Embargoed until ISSUE REPORT Ready or Not? 10:00 am ET on December 20 2016 PROTECTING THE PUBLIC’S HEALTH FROM DISEASES, DISASTERS AND BIOTERRORISM DECEMBER 2016 Acknowledgements Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. TFAH BOARD OF DIRECTORS REPORT AUTHORS REPORT CONTRIBUTORS Gail C. Christopher, DN Laura M. Segal, MA Alejandra Martín, MPH Chair of the Board, TFAH Vice President of Public Affairs Health Policy Research Manager Vice President for Policy and Senior Advisor Trust for America’s Health Trust for America’s Health WK Kellogg Foundation Dara Alpert Lieberman, MPP Rebecca St. Laurent, JD Cynthia M. Harris, PhD, DABT Senior Government Relations Manager Consultant Vice Chair of the Board, TFAH Trust for America’s Health Ryan Durga Director and Professor Kendra May, MPH Government Relations & Outreach Intern Institute of Public Health, Florida A&M Consultant Trust for America’s Health University Chris N. Mangal, MPH Theodore Spencer Director of Public Health Preparedness Secretary of the Board, TFAH and Response Senior Advocate, Climate Center Association of Public Health Laboratories Natural Resources Defense Council Robert T. Harris, MD Treasurer of the Board, TFAH Medical Director PEER REVIEWERS North Carolina Medicaid Support Services TFAH thanks the following individuals and organizations for their time, expertise and in- CSC, Inc. sights in the reviewing all or portions of the report. The opinions in the report do not neces- David Fleming, MD sarily represent the views of these individuals or their organizations. Vice President PATH James S. Blumenstock Emily Lord, MPA Octavio N. Martinez, Jr., MD, MPH, MBA, FAPA Chief Program Officer for Health Security Executive Director Executive Director Association of State and Territorial Health Healthcare Ready (formerly Rx Response) Hogg Foundation for Mental Health at the Officials Nicolette A. Louissaint, Ph.D. University of Texas at Austin Ellen P. Carlin, DVM Director of Programming C. Kent McGuire, PhD Senior Health and Policy Specialist Healthcare Ready (formerly Rx Response) President and CEO EcoHealth Alliance Alisha Powell Southern Education Foundation Sarah Despres, J.D. Program Director, Homeland Security and Public Eduardo Sanchez, MD, MPH Director, Government Relations – Health Programs Safety Chief Medical Officer for Prevention The Pew Charitable Trusts NGA Center for Best Practices American Heart Association Sandra Eskin, J.D. Kathy Talkington, MPA Director, Food Safety Project Director, Antibiotic Resistance Project The Pew Charitable Trusts The Pew Charitable Trusts Dan Hanfling, MD​ Eric Toner, MD Contributing Scholar Senior Associate UMPC Center for Health Security UMPC Center for Health Security The Ready or Not? report is funded by a grant from the Robert Wood Johnson Foundation (RWJF). TFAH would like to thank RWJF for its generous support. For more than 40 years, the Robert Wood Johnson Foundation has worked to improve the health and health care of all Americans. We are striving to build a national Culture of Health that will enable all Americans to live longer, healthier lives now and for generations to come. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook. 2 TFAH • healthyamericans.org Ready or Not? TABLE OF CONTENTS Table of Contents INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Protecting the SECTION 1: STATE-BY-STATE INFECTIOUS DISEASE PREVENTION AND CONTROL INDICATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Public’s Health Indicator Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 from Diseases, Indicator Map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Disasters and Indicator Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Bioterrorism Indicator 1: Public Health Funding Commitment — State Public Health Budgets . . . . 18 Indicator 2: National Health Security Preparedness Index™ . . . . . . . . . . . . . . . . . . 20 Indicator 3: Public Health Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Indicator 4: Flu Vaccination Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Indicator 5: Climate Change Readiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Indicator 6: Food Safety — DNA Fingerprinting Using Pulsed-Field Gel Electrophoresis for Testing Escherichia coli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Indicator 7: Reducing Healthcare Associated Infections (HAIs) — Implemented Four Recommended Activities to Build Capacity for HAI Prevention . . . . . . . . . . . . . . . . . 31 Indicator 8: Public Health Laboratories — State Laboratories Reported Having a Biosafety Professional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Indicator 9: Public Health Laboratories — State Laboratories Provided Biosafety Training and/or Provided Information about Biosafety Training Courses for Sentinel Clinical Labs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Indicator 10: Healthcare Preparedness Access to Disaster Sites . . . . . . . . . . . . . . . 38 SECTION 2: NATIONAL HEALTH SECURITY ISSUES AND RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Background Review of Major Recent Federal Directives, Strategies and Reports . . . . 42 A. Reforming Baseline Abilities to Diagnose, Detect and Control Health Crises: Foundational Capabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 B. Supporting Stable, Sufficient Funding for Ongoing Emergency Preparedness — and Funding a Permanent Public Health Emergency DECEMBER 2016 Fund for Immediate and “Surge” Needs During an Emergency . . . . . . . . . . . . . . . . 55 C. Supporting Global Health Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 D. Improving Federal Leadership Before, During and After Disasters . . . . . . . . . . . . 59 Table of Contents (continued) E. Innovating and Modernizing Infrastructure, Including Biosurveillance and Medical Countermeasures Development and Wider Implementation of Faster Diagnosis . . . . 64 F. Maintaining a Robust, Well-Trained Public Health Workforce . . . . . . . . . . . . . . . . . 72 G. Rebooting and Developing a New Strategy for Hospital and Healthcare Readiness; Improving Healthcare Infectious Control Practices . . . . . . . . . . . . . . . . . . . . . . . . . 74 H. Supporting Community Resilience — for Communities to Better Cope and Recover from Emergencies — With Better Behavioral Health Infrastructure and Capacity . . . . 80 I. Readying for Climate Change and Weather-Related Threats . . . . . . . . . . . . . . . . . 83 J. Stopping Superbugs and Antibiotic Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . 85 K. Improving Vaccination Rates — for Children and Adults . . . . . . . . . . . . . . . . . . . 87 L. Fixing Food Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 APPENDIX A: STATE PUBLIC HEALTH BUDGET METHODOLOGY . . . . . . . . . 93 APPENDIX B: PUBLIC HEALTH EMERGENCY PREPAREDNESS (PHP) AND HOSPITAL PREPAREDNESS PROGRAM (HPP) GRANTS TO STATES . . . . . . . 94 4 TFAH • healthyamericans.org I N TRO DUCT IO N Ready or Not? INTRODUCTION Ready or Not? Protecting the Public’s Health from Diseases, Protecting the Disasters and Bioterrorism Public’s Health Health emergencies disrupt the lives of millions of Americans from Diseases, and cost the country billions of dollars each year. Disasters and While emergencies are inevitable, the may be diverted from other ongoing Bioterrorism country is often caught “off guard” priorities to address immediate when a new threat arises, whether it is needs. This leads to situations where a disease outbreak like Zika or Ebola, a a significant amount of emergency natural disaster or a bioterrorist threat. supplemental funds are needed to “pay back” the diverted money, but The current system is not built for they are often insufficient to fill “readiness” — to be able to consistently the gaps that are left or make up respond in an effective and efficient way for the damage done by diverting when new crises occur. Health security from other priorities — such as the is chronically underfunded. So when escalating hepatitis C crisis, measles emergencies happens, they divert time, and whooping cough outbreaks, attention and resources away from other healthcare-associated infections and ongoing needs and priorities. maintaining food safety systems; l I nvestments are often made in l T he funding provided is often too response to new emergencies — once little, too late — and is not sufficient they have already become serious to backfill longstanding gaps in problems — instead of maintaining preparedness and response for ongoing core preparedness and ongoing and emerging threats; response capabilities; • ailure to invest in cross-cutting F • he country often relies on a T capabilities leads to insufficient series of emergency supplemental health security, such as not updating funding packages, which require surveillance and diagnostic new debate and analyses for each systems to keep pace with modern new problem instead of having a technology; maintaining a sustained, standing Health Emergency Fund modern public health workforce; or that can immediately provide a surge sufficiently investing in the research of funding to effectively and quickly and development of new medical respond to crises. While new funding countermeasures; is being deliberated, existing funds DECEMBER 2016 l O nce an emergency subsides, Operations Centers (federal and Healthcare Emergency complacency leads to funds being cut in states), Laboratory Response Preparedness Funds Have Been Cut that are needed to maintain baseline Network, Strategic National in Half Since 2004 public health capabilities; Stockpile and management of select biological agents and toxins;2, 3 • Many improvements made after 9/11, the anthrax tragedies and • nstable funding leads to a cycle of U Hurricane Katrina have eroded. The hiring and firing of trained specialists primary source for state and local — which often means the experts $515 million preparedness for health emergencies needed to respond are not on-staff or has been cut by around one-third available when new crises hit; $255 million (from $940 million in fiscal year (FY) l L ack of clear, consistent preparedness 2002 to $660 million in FY 2016, and response capabilities mean that including cuts restored by the Zika FY 2004 FY 2016 abilities range dramatically from supplemental funding) and hospital community to community across the emergency preparedness funds have country; and been cut in half ($515 million in FY 2004 to $255 million in FY 2016);1 l D isjointed, uncoordinated and inconsistent planning across the • urther cuts to preparedness F public health, healthcare and other programs at the Centers for emergency first responders and across Disease Control and Prevention federal, state and local agencies and (CDC) would disrupt key critical programs leads to inefficient and infrastructure — the nation’s unprepared responses, rather than disease command and control maintaining ongoing planning, testing centers — including the Emergency and readiness coordination. Management Program, Emergency HEALTH SECURITY MATTERS4, 5 l I n the course of one year, CDC’s Emer- in the past 2 years alone. There have gency Management Program has con- been more than 16 known terror plots ducted 585 global activities, including in New York City alone since 9/11. 