D.c. hav adtd y th egy maagt

Adtat Pga (emAP) (1 pt)

21 stats hav noT adtd yegy maagt Adtat

Pga (emAP) (0 pts)a akariz ciark Dwrciri hwiicrd IdD.c. KFrid Kk gri miIii miIdi mIw nvdlii nw hir

mrd nr Dkm ormii Rd Idmiiii s Dkmiri tnrk Winw Jr W Viriinw mi Wiinw yrk Winr crioiokpvis critu

VrVirii


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or improving evaluation and accountability, but itis also important to continue to work toward base-line perormance measures that go beyond plan-ning and even stricter accreditation standards.

The steps to EMAP accreditation include theollowing:

n Sel-assessment and documentation;

n On-site assessment by a team o trained, inde-pendent assessors;

n Committee review and recommendation; and

n Accreditation decision by an independentcommission.

EMAP reviews prevention, preparedness, miti-gation, response and recovery, including:

1. Fiscal and administrative procedures that sup-port day-to-day and disaster operations,

2. Legal statutes and regulations establishing au-thority or its development and maintenance.

3. Hazard identication, risk assessment andconsequence analysis.

4. A mitigation program or the eects o emer-gencies associated with the identied risks.

5. Prevention responsibilities, processes, poli-cies and procedures.

6. Plans that describe emergency response; con-tinuity o operations; continuity o govern-ment; and recovery.

7. An incident management system.

8. Pre-emergency, systematic identication oresource requirements, shortalls and inven-tories.

9. Agreements or sharing resources across ju-risdictional lines.

10. A communications plan that provides orusing, maintaining and augmenting all othe equipment necessary or preparation,response and recovery.

11. Operational plans and procedures devel-oped, coordinated and implemented amongall stakeholders.

12. Facilities necessary to adequately supportresponse and recovery activities.

13. A training program or program ocials,emergency management/response person-

nel, and the public.

14. An exercise, evaluation and corrective ac-tion process.

15. Crisis communication, public inormationand education plan and procedures.

In addition to the 29 accredited states and Wash-ington, D.C., a number o jurisdictions havebeen accredited by EMAP, including: Austin,Texas; Boston, Massachusetts; East Baton RougeParish, Louisiana; Great Lakes and Ohio RiverDistrict, Huntington, West Virginia; Colorado

Springs and Denver, Colorado; ConsolidateCity/County o Jacksonville/Duval, Florida;San Diego, Caliornia; Miami-Dade, Florida;Orange County, Florida; Pierce County, Wash-ington; City o Providence, Rhode Island; andSpringeld-Greene County, Missouri.

CDCs Emergency Management Program will beassessed by EMAP in June 2013 to become therst ederal agency-level program to be reviewed.

The lack o strong accountability standards andmeasures has been an ongoing problem in pub-lic health preparedness in terms o dening

baseline capabilities; measuring how prepared astate or locality is; and being accountable to thepublic. A Public Health Accreditation Board(PHAB), created in 2007, has created a volun-tary public health accreditation program orstate and local public health departments andis currently reviewing the rst wave o accredi-tation applicants.63 This accreditation processserves a major eort to improve and standardizecore capabilities o health departments includ-ing preparedness.

31


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32

publIc health accReDItatIon boaRD

t phab diir i i dr rdii rr i dr rd tri,, jridii d rriri.64phab i di, drd d

r. Di r r drd ri rd r i rvi. tr r 12 di; fr di ddr 10 ei pi hsrvi; di 11 ddr d diiri, d di 12 ddr

vr. sdrd r rqird v iv dr i -d , d r rvid w vi i drd i .65

t 12 di id:

Da 1: cd d dii -

d i di i i i.

Da 2: Ivi r d -vir i zrd r i.

Da 3: Ir d d i i d i.

Da 4: e wi i id-i d ddr r.

Da 5: Dv i ii d.

Da 6: er pi h lw.

Da 7: pr ri irv - r rvi.

Da 8: mii i wrkr.

Da 9: ev d i irv dr r, rr dirvi.

Da 10: cri d vi-d i .

Da 11: mii diiriv d - i.

Da 12: mii i i vri i.

sdrd 5.4 if rrd- d rqir i dr

ii zrd r ri. I rdr rdid dr :66

n prii i r r dv- d i a hzrder ori p (eop);

n ad d ii i rri (eop); d

n s rvid i d/r ii tri d dr- i rrdi vid-d

d/r rii ri/ i eopdv d i.


