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Progress in Public Health Emergency Preparedness—United States, 2001–2016 Bhavini Patel Murthy, MD, MPH, Noelle-Angelique M. Molinari, PhD, Tanya T. LeBlanc, MS, PhD, Sara J. Vagi, MS, PhD, and Rachel N. Avchen, MS, PhD Objectives. To evaluate the Public Health Emergency Preparedness (PHEP) program’s progress toward meeting public health preparedness capability standards in state, local, and territorial health departments. Methods. All 62 PHEP awardees completed the Centers for Disease Control and Prevention’s self-administered PHEP Impact Assessment as part of program review measuring public health preparedness capability before September 11, 2001 (9/11), and in 2014. We collected additional self-reported capability self-assessments from 2016. We analyzed trends in congressional funding for public health preparedness from 2001 to 2016. Results. Before 9/11, most PHEP awardees reported limited preparedness capabilities, but considerable progress was reported by 2016. The number of jurisdictions reporting established capability functions within the countermeasures and mitigation domain had the largest increase, almost 200%, by 2014. However, more than 20% of jurisdictions still reported underdeveloped coordination between the health system and public health agencies in 2016. Challenges and barriers to building PHEP capabilities included lack of trained personnel, plans, and sustained resources. Conclusions. Considerable progress in public health preparedness capability was observed from before 9/11 to 2016. Support, sustainment, and advancement of public health preparedness capability is critical to ensure a strong public health infrastructure. (Am J Public Health. 2017;107: S180–S185. doi:10.2105/AJPH.2017.304038)
T
he September 11, 2001 (9/11), and subsequent anthrax terrorist attacks were pivotal moments in US history. They heightened awareness about the need for system coordination among federal, state, and local governments. In 2002, Congress enacted the Public Health Security and Bioterrorism Preparedness and Response Act and appropriated nearly $1 billion annually to support state and local emergency preparedness and response to address bioterrorism threats; this was a significant effort to increase support for preparedness activities beyond the minimal funding that was available before 9/11.1–3 In 2006, Congress enacted the Pandemic and All-Hazards Preparedness Act (PAHPA) and enhanced public health preparedness and response by expanding the focus from bioterrorism to all hazards, which includes threats from natural disasters; chemical, nuclear, or radiological incidents; and emerging or
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reemerging infectious diseases (Figure 1).4 The Pandemic and All-Hazards Preparedness Reauthorization Act in 2013 (PAHPRA) focused on further strengthening public health preparedness and response and reauthorized PAHPA.5 Together, PAHPA and PAHPRA continue support for the Public Health Emergency Preparedness (PHEP) program6—first named the Public Health Preparedness and Response for Bioterrorism Program in 1999 and renamed the PHEP program in 2005. The PHEP program provides funding to state, local, and territorial governments to
advance public health to prevent, protect, respond, and rapidly recover from health emergencies (chemical, biological, radiological, nuclear, explosives, etc.) that threaten to overwhelm routine business and health security. Furthermore, PHEP supports the advancement of preparedness goals as outlined in the National Health Security Strategy by (1) establishing robust public health emergency management and response programs within state, local, and territorial public health agencies; (2) supporting key public health capabilities necessary for emergency planning and response; (3) ensuring response readiness for public health emergencies and disasters; and (4) promoting the health security of communities. In 2011, to assist state and local public health departments with their strategic planning, the Centers for Disease Control and Prevention (CDC) published national public health preparedness standards.7 This document enumerated 15 public health preparedness capabilities within 6 public health preparedness domains (biosurveillance, countermeasures and mitigation, information management, community resilience, incident management, and surge management) and listed associated functions within each capability describing elements needed to achieve that capability (Table 1).7 The purpose of this article is to describe the progress made toward developing preparedness capabilities among PHEP jurisdictions from before the 9/11 terrorist attacks through 2016.