65 Emergency Operations Center acti- l E very year, an average of one brand vations for outbreaks in 28 countries, new contagious disease emerges — for including in the United States, and the past 30 years. Infectious diseases 135 exercises. regularly cost the country a minimum l C DC’s Emergency Operations Center of $170 billion year — and major new has been activated more than 90 per- pandemics have the potential to disrupt cent of the time in the past 7 years. the global economy. A severe new flu CDC scientists have responded to pandemic could cost the country more more than 750 health emergencies in than $680 billion — 5.5 percent of the the United States and around the world Gross Domestic Product.6 6 TFAH • healthyamericans.org In 2003, TFAH first issued the Ready l ome major areas of accomplishment S or Not? report to examine the nation’s include: Emergency operations A modern and stable readiness to respond to public health planning and coordination; public biodefense requires refocusing emergencies. Over time, the report health laboratories; more advanced has tracked significant progress that development and manufacturing public health departments, has been achieved, but also remaining for vaccines and other medical healthcare and resources to vulnerabilities that have never been countermeasures; development of the more effectively use workforce, sufficiently addressed and the backsliding Strategic National Stockpile, a federal of some advances, as budgets needed to repository of medical countermeasures, emerging technology and support capabilities have been cut. as well as an improved system to develop strategies to achieve better medical countermeasures more quickly; A modern and stable biodefense outcomes and results. pharmaceutical and medical equipment requires refocusing public health distribution and administration; departments, healthcare and resources surveillance and epidemiologic to more effectively use workforce, investigation; information sharing and emerging technology and strategies to communications; legal and liability achieve better outcomes and results protections; advances in foodborne — and better protect Americans from illness detection; animal health new and ongoing threats. A strategic surveillance; increasing and upgrading modern biodefense also yields strong public health staffing trained to prevent returns — investing in prevention and and respond to emergencies; and effective standing response capabilities improving systems for deployment of helps avoid the costs in dollars and lives. emergency medical and public health Ready or Not? includes a review of state personnel. and federal public health preparedness. l ome major ongoing gaps include: S The report is intended to help inform Coordinated, interoperable, near real- policymakers, partners and the public time biosurveillance; a stable medical about the status of preparedness. It countermeasure strategy and funding provides a snapshot of a number of to continue research, development important indicators of preparedness and purchase of vaccines, antiviral and reviews key national policies medications, diagnostics and and priorities. It provides greater antibiotics; chemical and radiation transparency for programs; encourages laboratory services; limited increased accountability for spending of improvements in surge capacity preparedness funds; and recommends within the healthcare system for a ways to help the nation move toward a mass influx of patients — along with more strategic capabilities system that standards of care and in-place tiered is able to effectively respond to health systems of care for a range of threats; threats. While it is impossible to be 100 ongoing reductions in the public percent prepared for all emergencies, health workforce; and the ability to there are core basic capabilities that help communities — and especially experts agree are core basic capabilities their most vulnerable populations — that could be maintained to better become more resilient to cope with protect the public from the range of and recover from emergencies. possible concerns. In the past 15 years: TFAH • healthyamericans.org 7 In the 2016 Ready or Not? report: l E nsuring stable, sufficient health emergency preparedness funding Section 1 features 10 indicators of key to maintain a standing set of core areas in each state that together provide capabilities so they are ready when a snapshot of areas of health security. they are needed. In addition, a They are based on a range of concerns complementary Public Health — reflecting a broad definition of all- Emergency Fund is needed to provide hazards preparedness — of being able immediate surge funding for specific to respond to a wide range of crises, actions for major emerging threats. from infectious disease outbreaks to The current process of insufficient natural disasters to man-made attacks. funding means there are long- l T he scores in the report are not standing gaps in the baseline system. intended to serve as a reflection Emergency supplementals are delayed on the performance of specific and not able to backfill ongoing state or local health departments, vulnerabilities in the response system. since they reflect a much broader l S trengthening and maintaining context including resources, policy consistent support for global health environments, healthcare systems security as an effective strategy for and their availability and health status preventing and controlling health of communities — including many crises. Germs know no borders. factors that are beyond the direct control of health departments. The l Improving federal leadership before, report is intended to help identify during and after disasters — including where sufficient action has been taken at the White House level, such as by to support adequate public health designating a dedicated high-level preparedness, and where and how adviser to the President and National federal and state governments can Security Advisor on health security improve or overcome obstacles to to provide leadership, coordination better readiness. and expertise for a government-wide approach to preparedness, response and Section 2 is an examination of national recovery efforts. Clear federal leadership policy issues and recommendations and an agreed upon framework of from health and security experts for responsibilities — including fully how to improve the nation’s ability to utilizing authorities in existing law — ensure stronger baseline capabilities are can clarify roles, particularly in health in place and the system is more flexible emergency responses that cross federal and able to respond efficiently and agencies and involve domestic and effectively when new emergencies arise. international actions. Key priorities include: l nnovating and modernizing I l R equiring strong, consistent baseline infrastructure needs — including a more public health abilities in regions, states focused investment strategy to support and communities around the country. science and technology upgrades that Communities should maintain a key leverage recent breakthroughs and set of Foundational Capabilities and hold the promise of transforming focus on performance outcomes in the nation’s ability to promptly detect exchange for increased flexibility and and contain disease outbreaks and reduced bureaucracy. 8 TFAH • healthyamericans.org respond to other health emergencies. There should be special emphasis on effective preparedness and response For example, modernizing to near recruitment of Disease Intervention abilities. real-time, interoperable surveillance; Specialists (DIS), who help determine l Supporting a culture of resilience so developing the next generation of the source of a problem and how it may all communities are better prepared medical countermeasures, including be spread (such as contact tracing) and to cope with and recover from antivirals, vaccines and rapid diagnostic other services that are critical during emergencies, particularly focusing on tests; and adopting wider use of advances outbreaks. those who are most vulnerable. in genomics to detect and contain l Reconsidering health system outbreaks. l P reventing the negative health preparedness for new threats and mass consequences of climate change and l R ecruiting and training a next outbreaks. Develop stronger coalitions weather-related threats. generation public health workforce with and partnerships among providers, expert scientific abilities to harness and hospitals, insurance providers, l P rioritizing efforts to address one of use technological advances along with pharmaceutical and health equipment the most serious threats to human critical thinking and management skills businesses, emergency management health by expanding efforts to stop to serve as Chief Health Strategist for and public health agencies. More superbugs and antibiotic resistance. a community. The workforce should integrated approaches help leverage l I mproving rates of vaccinations for be able to lead health investigations; the strengths and coordinate activities children and adults — which are one build plans to address problems; bring across the public and private sectors, of the most effective public health partners and resources together across support regionalized health models tools against many infectious diseases. the health sector and other affected and incentivize and speed the use of sectors for increased collective impact; new technologies into practice. Engage l F ocusing on fixing the food safety and communicate and effectively all of the partners to invest in building system to better match and address educate the public on how to reduce a broader community response strategy the potential risks in modern risk and better protect themselves, since all partners in a community are agricultural and food processing, sales their families and their neighborhoods. at risk and stand to benefit from more and distribution approaches. “Simply put, the Nation does not afford the biological threat the same level of “The country does not think about health security the way we do to be “Our nation is experiencing an increasing number of emergencies that attention as it does other threats: There ready to respond to other threats.  