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8. inDicATor: HeALTH SYSTem PrePAreDneSS nUrSe LicenSUrecomPAcT

FinDinG: 24 stats patpat a nus Lsu cpat.

Surc: Nin Cunci S brs Nursing

The Nurse Licensure Compact (NLC),67 launchedin 2000 by the National Council o State Boardso Nursing, allows a registered nurse and licensedpractical/vocational nurse to have a single mul-tistate license that permits them to practicephysically, telephonically and electronicallyinother compact states beyond their home state oresidency. In order to be eligible or a multistatelicense, a nurse must have a nursing license ingood standing and a legal residence in an NLCstate. Advance practice registered nurses are notincluded in this compact and must apply througheach state they wish to practice in.

This indicator examines which states participatein the NLC. Currently, 24 states participate,allowing nurses to legally practice across state

lines with other states that are part o the NLC.The ability or nurses to be able to work acrossstate lines can be a tremendous benet duringdisasters or disease outbreaks, when aectedcommunities may experience severe workorceshortages. The NLC benets both nurses andstates in the ollowing ways:

n Allows nurses fexibility and mobility;

n Drives standardized licensure requirements;

n Enables states to act jointly and collectively;

n Facilitates continuity o care; and

n Allows dierent boards o nursing to buildrelationships and improve processes by learn-ing rom one another

33

24 stats patpat a nus Lsucpat (nLc) (1 pt)

26 stats ad Washgt, D.c. d noTpatpat a nus Lsu cpat(nLc) (0 pts)

ariz aark akcrd ciriDwr ciId D.c.Iw FridKk grimi hwiimrd Iiimiiii Idimiri Knrk liinw hir m

nw mi miinr cri minr Dk mRd Id nvds cri nw Jrs Dk nw yrkt oit oku or

Virii pviWii Vr

WiW Virii

Wi


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An article published in the journal o the Asso-ciation o Public Health Laboratories (APHL)

notes that during the rst wave o H1N1 in thespring o 2009, The peak public health labo-ratory response was unsustainable; state andederal cutbacks have drained critical surge ca-pacity rom a system already weakened by long-term workorce shortages.68

In the initial phases o an outbreak o a novel in-fuenza virus, public health labs are on the rontlines conducting diagnostic testing since otherlabs generally lack this capacity. Once the novelvirus is established in the population, diagnos-tic testing is no longer as important and public

health labs switch to surveillance testing. Thesurveillance testing allows public health ocials

to gather enough inormation to track the pandemic and monitor any genetic mutations orchanges in the virus.

During a pandemic fu or other inectious disease outbreak, the demand on the public healthlab workorce is great, and in some cases, exceeds supply. According to a survey APHL conducted o state public health laboratories in theall o 2012, 13 states report not having enoughstang capacity to work ve, 12-hour days or sixto eight weeks in response to an inectious disease outbreak, such as novel infuenza A H1N1

9. inDicATor: PUbLic HeALTH LAborATorieS SUrGe WorKForce

FinDinG: 37 stats ad D.c. pt havg ugh stag apaty t wk v, 12-hu

days sx t ght wks sps t a tus dsas utak, suh as vl

fuza A H1n1.

Surc: aPHl 2012 Surv S Puic Hh lrris

34

37 stats ad Washgt, D.c. pt havgugh stag apaty t wk v, 12-hu

days sx t ght wks sps t atus dsas utak, suh as vlfuza A H1n1 (1 pt).

13 stats pt noT havg ugh stagapaty t wk v, 12-hu days sx

t ght wks sps t a tusdsas utak, suh as vl fuza AH1n1 (0 pts).

a nrk akariz nw hir crdark nw mi griciri nw yrk hwiici nr cri IdiDwr nr Dk IwD.c. oi KFrid ok mId or nvdIii Rd Id nw Jr Kk s Dk pvilii t s crimi u tmrd Vrmii Viriimi Wimiiii W Viriimiri Wiim Wi


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Public health laboratories around the countryparticipate in the Laboratory Response Net-

work (LRN) to ensure an eective laboratoryresponse to bioterrorism. The network helpsimprove the nations public health laboratoryinrastructure, which, once, had limited abilityto respond to bioterrorism.