ABOUT THE AUTHORS All authors are with the Division of State and Local Readiness, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Bhavini Patel Murthy is also with Epidemic Intelligence Service, CDC, Atlanta. Tanya T. LeBlanc and Rachel N. Avchen are also guest editors for this supplement issue. Correspondence should be sent to Bhavini Patel Murthy, MD, MPH, CDC/OPHPR, 1600 Clifton Rd NE, MS D-18, Atlanta, GA 30329 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted July 12, 2017. Note. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. doi: 10.2105/AJPH.2017.304038
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Legislation
Event
9/11 Terrorist Attacks 2001 Anthrax Attacks Homeland Security Act
2002
Public Health Security and Bioterrorism Preparedness and Response Act (PHSBPRA)
Severe Acute Respiratory 2003 Syndrome (SARS)
2003
Homeland Security Presdential Directive 5 and 8 (HSPD-5 and HSPD-8)
2005
2005
Public Readiness and Emergency Preparedness (PREP) Act
Hurricanes Katrina and Rita
Post-Katrina Emergency Management Reform Act Global Spread of H5N1 2006 Avian Influenza
2006
Pets Evacuation and Transporation Standards Act Pandemic and All-Hazards Preparedness Act (PAHPA)
H1N1 Influenza 2009
Hurricane Sandy 2012 Sandy Recovery Improvement Act
2013
Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA)
Ebolo Virus Outbreak 2014 Zika Virus Outbreak 2015 Flint, Michigan, Water Contamination 2016
FIGURE 1—Timeline of Public Health Emergency Preparedness in the United States Since September 11, 2001
METHODS Public health departments from 62 jurisdictions received funding since 2002 through the PHEP cooperative agreement, which is administered by CDC.8 The awardees include all 50 US states, 8 US territories and freely associated states (Puerto Rico, US Virgin Islands, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Republic of the Marshall Islands, Republic of Palau, and the Federated States of Micronesia), and 4 local jurisdictions
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(Chicago, IL; Los Angeles County, CA; New York, NY; and Washington, DC). We obtained funding information from the PHEP cooperative agreement from the final funding tables from fiscal years 2002 to 2016.8 Jurisdictions were provided a base funding award plus allotments to account for population size. A jurisdiction might have received additional funding if eligible for the Cities Readiness Initiative and if it had a Level 1 chemical laboratory.9,10 We inflation-adjusted all funds to 2016 US dollars by using the
Consumer Price Index from the US Bureau of Labor Statistics.11 We calculated PHEP dollars per capita by dividing funds by population estimates for years 2002 to 2009 and 2011 to 2016 and census counts for 2010.12
Measures 2001 and 2014 Data From Public Health Emergency Preparedness Impact Assessment. In 2014, CDC evaluated the PHEP program by reviewing capability planning advancements
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TABLE 1—Six Domains and 15 Public Health Preparedness Capabilities Domains
Capabilities
Biosurveillance
Public health laboratory testing Public health surveillance and epidemiological investigation
Community resilience
Community preparedness Community recovery
Countermeasures and mitigation
Medical countermeasure dispensing Medical materiel management and distribution Nonpharmaceutical interventions Responder safety and health
Incident management
Emergency operations coordination
Information management
Emergency public information and warning Information sharing
Surge management
Fatality management Mass care Medical surge Volunteer management
Source. Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response.7
among all 62 awardees. PHEP directors completed a 45-item Web-based questionnaire that addressed capability status retrospectively (before 9/11) and at the time of the inquiry (June 2014). Directors had 6 weeks to submit their response. Periodic reminders were sent by e-mail and announced during awardee national conference calls.
2016 Annual Public Health Preparedness Capabilities Assessment. Since 2012, all 62 jurisdictions conducted annual capability planning self-assessments by using the 15 national capability standards as part of the program requirement.7 Jurisdictions reported current status for each function within a capability according to a 5-point Likert scale (1 = no ability or capacity; 2 = limited ability or capacity; 3 = some ability or capacity; 4 = significant ability or capacity; and 5 = full ability or capacity).7 We recoded this scale during analyses into a dichotomous variable in which jurisdictions that reported values of 3 or greater were considered to have established function and those that reported a value of less than 3 were considered “not established.” For functions rated less than full ability or capacity, jurisdictions were asked to indicate primary challenges or barriers from a predefined list.
points: (1) before 9/11, (2) as of 2014, and (3) as of 2016 (based on capability planning). We aligned data from the 2016 Public Health Preparedness Capabilities Assessment at the capability function level with the 2001 and 2014 data from the PHEP Impact Assessment. We collected similar content on capability function between these 2 assessments; however, the questions were not identical. We assessed descriptive and summary statistics including mean, median, range, frequencies, and percentages by using SAS version 9.3 (SAS Institute, Cary, NC). We used percent difference to measure change in capability over time.
RESULTS Response rate for the PHEP Impact Assessment was 97% (60 of 62). Most jurisdictions retrospectively reported limited to no capability functions before 9/11. However, by 2014, most jurisdictions reported substantial development and overall improvements in capability planning down to the function level across all 6 domains (Table 2).
Capability Improvements Statistical Analysis We analyzed preparedness status as measured by a range of capability functions at 3 time
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Most notably, by 2016, all 62 jurisdictions reported 100% incident management infrastructure capability. Greatest gains were
observed in countermeasures and mitigation, with an almost 200% increase in the number of jurisdictions reporting points of dispensing sites and storage and distribution capability, and similarly a 193% increase in those reporting inventory management systems. Smaller gains occurred in the biosurveillance domain, although still large, with a greater than 150% increase in the number of jurisdictions reporting capability for electronic lab reporting (Table 2). Significant improvements were reported in preparedness capability functions across all domains from 2014 to 2016, although gains were smaller. The largest gain occurred within the surge management domain, with a 55% increase in jurisdictions reporting sufficient plans for vulnerable populations; however, the only reduction in capability was also evident in this domain with a 12% decrease in the number of jurisdictions reporting developed coordination between the health system and public health agencies.
Capability Challenges The most commonly reported challenges for overall capability functions from 2012 to 2016 included (1) missing or incomplete plans, (2) difficulties securing trained personnel, and (3) inadequate funding for recruitment of personnel. Although these were consistently reported as the top 3 capability challenges each year, percentages of awardees reporting them decreased across the 3 time periods. Awardees reporting missing or incomplete plans decreased by 28%; awardees reporting difficulties securing trained personnel decreased by 9%; and awardees reporting inadequate funding for recruitment of personnel decreased by 25%. Other common challenges reported in 2016 include lack of supporting infrastructure (18%), administrative barriers (19%), and additional corrective actions or testing necessary for the function to be fully in place (30%).