We impact health, from natural disasters to is no centralized leader for biodefense. need to think of it more in terms of emerging infectious diseases in addition There is no comprehensive national maintaining an ongoing and steady to the ongoing threat of chemical and strategic plan for biodefense. There is defense, but having the surge capacity to biological weapons and explosives. no all-inclusive dedicated budget for be ready to respond when and if there is Creating and maintaining the necessary biodefense. The Nation lacks a single a threat.  Many health problems created level of readiness for all threats requires leader to control, prioritize, coordinate by Mother Nature can be our worst and sustained funding at all levels of and hold agencies accountable for working toward common national most unpredictable adversaries. ” government, continual collaboration with the private health care industry and – ear Admiral Steven C. Redd, M.D., R biodefense. This weakness precludes recognition that there is no end point to Director of Preparedness Programs, sufficient defense against biological Centers for Disease Control and preparedness. ” threats. ” 7 Prevention. – Dr. Nicole Lurie, M.D., MSPH, U.S. – National Blueprint for Biodefense: A Department of Health and Human Leadership and Major Reform Needed Services, Assistant Secretary for to Optimize Efforts, 2015. Preparedness and Response. TFAH • healthyamericans.org 9 EXAMPLES OF KEY EMERGING AND EMERGENCY HEALTH THREATS l Z ika: Primarily transmitted by the bite l H ealthcare-associated Infections (HAI): of an infected Aedes aegypti mosquito, Around one out of every 25 people who Zika can be passed from a pregnant are hospitalized each year contracts a Indirect Costs of the Flu woman to her fetus, resulting in severe healthcare-associated infection leading $87 billion birth defects, including microcephaly. The disease itself causes mild symptoms, to around 75,000 deaths a year.15 l I nfluenza (the Flu): Between 5 percent like fever and joint pain, though many and 20 percent of Americans get the flu of those infected have no symptoms each year. Flu-associated deaths ranged at all. Zika has also been shown to be from a low of 12,000 (during 2011 to + transmitted through sex. Cases have 2012) to a high of 56,000 (during 2012 to been reported in most of South and 2013). The flu contributes to more than Central America, as well as the Pacific $10 billion in direct medical expenses and Islands. As of November 28, 2016, more than $94 billion in total costs (direct Florida and Texas are the only U.S. states and indirect) each year.16, 17 with confirmed locally acquired cases Direct Costs (182), and there are ongoing outbreaks l P andemic Flu: In addition to the of the Flu in Puerto Rico, American Samoa and the seasonal flu, historically there have been $10.4 billion U.S. Virgin Islands. There is currently no three to four flu pandemics each century. vaccine or medicine for Zika.8 Pandemics occur when a new influenza virus emerges against which people have l M iddle East Respiratory Syndrome = little-to-no immunity and the virus spreads Coronavirus (MERS-CoV): MERS-CoV internationally with sustained human-to- is a novel coronavirus that causes a human transmission (an “A” virus that severe viral respiratory disease. It has is antigenically and genetically distinct infected more than 1,800 individuals, from already circulating seasonal flu “A” spreading from the Middle East to viruses, which most people have little- South Korea through international travel, to-no immunity to fight against). While causing a significant outbreak.9, 10 MERS experts predict influenza pandemics will is fatal in more than 30 percent of Total Costs of the Flu occur in the future, they cannot predict cases.11 As of July 2016, there have $97.4 billion only been two MERS-CoV cases in the United States, and those individuals when the next pandemic will occur, what strain of the virus will be involved, or how severe the outbreak will be.18 Once were traveling from other locations. a novel influenza strain mutates and l F oodborne Illness: An estimated 48 becomes easily transmissible among million Americans get sick, 128,000 humans, it can cause a worldwide are hospitalized and 3,000 die from pandemic in a relatively short time.19 A contaminated food annually.12 severe pandemic in 1918 resulted in 30 percent of the population becoming l S uperbugs: More than two million ill and more than 2.5 percent (625,000 Americans contract antibiotic-resistant Americans) of those who became ill died. infections each year, leading to more The most recent pandemic (H1N1 in than 23,000 deaths and $20 billion in 2009) while considered relatively mild, direct medical costs and more than $35 infected around 20 percent of Americans billion in lost productivity.13 Globally, by (approximately 60 million individuals), 2050, superbugs could claim 10 million and it resulted in approximately 274,000 lives a year and could cost a cumulative hospitalizations and more than 12,000 $100 trillion of economic output.14 10 TFAH • healthyamericans.org deaths.20 l hikungunya: A mosquito-borne virus C Many U.S. healthcare professionals l V alley Fever: An infection caused by that, while rarely fatal, causes fever and are not familiar with the disease which breathing in the fungus Coccidioides, joint pain that can be excruciating.21 leads to under-diagnosis. 28 which is endemic to the dusty soils There are no vaccines or treatments of the U.S. Southwest, mainly Arizona l W est Nile Virus: A potentially serious for chikungunya, but symptoms usually and California.34 Most people never illness, for which there is no vaccine, subside in about a week. However, in experience any symptoms, but some which is spread by infected mosquitoes some people, joint pain can persist patients develop flu-like symptoms, 5 that contract the virus from feeding on for months. In 2013, the disease percent to 10 percent develop long-term infected birds. The majority of infected first appeared in the Americas in the lung problems and one percent may individuals have no symptoms, but Caribbean Islands. As of May 2016, more develop meningitis or die.35 Blacks, up to 20 percent develop symptoms, than 1.7 million cases have been reported Filipinos, pregnant women and people including fever, headache, body aches, to the Pan American Health Organization with diabetes or weakened immune nausea, vomiting, swollen lymph (PAHO) in 45 countries, and in November systems are most susceptible to the glands and rashes on the trunk of the 2016, there have been around 120 cases severe forms of the infection. More body that can last several weeks, and reported from 34 states in the United than 147,000 Valley fever cases were one in 150 people infected develop States.22, 23 As of November 29, 2016, reported to CDC during 1998 to 2014 serious symptoms and in some cases a total of 141 chikungunya virus disease and fewer than 100 Americans die from permanent neurological effects.29 More cases with illness onset in 2016 have Valley fever annually.36, 37 than 1,600 cases of West Nile virus been reported from 36 states. disease have been reported to CDC. Of l A cute Flaccid Myelitis Outbreak: A l D engue Fever: A mosquito-borne illness these, 747 (52 percent) were classified recent uptick in children developing that causes flu-like symptoms and severe as neuroinvasive disease (such as severe neurological symptoms has joint, muscle and bone pain. There is a meningitis or encephalitis) and 681 spotlighted a rare and alarming condition dengue vaccine licensed in 10 countries, (49 percent) were classified as non- called acute flaccid myelitis (AFM).38 AFM but it is not currently available in the neuroinvasive disease. 30 Older adults is a syndrome that affects the nervous United States. Around 400 million are at higher risk for developing WNV system, especially the spinal cord, and people are infected each year, leading to neuroinvasive disease. can lead to temporary or permanent around 50 million to 100 million illnesses paralysis of the limbs. The cause of l M alaria: A mosquito-borne disease, and 22,000 deaths, mostly among AFM is unknown and there is no known which can also be transmitted through children. It is endemic in Puerto Rico way to prevent the infection or cure it. It blood contamination or childbirth, that and in many popular tourist destinations can be caused by a variety of infections, results in fever, headache, fatigue in Latin America, Southeast Asia and the including enteroviruses, adenoviruses and potentially coma and death.31 Pacific islands.24 In the United States, and West Nile virus. While the disease Antimalaria drugs can provide effective small dengue outbreaks occurred in can infect anyone, most patients in treatment, but resistance is emerging Texas in 2005, in Florida in 2013 and recent outbreaks have been children. and spreading globally. Globally, in most recently in Hawaii in 2015. 