According to the CDC, the LRN is charged withthe task o maintaining an integrated network ostate and local public health, ederal, military,and international laboratories that can respondto bioterrorism, chemical terrorism and otherpublic health emergencies. The LRN is a uniqueasset in the nations growing preparedness or

biological and chemical terrorism. The linkingo state and local public health laboratories,veterinary, agriculture, military, and water- andood-testing laboratories is unprecedented.69

Fity-three laboratories within U.S. states, territories,or metropolitan areas make up the chemical compo-nent o the LRN and are responsible or collectingand detecting exposure to toxic chemical agents.

n Nine labs are Level 3 laboratories whichmaintain the basic unctions that all o theLRN labs have to be able to work with hospi-tals and other rst responders within their ju-

risdiction to maintain competency in clinicalspecimen collection, storage, and shipment.

n Thirty-our labs are Level 2, meaning chemistswho are trained to detect exposure to a numbero toxic chemical agents are present. Analysis ocyanide, nerve agents, and toxic metals in humansamples are examples o Level 2 activities.

n Ten labs are Level 1. These laboratories canserve as surge capacity or CDC and also candetect exposure to an expanded number ochemical agents, including mustard agents,nerve agents, and other toxic industrial chem-icals. These labs expand CDCs ability to ana-lyze large numbers o patient samples when

responding to large-scale exposure incidents.

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

Forty-nine states reported they increased ormaintained their LRN chemical capabilities,one reported a decrease and Washington, D.C.declined to answer. This is based on their statusas part o the LRN.

35

10. inDicATor: PUbLic HeALTH LAbS cHemicAL TerroriSmPrePAreDneSS

FinDinG: 49 stat pul halth laats pt asg atag th Laaty

rsps ntwk chal Thats (Lrn-c) hal apalty August 10, 2011 t

August 9, 2012.

Surc: aPHl 2012 Surv S Puic Hh lrris

*Wshingn, d.C. cin nswr h qusin n h aPHl surv.

49 stats asd atad th Lrn-c hal

apalty (1 pt).

1 stat ad Washgt, D.c.

DecreASeD th Lrn-chal apalty (0 pts).

a lii oi D.c.*ak mi ok mariz mrd orark mii pviciri mi Rd Idcrd miiii s crici miri s DkDwr m tFrid nrk tgri nvd uhwii nw hir Vr

Id nw Jr ViriiIii nw mi WiIw nw yrk W ViriiIdi nr cri WiiK nr Dk WiKkm


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National Issues andRecommendations

This is a serious time or emergency preparedness in the United States. Inthe past decade, we have recognized the essential role that public health

plays in responding to crises and have acknowledged the ongoing threats, including

preventing inectious diseases and responding to serious storms. Investments have

led to signicant improvements, but now health departments across the country

are watching their progress erode. Federal, state and local budget cuts make it

impossible to maintain basic levels o preparedness.

The nations preparedness policy should not be

crossing our ngers that new emergencies wonthappen, or putting our head in the sand and ig-noring threats we see every day. There must bea baseline o better sae than sorry that shouldnot be crossed.

In addition to maintaining resources to coverthe basics, radical steps must be taken i we havea chance o improving persistent preparednessgaps. TFAH has identied a set o concerns andrecommendations or maintaining and improvingAmericas readiness or health threats, including:

A. Reauthorizing the Pandemic and All-Hazards

Preparedness Act;

B. Assuring Sucient, Dedicated Funds or Pub-

lic Health Preparedness;C. Ensuring Community Resilience;

D. Modernizing Biosurveillance;

E. Addressing Antibiotic Resistance;

F. Improving Medical Countermeasure Re-search, Development and Manuacturing;

G. Improving Health System Preparedness andEnhancing Surge Capacity;

H. Readying or Weather-Related Threats; and

I. Fixing Food Saety.

a. ReauthoRIZIng the panDemIc anD all-haZaRDs

pRepaReDness act

The 2006 PAHPA helped to greatly strengthenthe nations preparedness and response plan-ning, and its reauthorization provides anopportunity to update the statute to more ad-equately address ongoing challenges in public

health preparedness.