Funding Data Since 2001, Congress allocated $12.5 billion (in 2016 dollars) in PHEP funding and $1.9 billion (in 2016 dollars) in supplemental funding (appropriated after the fiscal year has begun) to support large-scale public health outbreaks of national concern including allocations for pandemic influenza in 2006, H1N1
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TABLE 2—Number and Percentage of Jurisdictions With Self-Reported Capability Functions by Domain: United States, Before September 11, 2001, and in 2014 and 2016 Jurisdictions With Function in Place
Percent Difference
Public Health Preparedness Capabilities Selected Functions Within Six Domains
Before 9/11, No. (%)
2014, No. (%)
2016, No. (%)
Before 9/11 and 2014, %
2014 and 2016, %
Biosurveillance Electronic platform to share epidemiological data with
5 (8)
46 (74)
62 (100)
161
30
3 (5)
44 (71)
59 (95)
174
29
12 (19)
53 (85)
60 (97)
126
12
laboratory Sufficient surveillance systems and integration between systems Sufficient laboratory testing capacity Community resilience Risk assessment or hazard vulnerability analysis
8 (13)
53 (85)
62 (100)
148
16
Meaningful community input and engagement
6 (10)
53 (85)
59 (95)
159
11
Mental health preparedness and response planning
1 (2)
50 (81)
56 (90)
192
11
Countermeasures and mitigation Preidentified points of dispensing sites
1 (2)
60 (97)
61 (98)
193
2
Inventory management system
1 (2)
55 (89)
61 (98)
193
10
Sufficient storage and distribution capability
0 (0)
59 (95)
62 (100)
200
5
12 (19)
59 (95)
62 (100)
132
5
3 (5)
60 (97)
62 (100)
181
3
13 (21)
57 (92)
62 (100)
126
8
3 (5)
54 (87)
62 (100)
179
14
Incident management Emergency operations center with ability to notify and mobilize Incident command structure with pre-assigned roles Operational response plan Continuity of operations plan Information management Sufficient inventory of risk communication materials
4 (6)
58 (94)
61 (98)
174
5
System to monitor and relay information using social media
0 (0)
53 (85)
58 (94)
200
9
Defined ESF-8 roles and health and medical coordination
9 (15)
56 (90)
59 (95)
145
5
Health system coordination with public health agencies
5 (8)
55 (89)
49 (79)
167
–12
Sufficient plans for vulnerable populations
0 (0)
33 (53)
58 (94)
200
55
System to manage volunteers
1 (2)
57 (92)
57 (92)
193
0
Surge management
Note. 9/11 = September 11, 2001; ESF-8 = Emergency Support Function 8 of the National Response Plan.13
pandemic influenza in 2009 and 2010, Ebola virus in 2014, and Zika virus in 2016. (Supplemental funding for H1N1 pandemic influenza was administered through the Public Health Emergency Response grant to upgrade state and local capacity for pandemic influenza preparedness and response. This funding was distributed in 4 phases over 2009 to 2010.) A review of the PHEP funding allocations shown in Figure 2 indicates that, beginning in 2003, funding per capita declined steadily for PHEP. Inflation-adjusted per capita PHEP funding for public health preparedness peaked at $4.41 per capita in 2003, and then fell by 60% to $1.75 per capita by 2016. Supplemental funding in 2010 for H1N1 influenza was $5.01 per capita and in 2014 for Ebola was $0.46 per capita for all 62 PHEP awardees. Zika supplemental funding was
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awarded to 53 jurisdictions on the basis of identification of competent mosquito vectors in 2016 and was $0.08 per capita.
DISCUSSION Public health preparedness capabilities standards were developed to assist public health departments with strategic development and planning. This article represents the first evaluation of progress in capability planning ascertained from PHEP-funded jurisdictions. All jurisdictions self-reported substantial improvements in preparedness capabilities across all 6 domains. The large increases that were noted across the domains may reflect an increase from the low baseline capabilities before 9/11. Advances in
preparedness capability are evident despite fluctuations in funding. However, there is widespread concern among public health professionals on the capacity of state and local health departments to sustain the capabilities developed or improved since 2001. Congressional funding supports the development of public health preparedness and response at the federal, state, local, and territorial levels. Per capita PHEP funding decreased with each successive fiscal year. Total funding for public health as a share of overall health spending declined from 3.18% in 2002 to 2.65% in 2014, and it is projected to fall further to 2.40% in 2023.14 Signs of deterioration of capability functions are evident by recent reports from city and local health departments. For example, the New York City Department of Health
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H1N1 (I, II, III)
5.00
4.50
Supplemental funds per capita, a 2016 US$ Nominal funds per capitab Real funds per capita,b 2016 US$
4.00
Funds Per Capita, US $
3.50
3.00
2.50
2.00
1.50
1.00 Ebola
Pandemic Influenza
0.50
H1N1 (IV)
Zika
0.00 2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Fiscal Year a Supplemental funding for H1N1 pandemic influenza was administered through the Public Health Emergency Response grant to upgrade state and local capacity for pandemic influenza preparedness and response. This funding was distributed in 4 phases (indicated in the figure as I, II, III, or IV) over 2009 to 2010. b
Nominal funding is unadjusted for inflation and reported in values according to funding year appropriated. Real funding is adjusted for inflation and reported in 2016 US dollars.