25, 26, 27 The largest outbreak occurred in 2014 2015, there were 214 million cases (120 reported cases) and CDC initially l C hagas Disease: Caused by the and 438,000 deaths, mostly among suspected it was caused by a coinciding parasite Trypanosoma cruzi, it can lead African children.32 The United States outbreak of the respiratory infection to severe cardiac and gastrointestinal experiences approximately 1,500 cases enterovirus D68, but it could ultimately disease. It is transmitted to animals to 2,000 cases of the disease per year, not find a clear link between the two. In and people by insect vectors found with most individuals exposed outside 2015, there were 50 cases, and as of exclusively in the Americas. As many the country.33 Proven interventions in September 2016, 89 people in 33 states as 8 million people in Mexico, Central malaria endemic countries can have a have been diagnosed with AFM. Spinal America and South America — and more profound impact on malaria control which fluid samples have been unable to point than 300,000 in the United States — saves lives, reduces risk of importation to one pathogen causing the paralysis. have Chagas disease, the majority of in the United States and advances the whom do not know they are infected. effort to eliminate malaria. TFAH • healthyamericans.org 11 BIOTERRORISM THREATS CDC classifies biological agents that 6. Francisella tularensis (tularemia) Public health laboratories were over- could be used for an intentional bio- 7. unin virus (hemorrhagic fever) J whelmed receiving samples of items to attack into three categories:39, 40 test all around the country — testing 8. Marburg virus (hemorrhagic fever) more than 70,000 samples following the l ategory A, or “High-Priority Agents,” C 9. Multidrug-resistant Bacillus anthracis identification of the anthrax attacks.43 are considered the most dangerous (MDR anthrax) Public health officials from CDC, New because they can be easily spread 10. Rickettsia prowazekii (typhus) Jersey and Washington, D.C. and other from person to person and/or have a 11. Variola major (smallpox) agencies were among the primary inves- high death rate. Examples include: tigators determining the sources of the Anthrax, botulism, plague, smallpox, 12. Yersinia pestis (plague) anthrax, helping to ensure it was con- tularemia and viral hemorrhagic fevers 13. Radiological agents tained and developing containment and (e.g., Ebola, Marburg). 14. Nuclear agents response strategies. l ategory B, or “Second-highest Priority C Two threats that have been of high Anthrax is a potentially lethal infection, Agents,” are moderately easily spread, focus in U.S. bioterrorism preparedness particularly when it manifests as inha- have a low mortality rate and include strategies include: lation anthrax. Historically, numerous food safety threats (e.g., Salmonella nations have experimented with anthrax and E. coli), ricin toxin, Typhus fever l A nthrax: Five people died, 22 people as a biological weapon, including the and viral encephalitis, among others. were sickened and more than 30 U.S. offensive biological weapons pro- more tested positive for exposure l ategory C, or “Third-highest Priority C gram that was disbanded in 1969.44 The during a set of anthrax attacks Agents,” include emerging pathogens worst documented outbreak of inhalation during September and October 2001, that could be engineered for mass anthrax in humans occurred in Russia immediately following the 9/11 dissemination in the future because in 1979, when anthrax spores were attacks.42 More than 32,000 people of availability; ease of production accidentally released from a military bio- took antibiotics for possible exposure, and dissemination; and potential for logical weapons facility near the town of including many Capitol Hill employees. high morbidity and mortality rates Sverdlovsk, killing at least 66 people.45 and major health impact. Hantavirus, Anonymous letters containing anthrax l S mallpox: Although the WHO declared Chikungunya and MERS-CoV are were sent to news agencies in Florida that smallpox was eradicated in 1980, examples of a Category C agent. and New York and to then-Senate Majority this contagious and deadly infectious Leader Tom Daschle (SD) and Senator Fourteen out of 17 chemical, biological, disease, caused by the Variola major Patrick Leahy (VT) in their offices in radiological and nuclear (CBRN) agents virus, remains high on the list of pos- Washington, D.C. Thirty-five post offices meet the Material Threat Determination sible bioterror threats. The last natu- and mailrooms were contaminated along (MTD) — recognized as a threat that could rally occurring case of smallpox was with seven buildings on Capitol Hill. be sufficient to affect national security reported in 1977.46 Currently, there Postal workers in Hamilton Township, — by the Secretary of the Department of is no evidence of naturally occurring New Jersey, where the letters originated Homeland Security (DHS), including: 41 smallpox transmission anywhere in the (postmarked Trenton, New Jersey), and 1. Bacillus anthracis (anthrax) world. Although a worldwide immuni- Brentwood in Washington, D.C. were zation program eradicated smallpox 2. Burkholderia mallei (glanders) among those exposed, and the facilities disease decades ago, small quantities 3. Burkholderia pseudomallei (melioidosis) in both locations underwent multi-year, of smallpox virus officially still exist in multi-million dollar decontamination 4. Clostridium botulinum (botulism toxin) research laboratories in Atlanta, Geor- processes. 5. Ebola virus (hemorrhagic fever) gia and in Novosibirsk, Russia. 12 TFAH • healthyamericans.org SECTI O N 1 State-by-State STATE-BY-STATE HEALTH SECURITY INDICATORS State-by-State Health Security Indicators Health Security All Americans deserve to be protected during health Indicators emergencies, no matter where they live. Readiness for health emergencies is of a community. Many of the indicators a concern in every state. However, are impacted by factors beyond the direct policies and programs vary from state- control of health officials. to-state. To help assess preparedness In addition, states differ in how they across the country, the Ready or Not? structure, deliver and fund public health report examines a series of 10 indicators services. For instance, states with high- based on high-priority areas and density urban areas may function very concerns. It is not a comprehensive differently than those with populations review; but collectively, it provides spread across smaller cities or towns. a snapshot of efforts to prevent and prepare for health threats in states and However, all states should be able to within the healthcare system. meet basic preparedness goals as defined by federal health officials and leading The indicators were selected after experts. This report was developed to consulting with leading public health provide taxpayers and policymakers with and healthcare officials and reflect: information about how well-prepared l F undamental, systemic needs for public their states and communities are for health emergency readiness; and different types of health threats. The American people deserve to know how l A reas where there is consistent data prepared their states and communities available across all 50 states and are for different types of health threats. Washington, D.C. — and information is publicly available and/or is able Using some consistent and some to be verified through surveys or updated indicators allows the report to consultation with state officials. reflect a range of preparedness issues, changing expectations for preparedness Each state received a score based on and differences in data availability over these 10 indicators. States received time. It is important to note that many one point for achieving an indicator states have taken action and developed and zero points if they did not. Zero is strengths in other areas of preparedness the lowest possible score and 10 is the or may be in the process of developing highest. The scores ranged from a high capabilities that may not be reflected of 10 in Massachusetts to a low of three in this report. In addition, limited data DECEMBER 2016 in Alaska and Idaho. is made publicly available to measure Scores are not intended to serve as public health preparedness. The Ready or a reflection of the performance of a Not? report compiles indicators based on specific state or local health department information that is timely and publicly or the healthcare system or hospitals available or data received from surveying within a state, since they reflect a much states directly, and where information is broader context, including resources, consistently available across states. policy environments and the health status STATE INDICATORS (2) (1) National Health Security (4) (5) Public Health Funding (3) Preparedness Index: Flu Vaccination Rate: Climate Change Readiness: Commitment: Public Health Accreditation: State met or exceeded the State vaccinated at least half of State received a grade of State increased or maintained State had at least one overall national average score their population (ages 6 months A, B or C in States at Risk: funding for public health from accredited public health (6.7) of the National Health and older) for the seasonal flu America’s Preparedness FY 2014 – FY 2015 to department. Security Preparedness Index™, from Fall 2015 to Spring 2016. Report Card. FY 2015 – FY 2016. as of 2016. Alabama 3 3 Alaska 3 Arizona 3 3 3 Arkansas 3 3 California 3 3 3 3 Colorado 3 3 3 Connecticut 3 3 3 3 Delaware 3 3 3 3 D.C. 3 3 3 Florida 3 3 3 Georgia 3 3 3 Hawaii 3 3 Idaho 3 Illinois 3 3 Indiana 3 3 3 Iowa 3 3 3 3 Kansas 3 3 Kentucky 3 3 Louisiana 3 3 Maine 3 3 Maryland 3 3 3 3 Massachusetts 3 3 3 3 3 Michigan 3 3 3 Minnesota 3 3 3 Mississippi 3 Missouri 3 3 Montana 3 3 Nebraska 3 3 3 Nevada 3 3 New Hampshire 3 3 3 New Jersey 3 3 3 New Mexico 3 3 3 New York 3 3 3 North Carolina 3 3 3 3 North Dakota 3 3 3 Ohio 3 3 Oklahoma 3 3 Oregon 3 3 3 3 Pennsylvania 3 3 3 3 Rhode Island 3 3 3 3 3 South Carolina 3 3 South Dakota 3 3 Tennessee 3 3 3 3 Texas 3 3 Utah 3 3 3 Vermont 3 3 3 3 Virginia 3 3 3 3 Washington 3 3 3 3 West Virginia 3 3 Wisconsin 3 3 3 Wyoming 3 Total 26 States 30 States + D.C.* 43 States + D.C. 10 States 32 States + D.C.* Note: *Washington, D.C. data not available; they were awarded a point for the indicator. 14 TFAH • healthyamericans.org (6) (7) (8) (9) (10) Food Safety: Reducing Healthcare- Public Health Laboratories: Public Health Emergency Healthcare Access: State increased the speed Associated Infections State public health laboratory Laboratories: State has a formal access of DNA fingerprinting (HAIs): provided biosafety training and/ State public health program or a program in Total using pulsed-field gel State implemented all four or provided information about laboratories reported having progress for getting private Score electrophoresis (PFGE) recommended activities biosafety training courses for a biosafety professional on sector healthcare staff and testing for all reported cases to build capacity for HAI sentinel clinical labs (from July 1, staff (from July 1, 2015 to supplies into restricted areas of E. coli O157. prevention. 