recommenDATionS

In the past year, the Senate and House eachpassed a reauthorization bill. As the chamberswork out the dierences in the bills, TFAHrecommends that the ollowing issues be con-sidered as top priorities or consideration tohelp strengthen authorities to address ongoinggaps in preparedness. These recommendationsocus on language that is in either the House or

Senate versions o the bill. There is not neces-sarily any active opposition to these measures;support or opposition to the inclusion or lacko inclusion o these sections is infuenced by aninterest in providing stronger language around

authorities or increased support or unding:

nTemporary Redeployment o Personnel Dur-ing a Public Health Emergency (H.R. 2405sec. 3): This provision in the House billwould allow states to request rom HHS theauthority to temporarily reassign personnelrom other HHS-unded grant programs torespond to a major emergency. The author-ity would allow states to meet the tremendousstang needs required by a disaster, as dem-onstrated during H1N1.

37

2S e c T i o n


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nMedical Countermeasure Strategic Investor(S. 1855 sec. 402): The Senate bills proposalor creation o a Strategic Investor would le-verage private capital and business expertiseto spur innovation in research and develop-ment. Given the limited availability o publicunds or MCM development, a public-privatepartnership is a novel approach worth trying.

nBiosurveillance (S. 1855 sec. 203/H.R. 2405 sec.4): Despite repeated attempts at strategies andreviews, the United States currently lacks an in-tegrated, national approach to biosurveillance,and the ragmented, siloed and overlappingsystems hamper our bioterrorism and diseaseoutbreak response capabilities. Both bills at-tempt to address this problem by requiring ad-ditional planning or integration. Additionaldiscussion o biosurveillance concerns can beound in Section 2D o the report. It is particu-larly important that the Senate legislation calls

or coordination with the Oce o the NationalCoordinator or Health Inormation Technol-ogy and a review o existing and duplicativesystems. The emergence o electronic healthrecords (EHRs) presents tremendous new pos-sibilities or outbreak detection and tracking.

nCarryover o Grant Use, Coordination (S.1855 sec. 201, 202): We support the updatesto the preparedness grant programs at Healthand Human Services included in the Senatelegislation, which would encourage fexibilityand eciency. Giving grantees limited abil-

ity to carryover unds will promote long-termplanning currently impossible in an unpredict-

able scal environment. It is also beneciathat the language supports ongoing eorts atHHS to better align the hospital and the stateand local preparedness grant processes.

nFunding Levels (S. 1855, H.R. 2405, throughout): While we recognize the dicult scasituation our nation aces, we are concerned

both bills, which reeze public health preparedness unding at FY 2011 levels, would notprovide sucient resources to modernize public health systems and ensure we are preparedin the event o an emergency. TFAH recommends restoring PHEP and HPP unding toFY 03 levels. Over the last several years, public health preparedness unding has declinedconsiderablycontributing to the loss o morethan 45,700 state and local public health jobsMany o these workers were trained in publichealth preparedness, emergency responsebiosurveillance and epidemiology. We mus

und public health preparedness with thesame level o commitment as we have made toother national security priorities.

nChildrens Preparedness (S. 1855 sec. 304throughout): The Senate bill would take signicant steps to consider the particular needso pediatric populations in MCM research anddevelopment and creates an Advisory Committee on Children and Disasters. The languagealso calls or consideration o the needs ochildren, as an at-risk population, into the National Health Security Strategy, the Nationa

Disaster Medical System, the Medical ReserveCorps and the PHEP grants.

b. assuRIng suFFIcIent, DeDIcateD, stable FunDs FoR

publIc health pRepaReDness

The United States made a signicant investmentto improve public health preparedness ater theSeptember 11, 2001 and anthrax tragedies. Themain unding streams have included bolsteringbasic ederal capabilities; improving national vac-cine and medication development, stockpilingand distribution; improving state, local and hos-pital preparedness; and emergency supplementalunding to support pandemic fu preparedness.

While the unding has resulted in signicantprogress in the past decade, the Ready or Not?re-ports have documented a number o major gapsthat still remain, particularly in maintaining aully-staed and trained workorce; vaccine andmedical countermeasure research and produc-tion; biosurveillance programs; medical surgecapacity; and providing support or communi-ties to cope with and respond to crises.