FIGURE 2—Public Health Emergency Preparedness Funding Per Capita in US Dollars: United States, Fiscal Years 2002–2016
and Mental Hygiene reported that an inability to offset the continuous decline in PHEP funding may lead to a decrease in surveillance and response capacity, public health emergency preparedness workforce staffing and development, and number of volunteers from Medical Reserve Corps.15 In addition, the report suggested that limited resources may have an impact on the department’s ability to respond to real emergencies, train and exercise, and participate in regional collaborations.15 Similarly, a study by the North Carolina Preparedness and Emergency Response Research Center invited 333 local health departments representing 40 states to complete a questionnaire on preparedness capacity
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from 2010 to 2012 and found declines in reported preparedness capabilities.16 Specifically, they found a reduction in surveillance and investigation and legal preparedness. Significant decreases in planning and protocols, communication, and incident command were also noteworthy.16 These reports have shown the importance of sustained resources to meet the basic preparedness needs at state, local, and city levels. Efforts to improve the definitions and measurement of public health emergency preparedness capabilities are ongoing. The progress made since 9/11 in developing, building, and sustaining robust public health preparedness capabilities are now foundational for public health preparedness and response systems that support large public health
responses.17 For example, the 2009 H1N1 influenza pandemic, 2014 Ebola virus outbreak, and 2016 Zika virus outbreak demonstrated the usefulness of preparedness and response capabilities in state, local, and territorial health departments across the nation.17–19 This analysis is subject to several limitations. First, analyses were based on selfreported data and are therefore subjective. Second, there were no baseline data systematically collected before 9/11, nor were health departments conducting capability assessments before 2012. As a result, pre-9/11 preparedness capabilities could be subject to recall bias; staffing and administration changes might influence institutional memory and reported data may not be accurate. However, responses represent best knowledge to date.
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Of note, the financial portion of this analysis does not take into account any additional funding that the jurisdictions may receive beyond the PHEP program. Public health emergencies affect more than the health of the nation; large emergencies can have far-reaching political, economic, and social consequences.20,21 To that end, the PHEP program highlights achievements in public health emergency preparedness and response. Support of the nation’s preparedness infrastructure is critical to safeguard national health security and ensure that the nation is prepared to respond and recover from all hazards that have an impact on public health. CONTRIBUTORS B. P. Murthy was involved in writing the article. N.-A.M. Molinari was involved in statistical analysis. S. J. Vagi, T. T. LeBlanc, and R. N. Avchen were involved with overall supervision of the project. All authors were involved in critical revision of the article.
ACKNOWLEDGMENTS We would like to thank the following individuals for their contributions while working with the Division of State and Local Readiness, Office of Public Health Preparedness and Response, CDC: Christine Kosmos, Sharon Sharpe, Michael Fanning, Thomas Morris, Brenda Chen, Terrance Jones, Nevin Krishna, and Christopher Reinold, of the Division of State and Local Readiness, Office of Public Health Preparedness and Response, CDC; Tara Strine, of the Center for Surveillance, Epidemiology, and Laboratory Services, Office of Public Health Scientific Services, CDC; Eric Carbone, of the Office of the Director, Office of Public Health Preparedness and Response, CDC; Emily Kahn, of the Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, CDC; and Morgane Donadel, Global Immunization Division, Center for Global Health, CDC.
HUMAN PARTICIPANT PROTECTION Human participant protection was not required because this activity was determined to be public health nonresearch.
REFERENCES
5. Pandemic and All-Hazards Preparedness Reauthorization Act of 2013, Pub L 113-5, 127 Stat 161(2013). Available at: https://www.gpo.gov/fdsys/pkg/BILLS-113hr307enr/ pdf/BILLS-113hr307enr.pdf. Accessed August 8, 2017. 6. Pandemic and All-Hazards Preparedness Reauthorization Act. US Department of Health and Human Services. March 22, 2016. Available at: http://www.phe. gov/Preparedness/legal/pahpa/Pages/pahpra.aspx. Accessed August 8, 2017. 7. Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response. Public health preparedness capabilities: national standards for state and local planning. 2011. Available at: https://www.cdc.gov/ phpr/readiness/00_docs/DSLR_capabilities_July.pdf. Accessed August 8, 2017. 8. Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response. Public Health Emergency Preparedness cooperative agreements. 2017. Available at: https://www.cdc.gov/phpr/archive.htm. Accessed August 8, 2017. 9. Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response. Medical countermeasure readiness. 2016. Available at: https://www.cdc. gov/phpr/stockpile/cri. Accessed August 8, 2017. 10. Laboratory Response Network for Chemical Threats (LRN-C). Centers for Disease Control and Prevention. 2014. Available at: https://emergency.cdc.gov/lrn/ chemical.asp. Accessed August 8, 2017. 11. US Bureau of Labor Statistics. CPI news releases. Available at: https://www.bls.gov/cpi/home.htm. Accessed August 8, 2017. 12. US Census Bureau. American FactFinder. Available at: http://factfinder2.census.gov. Accessed August 8, 2017. 13. Emergency support function #8. Public Health Emergency, Office of the Assistant Secretary for Preparedness and Response, US Department of Health and Human Services. 2012. Available at: https://www.phe. gov/Preparedness/planning/mscc/handbook/chapter7/ Pages/emergency.aspx. Accessed August 8, 2017. 14. Himmelstein DU, Woolhandler S. Public health’s falling share of US health spending. Am J Public Health. 2016;106(1):56–57. 15. Marquez M, Patel P, Raphael M, Morgenthau BM. The danger of declining funds: public health preparedness in NYC. Biosecur Bioterror. 2009;7(3):337–345. 16. Davis MV, Bevc CA, Schenck AP. Declining trends in local health department preparedness capacities. Am J Public Health. 2014;104(11):2233–2238.