2015 to June 30, 2016). June 30, 2016). during a disaster. Alabama 3 3 3 5 Alaska 3 3 3 Arizona 3 3 3 6 Arkansas 3 3 3 3 6 California 3 3 3 3 8 Colorado 3 3 3 3 7 Connecticut 3 3 3 3 8 Delaware 3 3 3 7 D.C. 3 3 3 6 Florida 3 3 3 3 7 Georgia 3 3 3 6 Hawaii 3 3 3 3 6 Idaho 3 3 3 Illinois 3 3 3 3 6 Indiana 3 3 3 3 7 Iowa 3 3 3 3 8 Kansas 3 3 3 3 6 Kentucky 3 3 3 3 6 Louisiana 3 3 3 3 6 Maine 3 3 3 3 6 Maryland 3 3 3 7 Massachusetts 3 3 3 3 3 10 Michigan 3 3 3 3 7 Minnesota 3 3 3 6 Mississippi 3 3 3 3 3 6 Missouri 3 3 3 5 Montana 3 3 3 3 6 Nebraska 3 3 3 6 Nevada 3 3 4 New Hampshire 3 3 3 3 7 New Jersey 3 3 3 3 3 8 New Mexico 3 3 3 3 7 New York 3 3 3 3 7 North Carolina 3 3 3 3 3 9 North Dakota 3 3 3 3 7 Ohio 3 3 3 3 6 Oklahoma 3 3 3 5 Oregon 3 3 3 7 Pennsylvania 3 3 6 Rhode Island 3 3 7 South Carolina 3 3 3 3 3 7 South Dakota 3 3 3 5 Tennessee 3 3 3 3 8 Texas 3 3 3 3 6 Utah 3 3 3 3 7 Vermont 3 3 6 Virginia 3 3 3 3 8 Washington 3 3 3 3 3 9 West Virginia 3 3 3 5 Wisconsin 3 3 3 3 7 Wyoming 3 3 3 4 45 States + D.C.* 35 States + D.C. 44 States 47 States + D.C. 10 States TFAH • healthyamericans.org 15 STATE-BY-STATE INFECTIOUS DISEASE PREVENTION AND WA MT ME CONTROL INDICATORS AND ND VT OR MN KEY FINDINGS ID NH SD WI NY MA WY MI CT RI NE IA PA NJ NV OH DE UT IL IN CA MD CO WV KS MO VA DC KY NC AZ TN OK NM AR SC Scores Color MS AL GA 3 TX LA 4 5 FL 6 AK 7 HI 8 9 10 SCORES BY STATE 10 9 8 7 6 5 4 3 (1 state) (2 states) (6 states) (15 states) (17 states & D.C.) (5 states) (2 states) (2 states) Massachusetts North Carolina California Colorado Arizona Alabama Nevada Alaska Washington Connecticut Delaware Arkansas Missouri Wyoming Idaho Iowa Florida D.C. Oklahoma New Jersey Indiana Georgia South Dakota Tennessee Maryland Hawaii West Virginia Virginia Michigan Illinois New Hampshire Kansas New Mexico Kentucky New York Louisiana North Dakota Maine Oregon Minnesota Rhode Island Mississippi South Carolina Montana Utah Nebraska Wisconsin Ohio Pennsylvania Texas Vermont 16 TFAH • healthyamericans.org INDICATOR SUMMARY Indicator Finding 1. Public Health Funding Commitment 26 states increased or maintained funding for public health from Fiscal Year (FY) 2014 – FY 2015 to FY 2015 – FY 2016. Source: Publicly available state budget information; distributed to state officials for updates and verification 2. ational Health Security N 30 states and Washington, D.C.* met or exceeded the overall national average score (6.7) of the National Preparedness Index Health Security Preparedness Index™ (NHSPI™) (as of 2016). Source: NHSPI 3.Public Health Accreditation 43 states and Washington, D.C. have at least one accredited public health department. Source: Public Health Accreditation Board 4.Vaccinations 10 states vaccinated at least half of their population (ages 6 months and older) against the seasonal flu during the 2015-2016 flu season (from July 2015 to May 2016). Source: CDC 5.Climate Change Readiness 32 states and Washington, D.C.* received a grade of C or above in States at Risk: America’s Preparedness Report Card, a national assessment of state-level preparedness for climate change-related threats. Source: Climate Center and ICF 6.Food Safety 45 states and Washington, D.C.* increased the speed of DNA fingerprinting using pulsed-field gel electrophoresis (PFGE) testing for all reported cases of Shiga toxin-producing Escherichia coli (E. coli) O157. Source: CDC 7.Healthcare-Associated Infection Control 35 states and Washington, D.C. have implemented four recommended activities to build capacity for Healthcare-Associated Infection (HAI) prevention. Source: CDC 8. Public Health Laboratories 44 state laboratories provided biosafety training and/or provided information about biosafety training courses for sentinel clinical labs in their jurisdiction (from July 1, 2016 to June 30, 2016). Source: Association of Public Health Laboratories annual survey 9. Public Health Laboratories 47 state laboratories and Washington, D.C.’s laboratory have a biosafety professional. Source: Association of Public Health Laboratories annual survey 10. Emergency Healthcare Access 10 states have a formal access program or a program in progress for getting private sector healthcare staff and supplies into restricted areas during a disaster. Source: Healthcare Ready Note: Washington, D.C. data not available; they were awarded a point for the indicator FEDERAL, STATE AND LOCAL PUBLIC HEALTH JURISDICTIONS The federal role: Includes policymaking, funding programs, State and local roles: Under U.S. law, state governments overseeing national prevention and response efforts, collecting have primary responsibility for the health of their citizens. and disseminating health information, building capacity and Constitutional police powers give states the ability to enact directly managing some select services and supporting laws and issue regulations to protect, preserve and promote biomedical research and production capabilities. Some public the health, safety and welfare of their residents. In most health emergency preparedness and response capabilities, such states, local governments are also charged with responsibility as the Strategic National Stockpile and the National Disaster for the health of their populations. State and local health Medical System, are federal assets managed by federal agencies departments and first responders are the front line during that supplement state and local capabilities, particularly when health emergencies. surge capacity is needed to meet overwhelming needs. TFAH • healthyamericans.org 17 INDICATOR 1: PUBLIC 26 states increased or maintained public health 24 states and Washington, D.C. cut public health funding from FY 2014 – FY 2015 to FY 2015 – FY 2016. funding from FY 2014 – FY 2015 to FY 2015 – FY 2016. HEALTH FUNDING (1 point.) (0 points.) COMMITMENT — STATE Alabama (1.4%) New Jersey (3.4%) Alaska (-9.1%) Maryland (-8.7%) Arizona (0.4%) North Dakota (13.6%) Colorado (-8.1%) Minnesota (-2.6%) PUBLIC HEALTH BUDGETS Arkansas (7.9%) Ohio (2.0%) Connecticut (-4.2%)* Missouri (-1.3%) California (4.2%) Oregon (73.1%) Delaware (-2.0%) New Hampshire (-20.7%)* Georgia (2.6%) Pennsylvania (0.1%) D.C. (-1.6%) New Mexico (-4.4%)* KEY FINDING: 26 states Hawaii (1.4%) Rhode Island (0.9%) Florida (-8.2%) New York (-7.3%) increased or maintained Indiana (6.3%) South Carolina (17.4%) Idaho (-4.8%) North Carolina (-2.3%)^ Massachusetts (1.9%) South Dakota (0.0%) Illinois (-16.7%) Oklahoma (-3.3%)* funding for public health from Michigan (0.0%) Tennessee (1.3%) Iowa (-1.4%) Texas (-2.9%)* Mississippi (3.5%) Vermont (13.9%) Kansas (-3.7%)^ Utah (-1.3%) FY 2014 – FY 2015 to Montana (9.5%) Virginia (2.4%) Kentucky (-7.0%) West Virginia (-13%) FY 2015 – FY 2016. Nebraska (11.0%) Washington (8.3%) Louisiana (-3.1%) Wisconsin (-0.7%) Nevada (4.4%) Wyoming (2.7%) Maine (-1.7%) Source: Publicly available state budget information; distributed to state officials for updates and verification. Notes: Bolded states did not respond to a request to review their state budget information, sent October 20, 2016 in coordination with ASTHO. States were able to provide confirmations or updates to information through December 14, 2016 to be reflected in the report. *Budget decreased for second year in a row. ^Budget decreased for third year in a row. This indicator illustrates a state’s cycles, based on how each state reports commitment and ability to provide data. TFAH defined “public health funding for public health programs services” broadly to include all state- that support the infrastructure and level health spending with the exception workforce needed to improve health of Medicaid, Medicaid/State Children’s in each state, including the ability to Health Insurance Program (CHIP) or detect, prevent and control disease comparable health coverage programs outbreaks and mitigate the health for low-income residents. impacts of disasters. Based on this analysis (adjusted Every state allocates and reports its for inflation), 26 states increased budget in different ways. States also or maintained their public health vary widely in the budget details they budgets, while 24 states and provide. This makes comparisons Washington, D.C. made cuts. Five across states difficult. For this analysis, states (Connecticut, New Hampshire, TFAH examined state budgets and New Mexico, Oklahoma and Texas) appropriations bills for the agency, cut their budget for two or more years department or division in charge of in a row, and two states had cuts for public health services for FY 2014 - FY three or more years in a row (Kansas 2015 and FY 2015 - FY 2016, using a and North Carolina). The median definition as consistent as possible spending in FY 2016 was $36.31 per across the analyses of the two budget capita, up from $33.71 in FY 2008. 