Historically, the ederal approach to preparedness has not provided a stable or sustainedlevel o support or ederal, state or locaneeds. The most consistent pattern in U.Spreparedness unding is inconsistency. Theseinconsistencies make it dicult or states tomaintain programs, capabilities and sucienemployeesparticularly trained scientic expertsor robust disaster preparedness andresponse systems.

Preparedness requires ongoing, stable, pre

dictable unding dedicated to ensure that basic

capabilities exist to respond to the threats pub

lic health departments ace every day and

also to have trained experts and systems in

place to quickly act in the ace o major and

unexpected emergencies.

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Eleven years ago, the nation was caught o-guardwhen the public health system was unpreparedor emergencies. Many core public health unc-tions, including epidemiology, laboratories andoutbreak surveillance were lacking. Reviews bythe Institute o Medicine (IOM), CDC, Govern-ment Accountability Oce (GAO) and otherexperts ound the countrys public health in-

rastructure had greatly deteriorated.70, 71, 72 Ontop o that, little groundwork was in place orhospitals and public health departments to re-spond to the massive infux o potential anthraxsamples, and there was a lack o coordination,training, leadership and communication withinthe eld and or public health departments towork with other rst responders. Similar tomilitary-readiness, public health emergencyreadiness necessitates ongoing planning, train-ing and upgrading o systems and technology.

Basic preparedness involves:

n Rapid detection o and response to majordisease threats, including those caused by na-ture and bioterrorism.

n Intensive investigative and diagnostic capabil-ities to detect an inectious disease outbreakor identiy the biological or chemical agentused in an attack.

nSurge capacity or mass events, includingadequate acilities, equipment, supplies andtrained health proessionals.

nMass containment strategies, including phar-

maceuticals needed or antibiotic or antidoteadministration and isolation and quarantin-ingwhen necessary.

n Streamlined and eective communicationchannels so health workers can switly and ac-curately communicate with each other, otherront line workers, and the public about 1)the nature o an emergency or attack, 2) therisk o exposure and how to seek treatmentwhen needed, and 3) any actions they or theiramilies should take to protect themselves.

nCommunication that is culturally competentand is able to reach and take into consider-ation at-risk populations.

n Streamlined and eective evacuation o at-risk populations with special medical needs.

n An inormed and involved public that can pro-vide material and moral support to proessionalresponders, and can render aid when necessaryto riends, amily, neighbors and associates.

Dedicated, predictable unding over time isneeded to support the unique capabilities and

training required to maintain adequate levels oemergency preparedness, including:

nLeadership, planning and coordination: An es-tablished chain-o-command and well-denedroles and responsibilities or seamless operationacross dierent medical and logistical unctionsand among ederal, state and local authorities

during crisis situations, including police, publicsaety ocials and other rst responders.

nCore public health capabilities: Basic publichealth systems and equipment, including lab-oratory testing and communications that keeppace with advances in science and technology.

nAn expert and ully-staed workorce: Highlytrained and sucient numbers o publichealth proessionals, including epidemiolo-gists, lab scientists, public health nurses, doc-tors and other experts, in addition to back-upworkers or surge capacity.

nModernized technology: State-o-the-art labo-ratory equipment and inormation collectionand health tracking systems.

nRapid development and ability to manuacturevaccines and medications: A streamlined, sae,eective system to ensure rapid research, pro-duction and dispensing o medical countermea-sures to protect people rom emerging threats.

nSaety protections or irst responders:Tested plans and saety precautions to miti-gate potential harm to communities, public

health proessionals and rst responders.nImmediate, streamlined communications capa-

bilities: Coordinated and integrated commu-nications among all parts o the public healthsystem, health care system, rontline respond-ers, and the public. Communications capabili-ties must include back-up systems in the evento power loss or overloaded wireless channels.

It is also essential to consider the costs o re-sponding to disasters and the toll it takes onhealth departments to nd mechanisms to pro-vide support or rebuilding ater an incident

and its response are over.

The current economic situation is compoundingthe problems created by the historic inconsistentunding or emergency preparedness. Com-bined ederal, state and local budget cuts have re-sulted in the loss o core programs and unctionsas well as major sta losses. Even beore the re-cession, ederal support or preparedness beganto decline. From FY 2005 to FY 2012, ederalsupport rom CDC or state and local activitiesdecreased by 38 percent, adjusted or infation.

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A decade o progress in preparedness is atrisk due to the cuts. Federal, state and localhealth departments w