1. Centers for Disease Control and Prevention. 2013– 2014 national snapshot of public health preparedness. Available at: https://www.cdc.gov/phpr/pubslinks/2013/documents/2013_preparedness_report_ background.pdf. Accessed August 8, 2017.
17. Redd SC, Frieden TR. CDC’s evolving approach to emergency response. Health Secur. 2017;15(1):41–52.
2. Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Pub L 107–188, 116 Stat 594(2002). Available at: https://www.congress.gov/107/plaws/ publ188/PLAW-107publ188.pdf. Accessed August 8, 2017.
19. Uzun Jacobson E, Inglesby T, Khan AS, et al. Design of the national health security preparedness index. Biosecur Bioterror. 2014;12(3):122–131.
3. Heinrich J. Bioterrorism: the Centers for Disease Control and Prevention’s role in public health protection. US General Accounting Office. 2002. Available at: http://www.gao.gov/assets/90/81756.html. Accessed August 8, 2017.
18. Oussayef NL, Pillai SK, Honein MA, et al. Zika virus— 10 public health achievements in 2016 and future priorities. MMWR Morb Mortal Wkly Rep. 2017;65(52):1482–1488.
20. Heymann DL, Chen L, Takemi K, et al. Global health security: the wider lessons from the West African Ebola virus disease epidemic. Lancet. 2015;385(9980):1884–1901. 21. Patel MS, Phillips CB. Health security and political and economic determinants of Ebola. Lancet. 2015; 386(9995):737–738.
4. Pandemic and All-Hazards Preparedness Act, Pub L 109–417, 120 Stat 2832(2006). Available at: https:// www.gpo.gov/fdsys/pkg/PLAW-109publ417/pdf/ PLAW-109publ417.pdf. Accessed August 8, 2017.
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Progress in Public Health Emergency Preparedness—United States, 2001–2016 Bhavini Patel Murthy, MD, MPH, Noelle-Angelique M. Molinari, PhD, Tanya T. LeBlanc, MS, PhD, Sara J. Vagi, MS, PhD, and Rachel N. Avchen, MS, PhD Objectives. To evaluate the Public Health Emergency Preparedness (PHEP) program’s progress toward meeting public health preparedness capability standards in state, local, and territorial health departments. Methods. All 62 PHEP awardees completed the Centers for Disease Control and Prevention’s self-administered PHEP Impact Assessment as part of program review measuring public health preparedness capability before September 11, 2001 (9/11), and in 2014. We collected additional self-reported capability self-assessments from 2016. We analyzed trends in congressional funding for public health preparedness from 2001 to 2016. Results. Before 9/11, most PHEP awardees reported limited preparedness capabilities, but considerable progress was reported by 2016. The number of jurisdictions reporting established capability functions within the countermeasures and mitigation domain had the largest increase, almost 200%, by 2014. However, more than 20% of jurisdictions still reported underdeveloped coordination between the health system and public health agencies in 2016. Challenges and barriers to building PHEP capabilities included lack of trained personnel, plans, and sustained resources. Conclusions. Considerable progress in public health preparedness capability was observed from before 9/11 to 2016. Support, sustainment, and advancement of public health preparedness capability is critical to ensure a strong public health infrastructure. (Am J Public Health. 2017;107: S180–S185. doi:10.2105/AJPH.2017.304038)
T
he September 11, 2001 (9/11), and subsequent anthrax terrorist attacks were pivotal moments in US history. They heightened awareness about the need for system coordination among federal, state, and local governments. In 2002, Congress enacted the Public Health Security and Bioterrorism Preparedness and Response Act and appropriated nearly $1 billion annually to support state and local emergency preparedness and response to address bioterrorism threats; this was a significant effort to increase support for preparedness activities beyond the minimal funding that was available before 9/11.1–3 In 2006, Congress enacted the Pandemic and All-Hazards Preparedness Act (PAHPA) and enhanced public health preparedness and response by expanding the focus from bioterrorism to all hazards, which includes threats from natural disasters; chemical, nuclear, or radiological incidents; and emerging or
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reemerging infectious diseases (Figure 1).4 The Pandemic and All-Hazards Preparedness Reauthorization Act in 2013 (PAHPRA) focused on further strengthening public health preparedness and response and reauthorized PAHPA.5 Together, PAHPA and PAHPRA continue support for the Public Health Emergency Preparedness (PHEP) program6—first named the Public Health Preparedness and Response for Bioterrorism Program in 1999 and renamed the PHEP program in 2005. The PHEP program provides funding to state, local, and territorial governments to
advance public health to prevent, protect, respond, and rapidly recover from health emergencies (chemical, biological, radiological, nuclear, explosives, etc.) that threaten to overwhelm routine business and health security. Furthermore, PHEP supports the advancement of preparedness goals as outlined in the National Health Security Strategy by (1) establishing robust public health emergency management and response programs within state, local, and territorial public health agencies; (2) supporting key public health capabilities necessary for emergency planning and response; (3) ensuring response readiness for public health emergencies and disasters; and (4) promoting the health security of communities. In 2011, to assist state and local public health departments with their strategic planning, the Centers for Disease Control and Prevention (CDC) published national public health preparedness standards.7 This document enumerated 15 public health preparedness capabilities within 6 public health preparedness domains (biosurveillance, countermeasures and mitigation, information management, community resilience, incident management, and surge management) and listed associated functions within each capability describing elements needed to achieve that capability (Table 1).7 The purpose of this article is to describe the progress made toward developing preparedness capabilities among PHEP jurisdictions from before the 9/11 terrorist attacks through 2016.