18 TFAH • healthyamericans.org Public health funding is discretionary STATE PUBLIC HEALTH BUDGETS spending in most states and, therefore, FY 2015 - FY 2016 FY 2015- FY 2016 Per Capita is at high risk for significant cuts during Alabama $286,634,894 $59.95 tight fiscal climates. States rely on a Alaska $87,298,217 $120.14 Arizona $60,762,590 $9.04 combination of federal, state and local Arkansas $156,951,808 $53.56 funds to support public health activities. California $2,201,846,616 $57.16 The overall infrastructure of public Colorado $239,660,934 $44.64 health programs supports the ability to Connecticut $106,756,130 $30.18 carry out all of their responsibilities, Delaware $40,641,266 $43.66 D.C. $90,552,600 $136.90 which includes infectious disease Florida $369,559,682 $18.53 prevention, immunization services and Georgia $197,288,342 $19.63 health emergency preparedness. Hawaii $256,746,571 $182.26 Idaho $147,298,109 $90.45 It is important to note that several Illinois $273,955,538 $21.65 states that received points for this Indiana $86,868,535 $13.34 indicator may not have actually Iowa $250,888,243 $81.62 Kansas $34,758,479 $12.13 increased their spending on public Kentucky $137,699,922 $31.62 health programs. The ways some states Louisiana $89,632,324 $19.50 report their budgets, for instance, by Maine $28,370,095 $21.69 including federal funding in the totals Maryland $217,051,704 $36.72 Massachusetts $342,230,567 $51.19 or including public health dollars Michigan $166,799,513 $17.08 within healthcare spending totals, make Minnesota $301,749,504 $55.86 it very difficult to determine “public Mississippi $37,331,149 $12.68 health” as a separate item. Missouri $35,214,294 $5.88 Montana $24,834,043 $24.43 This indicator is limited to examining Nebraska $90,437,475 $48.47 whether states’ public health budgets Nevada $12,031,513 $4.23 New Hampshire $16,613,281 $12.69 increased or decreased; it does not New Jersey $236,248,560 $26.80 assess if the funding is adequate to New Mexico $94,992,998 $46.30 cover public health needs in the states, New York $1,738,033,394 $89.23 and it should not be interpreted as North Carolina $139,115,184 $14.08 an indicator or surrogate for a state’s North Dakota $71,166,521 $95.55 Ohio $162,903,149 $14.26 overall performance. Oklahoma $163,753,344 $42.55 Oregon $111,493,271 $28.12 For additional information on the Pennsylvania $185,414,136 $14.72 methodology of the budget analysis, Rhode Island $56,064,811 $53.94 please see Appendix A: Methodology South Carolina $117,998,151 $24.49 for Select State Indicators. And for South Dakota $30,364,445 $35.95 the federal grants to states via the Tennessee $302,486,126 $46.57 Texas $733,493,099 $27.14 Preparedness Health Emergency Utah $92,180,136 $31.27 Preparedness (PHEP) cooperative Vermont $32,087,244 $52.09 agreements and the Hospital Virginia $298,672,158 $36.21 Preparedness Program (HPP), see Washington $292,304,651 $41.43 West Virginia $117,179,807 $64.58 Appendix B. Wisconsin $86,335,078 $15.20 Wyoming $32,539,129 $56.42 National $11,669,899,417 $36.31 *Note: Adjusted for inflation. TFAH • healthyamericans.org 19 INDICATOR 2: NATIONAL 30 states and Washington, D.C.* met or exceeded the 20 states were below the overall national average overall national average score (6.7) in the National score (6.7) in the National Health Security HEALTH SECURITY Health Security Preparedness Index.™ (1 point.) Preparedness Index.™ (0 points.) PREPAREDNESS INDEX™ California (6.8) New Hampshire (7.3) Alabama (5.9) Mississippi (5.8) Colorado (6.7) New Jersey (6.8) Alaska (6.0) Montana (5.7) Connecticut (7.0) New Mexico (6.8) Arizona (5.8) Nevada (5.9) D. C. (N/A)* KEY FINDING: 30 states New York (7.5) Arkansas (6.2) North Dakota (6.5) Delaware (6.7) North Carolina (7.0) Georgia (6.2) Ohio (6.5) and Washington, D.C.* met Florida (6.7) Oregon (7.0) Hawaii (6.1) Oklahoma (6.5) Illinois (7.1) Pennsylvania (6.9) Indiana (6.4) South Carolina (6.5) or exceeded the overall Iowa (6.8) Rhode Island (7.2) Idaho (6.1) South Dakota (6.1) Kansas (6.7) national average score Kentucky (6.9) Tennessee (6.7) Louisiana (5.6) West Virginia (6.3) Maine (7.0) Texas (6.7) Michigan (6.5) Wyoming (6.4) (6.7) of the National Health Maryland (7.6) Utah (7.0) Massachusetts (6.8) Vermont (7.3) Security Preparedness Index™ Minnesota (7.4) Virginia (7.3) (NHSPI™). 47 Missouri (6.8) Washington (6.8) Nebraska (7.1) Wisconsin (6.9) Note: *Washington, D.C. was not included in the NHSPI (since information was not available, D.C. was awarded a point for the indicator). Source: National Health Security Preparedness Index This indicator examines whether a state from RWJF, took the lead for managing investigate events related to medical met the national average for the National and maintaining the Index. countermeasures; and 2) the ability Health Security Preparedness Index™ of agencies to conduct rapid and The overall national average was a 6.7 (NHSPI), which was developed as a new accurate laboratory tests to identify out of a possible 10 in 2015. This is a way to measure and track the nation’s biological, chemical and radiological 1.8 percent improvement from 2014 progress in preparing for, responding to agents to address actual or potential across all NHSPI domains, and a 3.6 and recovering from disasters and other exposure to all hazards, focusing on percent improvement from 2013. State large-scale emergencies. testing human and animal clinical scores ranged from a low of 5.6 in specimens. The NHSPI measures the health security Louisiana to a high of 7.6 in Maryland. preparedness of the nation by looking Generally, Northeastern states scored l ommunity Planning and Engagement: C collectively at existing state-level data from highest, while those in the Deep South National score 5.4 out of 10. How a wide variety of sources. Uses of the Index and Mountain West scored lowest. communities mobilize different include guiding quality improvement, stakeholders to work together during The scores from the Index includes 134 informing policy and resource decisions times of crisis. Supportive relationships individual measures, aggregated into six and encouraging shared responsibility for among community stakeholders — domains and 19 sub-domains. The six preparedness across a community. government agencies, community domains encompass:48 organizations and individual residents NHSPI was developed by the Association l ealth Security Surveillance: National H — enable communities to effectively of State and Territorial Health Officials score 7.5 out of 10. The ability to work together during crises and (ASTHO) in partnership with CDC and collect and analyze data to identify recover faster in the aftermath. more than 30 development partners — possible threats before they arise. • ub-domains include: 1) S including TFAH and the Robert Wood Johnson Foundation (RWJF) — and • ub-domains include: 1) strong S collaboration across sectors primarily was first released in 2013. In 2015, the passive and active surveillance to responsible for providing direct National Coordinating Center for Public identify, discover, locate and monitor health-related services; 2) actions Health Services and Systems Research at threats, provide relevant information to protect at-risk populations, the University of Kentucky, with support to stakeholders and monitor/ including children and the elderly, 20 TFAH • healthyamericans.org as well as those with physical/ Preparedness by Domain mental challenges, limited English proficiency and transportation limitations; 3) management and coordination of volunteers during an emergency; and 4) social cohesion — the degree of connection and sense of “belongingness” among residents. This domain has improved 8.4 percent since 2013. l ncident and Information Management: I National score 8.4 out of 10. The ability to mobilize and manage Source: nhspi.org resources during a health incident. • ub-domains include: 1) multi- S Preparedness by State agency coordination; 2) effective communication to the public; and 3) legal and administrative capabilities and capacities responsible for assisting in the execution activities, systems and decision-making. l ealthcare Delivery: National score H 5.1 out of 10. The state of healthcare systems during everyday life, as well as in emergency situations. • ub-domains include: 1) prehospital S care provided by emergency medical services (EMS); 2) inpatient care defined as a minimum of one night in the hospital or other institution; 3) long-term care in a residential setting; 4) access to medical and mental/ behavioral health services; and 5) effectiveness of countermeasure and protection of safe and clean clinical and nonclinical home care. utilization, including community food and water resources; and 2) preparedness for usage and follow the monitoring of air, water, land/ l ountermeasure Management: C through of usage; and 3) non- soil and plants for hazards to assess National score 7.0 out of 10. The pharmaceutical intervention to past and current status and predict ability to mitigate harm from biologic, contain disease spread or exposure future trends. The score for this chemical, or nuclear agents. using community mitigation strategies. domain decreased by 4.5 percent • ub-domains include: 1) the S between 2013 and 2015, reflecting l nvironmental and Occupational Health: E management, distribution and challenges in rapidly detecting National score 6.4 out of 10. The dispensing of medical materiel and responding to environmental ability to prevent health impacts from before and during an incident and risks, as exemplified by events like environmental or occupational hazards. the management of the research, the water contamination crises in development and procurement of • Sub-domains include: 1) the Michigan and West Virginia. medical countermeasures; 2) the sufficient availability, access, use TFAH • healthyamericans.org 21 INDICATOR 3: PUBLIC 43 states and Washington D.C. have at least one accredited public health 7 states have no accredited public department. (1 point.) health departments. (0 points.) HEALTH DEPARTMENT Alabama Kentucky North Dakota Alaska ACCREDITATION Arizona Louisiana Ohio* Hawaii Arkansas* Maine* Oklahoma* Mississippi California* Maryland Oregon* New Hampshire KEY FINDING: 43 states and Colorado* Massachusetts Pennsylvania South Carolina Connecticut Michigan Rhode Island* South Dakota Washington, D.C. have at least D.C.