ABOUT THE AUTHORS All authors are with the Division of State and Local Readiness, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Bhavini Patel Murthy is also with Epidemic Intelligence Service, CDC, Atlanta. Tanya T. LeBlanc and Rachel N. Avchen are also guest editors for this supplement issue. Correspondence should be sent to Bhavini Patel Murthy, MD, MPH, CDC/OPHPR, 1600 Clifton Rd NE, MS D-18, Atlanta, GA 30329 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted July 12, 2017. Note. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. doi: 10.2105/AJPH.2017.304038
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Legislation
Event
9/11 Terrorist Attacks 2001 Anthrax Attacks Homeland Security Act
2002
Public Health Security and Bioterrorism Preparedness and Response Act (PHSBPRA)
Severe Acute Respiratory 2003 Syndrome (SARS)
2003
Homeland Security Presdential Directive 5 and 8 (HSPD-5 and HSPD-8)
2005
2005
Public Readiness and Emergency Preparedness (PREP) Act
Hurricanes Katrina and Rita
Post-Katrina Emergency Management Reform Act Global Spread of H5N1 2006 Avian Influenza
2006
Pets Evacuation and Transporation Standards Act Pandemic and All-Hazards Preparedness Act (PAHPA)
H1N1 Influenza 2009
Hurricane Sandy 2012 Sandy Recovery Improvement Act
2013
Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA)
Ebolo Virus Outbreak 2014 Zika Virus Outbreak 2015 Flint, Michigan, Water Contamination 2016
FIGURE 1—Timeline of Public Health Emergency Preparedness in the United States Since September 11, 2001
METHODS Public health departments from 62 jurisdictions received funding since 2002 through the PHEP cooperative agreement, which is administered by CDC.8 The awardees include all 50 US states, 8 US territories and freely associated states (Puerto Rico, US Virgin Islands, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Republic of the Marshall Islands, Republic of Palau, and the Federated States of Micronesia), and 4 local jurisdictions
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(Chicago, IL; Los Angeles County, CA; New York, NY; and Washington, DC). We obtained funding information from the PHEP cooperative agreement from the final funding tables from fiscal years 2002 to 2016.8 Jurisdictions were provided a base funding award plus allotments to account for population size. A jurisdiction might have received additional funding if eligible for the Cities Readiness Initiative and if it had a Level 1 chemical laboratory.9,10 We inflation-adjusted all funds to 2016 US dollars by using the
Consumer Price Index from the US Bureau of Labor Statistics.11 We calculated PHEP dollars per capita by dividing funds by population estimates for years 2002 to 2009 and 2011 to 2016 and census counts for 2010.12
Measures 2001 and 2014 Data From Public Health Emergency Preparedness Impact Assessment. In 2014, CDC evaluated the PHEP program by reviewing capability planning advancements
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TABLE 1—Six Domains and 15 Public Health Preparedness Capabilities Domains
Capabilities
Biosurveillance
Public health laboratory testing Public health surveillance and epidemiological investigation
Community resilience
Community preparedness Community recovery
Countermeasures and mitigation
Medical countermeasure dispensing Medical materiel management and distribution Nonpharmaceutical interventions Responder safety and health
Incident management
Emergency operations coordination
Information management
Emergency public information and warning Information sharing
Surge management
Fatality management Mass care Medical surge Volunteer management
Source. Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response.7
among all 62 awardees. PHEP directors completed a 45-item Web-based questionnaire that addressed capability status retrospectively (before 9/11) and at the time of the inquiry (June 2014). Directors had 6 weeks to submit their response. Periodic reminders were sent by e-mail and announced during awardee national conference calls.
2016 Annual Public Health Preparedness Capabilities Assessment. Since 2012, all 62 jurisdictions conducted annual capability planning self-assessments by using the 15 national capability standards as part of the program requirement.7 Jurisdictions reported current status for each function within a capability according to a 5-point Likert scale (1 = no ability or capacity; 2 = limited ability or capacity; 3 = some ability or capacity; 4 = significant ability or capacity; and 5 = full ability or capacity).7 We recoded this scale during analyses into a dichotomous variable in which jurisdictions that reported values of 3 or greater were considered to have established function and those that reported a value of less than 3 were considered “not established.” For functions rated less than full ability or capacity, jurisdictions were asked to indicate primary challenges or barriers from a predefined list.
points: (1) before 9/11, (2) as of 2014, and (3) as of 2016 (based on capability planning). We aligned data from the 2016 Public Health Preparedness Capabilities Assessment at the capability function level with the 2001 and 2014 data from the PHEP Impact Assessment. We collected similar content on capability function between these 2 assessments; however, the questions were not identical. We assessed descriptive and summary statistics including mean, median, range, frequencies, and percentages by using SAS version 9.3 (SAS Institute, Cary, NC). We used percent difference to measure change in capability over time.
RESULTS Response rate for the PHEP Impact Assessment was 97% (60 of 62). Most jurisdictions retrospectively reported limited to no capability functions before 9/11. However, by 2014, most jurisdictions reported substantial development and overall improvements in capability planning down to the function level across all 6 domains (Table 2).
Capability Improvements Statistical Analysis We analyzed preparedness status as measured by a range of capability functions at 3 time
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Most notably, by 2016, all 62 jurisdictions reported 100% incident management infrastructure capability. Greatest gains were
observed in countermeasures and mitigation, with an almost 200% increase in the number of jurisdictions reporting points of dispensing sites and storage and distribution capability, and similarly a 193% increase in those reporting inventory management systems. Smaller gains occurred in the biosurveillance domain, although still large, with a greater than 150% increase in the number of jurisdictions reporting capability for electronic lab reporting (Table 2). Significant improvements were reported in preparedness capability functions across all domains from 2014 to 2016, although gains were smaller. The largest gain occurred within the surge management domain, with a 55% increase in jurisdictions reporting sufficient plans for vulnerable populations; however, the only reduction in capability was also evident in this domain with a 12% decrease in the number of jurisdictions reporting developed coordination between the health system and public health agencies.
Capability Challenges The most commonly reported challenges for overall capability functions from 2012 to 2016 included (1) missing or incomplete plans, (2) difficulties securing trained personnel, and (3) inadequate funding for recruitment of personnel. Although these were consistently reported as the top 3 capability challenges each year, percentages of awardees reporting them decreased across the 3 time periods. Awardees reporting missing or incomplete plans decreased by 28%; awardees reporting difficulties securing trained personnel decreased by 9%; and awardees reporting inadequate funding for recruitment of personnel decreased by 25%. Other common challenges reported in 2016 include lack of supporting infrastructure (18%), administrative barriers (19%), and additional corrective actions or testing necessary for the function to be fully in place (30%).
Funding Data Since 2001, Congress allocated $12.5 billion (in 2016 dollars) in PHEP funding and $1.9 billion (in 2016 dollars) in supplemental funding (appropriated after the fiscal year has begun) to support large-scale public health outbreaks of national concern including allocations for pandemic influenza in 2006, H1N1
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TABLE 2—Number and Percentage of Jurisdictions With Self-Reported Capability Functions by Domain: United States, Before September 11, 2001, and in 2014 and 2016 Jurisdictions With Function in Place
Percent Difference
Public Health Preparedness Capabilities Selected Functions Within Six Domains
Before 9/11, No. (%)
2014, No. (%)
2016, No. (%)
Before 9/11 and 2014, %
2014 and 2016, %
Biosurveillance Electronic platform to share epidemiological data with
5 (8)
46 (74)
62 (100)
161
30
3 (5)
44 (71)
59 (95)
174
29
12 (19)
53 (85)
60 (97)
126
12
laboratory Sufficient surveillance systems and integration between systems Sufficient laboratory testing capacity Community resilience Risk assessment or hazard vulnerability analysis
8 (13)
53 (85)
62 (100)
148
16
Meaningful community input and engagement
6 (10)
53 (85)
59 (95)
159
11
Mental health preparedness and response planning
1 (2)
50 (81)
56 (90)
192
11
Countermeasures and mitigation Preidentified points of dispensing sites
1 (2)
60 (97)
61 (98)
193
2
Inventory management system
1 (2)
55 (89)
61 (98)
193
10
Sufficient storage and distribution capability
0 (0)
59 (95)
62 (100)
200
5
12 (19)
59 (95)
62 (100)
132
5
3 (5)
60 (97)
62 (100)
181
3
13 (21)
57 (92)
62 (100)
126
8
3 (5)
54 (87)
62 (100)
179
14
Incident management Emergency operations center with ability to notify and mobilize Incident command structure with pre-assigned roles Operational response plan Continuity of operations plan Information management Sufficient inventory of risk communication materials
4 (6)
58 (94)
61 (98)
174
5
System to monitor and relay information using social media
0 (0)
53 (85)
58 (94)
200
9
Defined ESF-8 roles and health and medical coordination
9 (15)
56 (90)
59 (95)
145
5
Health system coordination with public health agencies
5 (8)
55 (89)
49 (79)
167
–12
Sufficient plans for vulnerable populations
0 (0)
33 (53)
58 (94)
200
55
System to manage volunteers
1 (2)
57 (92)
57 (92)
193
0
Surge management
Note. 9/11 = September 11, 2001; ESF-8 = Emergency Support Function 8 of the National Response Plan.13
pandemic influenza in 2009 and 2010, Ebola virus in 2014, and Zika virus in 2016. (Supplemental funding for H1N1 pandemic influenza was administered through the Public Health Emergency Response grant to upgrade state and local capacity for pandemic influenza preparedness and response. This funding was distributed in 4 phases over 2009 to 2010.) A review of the PHEP funding allocations shown in Figure 2 indicates that, beginning in 2003, funding per capita declined steadily for PHEP. Inflation-adjusted per capita PHEP funding for public health preparedness peaked at $4.41 per capita in 2003, and then fell by 60% to $1.75 per capita by 2016. Supplemental funding in 2010 for H1N1 influenza was $5.01 per capita and in 2014 for Ebola was $0.46 per capita for all 62 PHEP awardees. Zika supplemental funding was
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awarded to 53 jurisdictions on the basis of identification of competent mosquito vectors in 2016 and was $0.08 per capita.