* Minnesota* Tennessee Wyoming one accredited public health Delaware* Missouri* Texas Florida* Montana* Utah department.49 Georgia Nebraska* Vermont* Idaho Nevada Virginia Illinois* New Jersey Washington* Indiana New Mexico* West Virginia Iowa New York* Wisconsin Kansas North Carolina Source: Public Health Accreditation Board. * Accredited states. This indicator examines whether to a range of health threats, such as l T he continual development, revision states have at least one public health an identification and investigation of and distribution of public health department that is accredited by the health hazards, educating the public, standards. Public Health Accreditation Board maintaining a competent workforce and According to surveys of accredited (PHAB).50 PHAB — jointly funded serving as an expert resource.51 health departments conducted for a by CDC and RWJF — is a non-profit, PHAB has accredited 162 health recent report titled “Evaluating the non-governmental organization that departments and one integrated local Impact of National Public Health administers the national public health public health department system — Department Accreditation—United accreditation program. It aims to improve together covering around 56 percent of States, 2016,” in the August 12, 2016 and protect the health of the public by the U.S. population. Forty-three states Morbidity and Mortality Weekly advancing and ultimately transforming and D.C. have at least one accredited Report, the “overwhelming majority the quality and performance of health department.52 Another 173 of respondents agreed or strongly the nation’s state, tribal, local and health departments are in process.53 agreed that accreditation stimulated territorial public health departments. Most recently, the Cherokee Nation quality and performance improvement The development of national public became the first tribal public health opportunities within the health health accreditation has involved, and is department to achieve accreditation. department, allowed the health supported by, public health leaders and department to better identify strengths practitioners from the national, tribal, According to PHAB, aspects of public and weaknesses, helped the health state, local and territorial levels. health department accreditation include: department document the capacity The goal of the voluntary national l T he measurement of health to deliver the three core functions of accreditation program is to improve department performance against a public health and the 10 Essential Public and protect the health of the public by set of nationally recognized, practice- Health Services, stimulated greater advancing the quality and performance focused and evidenced-based standards; accountability and transparency within of tribal, state, local and territorial public the health department and improved l T he issuance of recognition of health departments. Accreditation is the management processes used by achievement of accreditation within an important benchmark of a public the leadership team in the health a specified time frame by a nationally health system capable of responding department, among other benefits.”54, 55 recognized entity; 22 TFAH • healthyamericans.org 10 states vaccinated at least 40 states and Washington, D.C. did not vaccinate half of their population INDICATOR 4: FLU half of their population (ages 6 (ages 6 months and older) against the seasonal flu from July 2015 to May months and older) against the 2016. (0 points.) VACCINATION RATES seasonal flu from July 2015 to May 2016. (1 point.) Connecticut (52.6%) Alabama (43.9%) Louisiana (44.0%) Oklahoma (45.8%) KEY FINDING: 10 states Delaware (50.5%) Alaska (37.9%) Maine (49.0%) Oregon (42.0%) Hawaii (50.2%) Arizona (41.5%) Michigan (42.2%) Pennsylvania (48.2%) vaccinated at least half of Iowa (51.8%) Arkansas (45.4%) Minnesota (49.7%) South Carolina (46.9%) their population (ages 6 Maryland (51.7%) California (43.7%) Mississippi (42.1%) Tennessee (46.3%) Massachusetts (50.4%) Colorado (49.1%) Missouri (47.4%) Texas (47.9%) months and older) against the New Hampshire (50.9%) D.C. (47.6%) Montana (43.8%) Utah (43.5%) North Carolina (50.9%) Florida (39.5%) Nebraska (49.1%) Vermont (49.2%) seasonal flu from July 2015 Rhode Island (56.1%) Georgia (41.2%) Nevada (36.8%) Virginia (49.5%) through May 2016. South Dakota (56.6%) Idaho (39.2%) New Jersey (45.4%) Washington (47.9%) Illinois (42.9%) New Mexico (47.4%) West Virginia (49.6%) Indiana (43.2%) New York (49.1%) Wisconsin (42.7%) Kansas (44.4%) North Dakota (48.8%) Wyoming (38.1%) Kentucky (44.2%) Ohio (43.8%) Source: CDC, Flu Vaccination Coverage, United States, 2015-2016 Influenza Season Vaccination is the best prevention against the seasonal flu. CDC recommends everyone ages 6 months and older get vaccinated annually, yet fewer than half of Americans ages 6 months and older were vaccinated against the flu during the last three flu seasons (2013 to 2014, 2014 to 2015 and 2015 to 2016). CDC estimates that 144.5 million people were vaccinated this past flu season in the United States.56 This measure provides important context for a state’s preparedness for pandemics. In addition to protecting Americans from the seasonal flu, establishing a cultural norm of vaccination, building vaccination infrastructure and establishing policies that support vaccinations can help ensure the country has a strong system in place to be better able to vaccinate all Americans quickly during a new pandemic or unexpected disease outbreak. Source: CDC This indicator examines whether at has set a goal for the nation to vaccinate least half (50 percent) of a state’s 70 percent of adults and 70 percent of population (ages 6 months and older) children as part of the Healthy People was vaccinated against the flu during the 2020 initiative.57 This indicator uses 50 2015-2016 season. The U.S. Department percent as a marker of showing progress of Health and Human Services (HHS) toward achieving this goal. TFAH • healthyamericans.org 23 Source: CDC 24 TFAH • healthyamericans.org The highest flu vaccination coverage was Between 2004 and 2016, 1,176 children percent) and lowest among personnel in South Dakota at 56.6 percent and the between 6 months and 18 years old working in settings where vaccination lowest was in Nevada at 36.8 percent.58, 59 died from flu complications; 43 percent was neither required, promoted, nor Ten states vaccinated 50 percent or of these children were otherwise offered on-site (44.9 percent).71 more of their population and 45 states completely healthy.66 Seasonal flu vaccinations reduce and Washington, D.C. vaccinated 40 In addition to its health effects, flu has hospitalizations and deaths. CDC percent or higher. Nationally, 45.6 a serious impact in terms of healthcare estimates that the seasonal flu vaccine percent of Americans ages 6 months and worker absenteeism costs. Seasonal prevented more than 27,000 flu- and older were vaccinated. flu can often result in a half day to five associated deaths in the United States l F lu vaccination coverage levels were days of work missed, which affects both during the four flu seasons from 2010- significantly higher for children the individual and his or her employer. 2011 to 2013-2014 — representing a (59.3 percent) compared to adults One study projected that an increase of 16 percent reduction in deaths than (41.7 percent). vaccinations by 5 percent would prevent would have occurred in the absence more than 500,000 illnesses and nearly of a flu vaccination during that time l T he lowest vaccination coverage was 6,000 hospitalizations.67 Annually, frame.72 For the 2015-2016 season, CDC among adults ages 18 to 49 at just the flu leads to approximately $94 estimates the seasonal flu prevented 5.1 32.7 percent. billion in economic losses each year — million illnesses, 71,000 hospitalizations l 6 3.4 percent of persons 65 or older including $10.4 billion in direct costs for and about 3,000 deaths.73 were vaccinated. hospitalizations and outpatient visits and Under the Affordable Care Act (ACA), $76.7 million in indirect costs.68 Vaccination is particularly important all vaccines routinely recommended for people who are at high risk of more According to a CDC survey of by the Advisory Committee on severe flu-related illnesses, including healthcare personnel, about one-fifth Immunization Practices (ACIP), young children, pregnant women, (21 percent) of healthcare workers were including flu shots, are covered when people with certain chronic health not vaccinated against the flu during the provided by in-network providers conditions and people 65 years and 2015 to 2016 season.69 Healthy People in group and individual private older. For example, about 90 percent of 2020 has set a goal of 90 percent of health plans and for the Medicaid all flu-related deaths occur in persons 65 healthcare workers vaccinated each flu expansion population with no co- and older.60 If all seniors received the season.70 Among healthcare workers, payments or cost sharing, but states flu shot, flu cases among this vulnerable vaccination coverage was highest are still able to determine coverage population could drop an estimated 15 among healthcare personnel working and cost-sharing for their traditional percent to 25 percent.61, 62 in hospitals (91.2 percent) and lowest Medicaid population. As of 2013, all among those working in long-term state Medicaid programs, with the Each year, millions of Americans care settings (69.2 percent); however, exception of Florida, incorporate get the flu — ranging from around coverage in long-term care settings some level of vaccination coverage 9 million to 36 million people, increased by 5.3 percentage points benefit as part of comprehensive depending on the severity and strain compared with the previous season. Flu healthcare — 36 programs now cover in different years. In recent years, vaccination coverage levels were higher vaccines in accordance with ACIP flu-related deaths ranged from a low among healthcare professionals whose recommendations, including 8 of the 10 of 12,000 (2011 to 2012 flu season) employers required vaccination (96.5 largest programs (not Florida or Texas). to a high of 56,000 (2013 to 2014 flu percent). In settings with no employer Seventeen of these programs (17/36) season). Flu-related hospitalizations requirement for vaccination, coverage also prohibit copayments.74 Medicare ranged from a low of 140,000 (2011- was higher where vaccination was Part B covers annual flu vaccinations for 2012 flu season) to a high of 710,000 offered on-site at no cost for one day beneficiaries with no co-pay. (2014-2015 flu season).63, 64, 65 (82.1 percent) or multiple days (82.8 TFAH • healthyamericans.org 25 INDICATOR 5: CLIMATE 32 states and Washington, D.C.* received a grade 18 states received a grade of D or below on climate of A, B or C on climate change preparedness. (1 change preparedness. (0 points.) CHANGE READINESS point.) Alaska (B+) New Mexico (B-) Alabama (D-) Missouri (F) Arizona (C-) New York (A) Arkansas (F) Montana (D-) Key Finding: 32 states and California (A) North Carolina (B+) Hawaii (D-) Nebraska (D+) Washington, D.C.