DISCUSSION Public health preparedness capabilities standards were developed to assist public health departments with strategic development and planning. This article represents the first evaluation of progress in capability planning ascertained from PHEP-funded jurisdictions. All jurisdictions self-reported substantial improvements in preparedness capabilities across all 6 domains. The large increases that were noted across the domains may reflect an increase from the low baseline capabilities before 9/11. Advances in
preparedness capability are evident despite fluctuations in funding. However, there is widespread concern among public health professionals on the capacity of state and local health departments to sustain the capabilities developed or improved since 2001. Congressional funding supports the development of public health preparedness and response at the federal, state, local, and territorial levels. Per capita PHEP funding decreased with each successive fiscal year. Total funding for public health as a share of overall health spending declined from 3.18% in 2002 to 2.65% in 2014, and it is projected to fall further to 2.40% in 2023.14 Signs of deterioration of capability functions are evident by recent reports from city and local health departments. For example, the New York City Department of Health
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H1N1 (I, II, III)
5.00
4.50
Supplemental funds per capita, a 2016 US$ Nominal funds per capitab Real funds per capita,b 2016 US$
4.00
Funds Per Capita, US $
3.50
3.00
2.50
2.00
1.50
1.00 Ebola
Pandemic Influenza
0.50
H1N1 (IV)
Zika
0.00 2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Fiscal Year a Supplemental funding for H1N1 pandemic influenza was administered through the Public Health Emergency Response grant to upgrade state and local capacity for pandemic influenza preparedness and response. This funding was distributed in 4 phases (indicated in the figure as I, II, III, or IV) over 2009 to 2010. b
Nominal funding is unadjusted for inflation and reported in values according to funding year appropriated. Real funding is adjusted for inflation and reported in 2016 US dollars.
FIGURE 2—Public Health Emergency Preparedness Funding Per Capita in US Dollars: United States, Fiscal Years 2002–2016
and Mental Hygiene reported that an inability to offset the continuous decline in PHEP funding may lead to a decrease in surveillance and response capacity, public health emergency preparedness workforce staffing and development, and number of volunteers from Medical Reserve Corps.15 In addition, the report suggested that limited resources may have an impact on the department’s ability to respond to real emergencies, train and exercise, and participate in regional collaborations.15 Similarly, a study by the North Carolina Preparedness and Emergency Response Research Center invited 333 local health departments representing 40 states to complete a questionnaire on preparedness capacity
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from 2010 to 2012 and found declines in reported preparedness capabilities.16 Specifically, they found a reduction in surveillance and investigation and legal preparedness. Significant decreases in planning and protocols, communication, and incident command were also noteworthy.16 These reports have shown the importance of sustained resources to meet the basic preparedness needs at state, local, and city levels. Efforts to improve the definitions and measurement of public health emergency preparedness capabilities are ongoing. The progress made since 9/11 in developing, building, and sustaining robust public health preparedness capabilities are now foundational for public health preparedness and response systems that support large public health
responses.17 For example, the 2009 H1N1 influenza pandemic, 2014 Ebola virus outbreak, and 2016 Zika virus outbreak demonstrated the usefulness of preparedness and response capabilities in state, local, and territorial health departments across the nation.17–19 This analysis is subject to several limitations. First, analyses were based on selfreported data and are therefore subjective. Second, there were no baseline data systematically collected before 9/11, nor were health departments conducting capability assessments before 2012. As a result, pre-9/11 preparedness capabilities could be subject to recall bias; staffing and administration changes might influence institutional memory and reported data may not be accurate. However, responses represent best knowledge to date.
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Of note, the financial portion of this analysis does not take into account any additional funding that the jurisdictions may receive beyond the PHEP program. Public health emergencies affect more than the health of the nation; large emergencies can have far-reaching political, economic, and social consequences.20,21 To that end, the PHEP program highlights achievements in public health emergency preparedness and response. Support of the nation’s preparedness infrastructure is critical to safeguard national health security and ensure that the nation is prepared to respond and recover from all hazards that have an impact on public health. CONTRIBUTORS B. P. Murthy was involved in writing the article. N.-A.M. Molinari was involved in statistical analysis. S. J. Vagi, T. T. LeBlanc, and R. N. Avchen were involved with overall supervision of the project. All authors were involved in critical revision of the article.
ACKNOWLEDGMENTS We would like to thank the following individuals for their contributions while working with the Division of State and Local Readiness, Office of Public Health Preparedness and Response, CDC: Christine Kosmos, Sharon Sharpe, Michael Fanning, Thomas Morris, Brenda Chen, Terrance Jones, Nevin Krishna, and Christopher Reinold, of the Division of State and Local Readiness, Office of Public Health Preparedness and Response, CDC; Tara Strine, of the Center for Surveillance, Epidemiology, and Laboratory Services, Office of Public Health Scientific Services, CDC; Eric Carbone, of the Office of the Director, Office of Public Health Preparedness and Response, CDC; Emily Kahn, of the Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, CDC; and Morgane Donadel, Global Immunization Division, Center for Global Health, CDC.
HUMAN PARTICIPANT PROTECTION Human participant protection was not required because this activity was determined to be public health nonresearch.
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