* received a Colorado (B) North Dakota (C+) Idaho (D+) Nevada (F) Connecticut (A-) Oklahoma (C+) Illinois (D) New Jersey (D+) grade of A, B or C in States at D.C. (N/A)* Oregon (B-) Kansas (D+) Ohio (D-) Delaware (B+) Pennsylvania (A) Kentucky (D) South Dakota (D-) Risk: America’s Preparedness Florida (C-) Rhode Island (B) Maine (D) Texas (F) Report Card, a national Georgia (C-) South Carolina (C-) Mississippi (F) Wyoming (D) Indiana (C-) Tennessee (C) assessment of state-level Iowa (C+) Utah (C+) Louisiana (C) Vermont (C+) preparedness for climate Maryland (B+) Virginia (B) change-related threats. Massachusetts (A) Washington (B+) Michigan (B) West Virginia (C) Minnesota (B-) Wisconsin (B-) New Hampshire (C) Note: *Washington, D.C. data were not available; they were awarded a point for the indicator. Source: Climate Central and ICF. Extreme weather events are becoming Climate Change Readiness Grades by State more and more common in the United States — which has major implications WA for health. Different regions of the MT ND ME VT country face different health threats due OR MN ID NH to climate change — including those SD WI NY MA WY MI related to sea-level rise and associated CT RI NE IA PA NJ NV flooding, prolonged drought and water IL IN OH DE CA UT MD insecurity, hurricanes and other severe CO KS MO WV VA DC KY weather and extreme heat events.75, 76 NC TN Pounding rains cause devastating floods, AZ NM OK AR SC extended droughts threaten agriculture GA MS AL A and massive wildfires threaten homes TX LA B and businesses. Every year it seems C FL there are new historic weather-related AK D HI F disasters — displacing families and putting human health at risk. Climate change and weather-related events can impact human health in a wide range of ways. Factors like potential and waterborne diseases, may increase l T he presence and number of rodents, changes in water quantity and quality, air in incidence and spread as changes in mosquitoes, ticks and other insects quality, average and extreme temperatures temperature and weather patterns allow and animals that can carry infectious and insect control are all important public pathogens to expand into different diseases (disease vectors) rise in health concerns. Certain zoonotic and geographic regions. For instance: warmer temperatures. As extreme vector-borne diseases, as well as food 26 TFAH • healthyamericans.org temperatures increase in severity In 2016, the White House Council on and duration, the geographic and Climate Preparedness and Resilience spatiotemporal patterns of diseases released a report, Opportunities to Enhance ranging from West Nile virus and Zika the Nation’s Resilience to Climate Change. to Lyme and other tick-borne diseases Among the highlights include integrating to encephalitis are expected to shift.77 climate resilience into federal agency activities; supporting community efforts to l C limate change may have an effect on enhance climate resilience; ensuring the the timing of migration of wild birds. impacts of climate change be considered Wild birds are a concern for public in the implementation of national security health because they can be infected policy; integrating resilience into health by a number of microbes that can be and social service delivery to ensure transmitted to humans. In addition, continuity of care and services; and birds migrating across national and continuing to promote sustainable and intercontinental borders can become climate resilient healthcare facilities.82 long-range carriers of any bacteria, virus or parasite they harbor. Birds This indicator examines how prepared were the source of the rapid spread states are for the climate change- of West Nile virus after it was first driven, weather-related threats they identified in 1999. By 2012, the face. States scoring B or above received virus had been reported in humans, a point. Of the 50 states, 5 states mosquitoes and birds in 48 states.78 scored A; 13 scored B; 14 scored C; 13 scored D; and 5 scored F. l C hanging weather patterns put people in different regions at increased risk States at Risk: America’s Preparedness Report for different types of diseases.79, 80 Card, prepared by Climate Central* and ICF,** is the first national analysis of state- l T he rise in extreme weather events level preparedness for climate change- and natural disasters also leads to related threats ever developed.83 The a more fertile environment for the five weather-related threats examined spread of infectious diseases and are extreme heat (48 states), drought germs. For instance, cryptosporidiosis (36 states), wildfires (24 states), inland outbreaks, which cause diarrheal flooding (32 states) and coastal flooding disease, are associated with heavy (24 states). Each state is evaluated based rainfall, which can overwhelm sewage only on the threats it faces. Some states treatment plants or cause lakes, rivers face fewer threats, while others, like and streams to become contaminated Florida, Texas and California, are at risk by runoff containing waste from from multiple weather-related disasters. infected animals. Experts also believe that an El Niño occurrence The report card assesses the changing may have contributed to increases of characteristics of the five climate- cholera.81 Communities recovering related threats for the baseline period from a disaster may see food or (around year 2000) through the year waterborne illnesses associated with 2050, using the latest fine-scale climate power outages or flooding, as well and hydrology projections based on as infectious disease transmission in the high emission scenario for multiple emergency shelters. global climate models.84 TFAH • healthyamericans.org 27 The report card’s goal is to help states people living in poverty, experiencing California have the largest vulnerable improve their level of preparedness by homelessness, under the age of 5 or populations at risk with 1.5 million recognizing their vulnerabilities and over the age of 65 and those with and 1.3 million people living in the building and implementing action mental illness. Alaska faces a unique inland FEMA 100-year floodplain, plans. States are evaluated against a threat from extreme heat — permafrost respectively. Georgia is third most at core set of actions that they must take to thaw — which can cause enormous risk with 570,000 people. More than be prepared in each threat area in five damage to buildings and infrastructure half of all states assessed (17 out of 32) critical sectors — Health, Communities, constructed on top of it. have taken no action to plan for future Transportation, Energy and Water. climate change-related inland flooding Summer drought: Texas is threatened risks or implemented strategies to The core set of actions review the by summer droughts more than any address them. following questions: other state by a significant margin. However, by 2050, Colorado, Idaho, Coastal flooding: Rising sea levels 1) s the state taking action to address its I Montana, New Mexico, Texas, Michigan, put all 24 coastal states at risk for current risks from the climate threat? Wisconsin, Minnesota and Washington flooding — none more than Florida and 2) as the state undertaken activities H are projected to face a greater summer Louisiana. By 2050, 4.6 million people to understand its future changes in drought threat than Texas does today. are projected at risk (living in the 100- vulnerabilities and risks from each year coastal floodplain) in Florida and Wildfires: The number of large climate threat? 1.2 million in Louisiana. More states are wildfires out west has doubled since the prepared for coastal flooding than for 3) as the state planned for adaptation H 1970s and in some states, the rate has any other threat, but despite Florida’s to the future changes in risks from increased fourfold. Fighting wildfires enormous vulnerability, it is among the each climate threat? now accounts for more than half of least prepared for coastal flooding. the annual budget of the U.S. Forest 4) s the state implementing specific I Service, up from 16 percent just 20 *Climate Central is an independent actions to address future changes in years ago. Texas, California, Arizona organization of leading scientists and risks to each climate threat? and Nevada face the greatest threat journalists that surveys and conducts Extreme heat: Despite being the most from wildfires. In those four states, scientific research on climate change and pervasive — and deadly — threat, more than 35 million people live in the informs the public of key findings. Its states are the least prepared for high threat zone — the wildland-urban scientists publish and its journalists report extreme heat. The combination of interface — which is the point where on climate science, energy, sea level rise, heat and humidity in the Southeast wildlands and development converge. wildfires, drought and related topics.85 and Gulf Coast is projected to cross Florida, North Carolina and Georgia **ICF is an organization that is thresholds dangerous for human combine for another 15 million people internationally recognized for its leadership health within the next decade. By at risk, and four southeastern states in carbon accounting, greenhouse gas 2050, 11 states are projected to have an — Arkansas, Alabama, Louisiana and mitigation, climate and extreme weather additional 50 or more heat wave days Mississippi — all face above average vulnerability assessment and adaptation per year, two will have an additional increases in wildfire risks by 2050. planning. It supported the first greenhouse 60, and Florida is expected to have Inland flooding: Risks depend gas inventory, the first mandatory greenhouse 80. Extreme heat has killed more than on many factors — precipitation gas reporting program, the first federal 1,200 Americans in the last 10 years, (locally or far away), soil saturation, agency climate adaptation program and the more than any other form of extreme topography and flood protections first federal agency infrastructure resilience weather during that time. Those like levees and dams. Florida and framework in the United States.86 most vulnerable to extreme heat are 28 TFAH • healthyamericans.org 45 states and Washington, D.C.* met the national 5 states did not meet the national performance target INDICATORS 6: FOOD performance target of testing 90 percent of reported of testing 90 percent of reported E. coli O157 cases E. coli O157 cases within four days (in 2014). (1 point.) within four days (in 2014). (0 points.) SAFETY Alabama (100%) Mississippi (100%) Louisiana (71.4%) Alaska (100%) Missouri (100%) Rhode Island (0.0%) Arizona (100%) Montana (100%) Oregon (61.6%) KEY FINDING: 45 states and Arkansas (100%) Nebraska (97.1%) South Dakota (85.0%) Washington, D.C.* increased California (95.7%) Nevada (100%) Vermont (83.3%) Colorado (100%) New Hampshire (100%) the speed of DNA fingerprinting Connecticut (100%) New Jersey (96.7%) D.C. (N/A)* New Mexico (100%) using pulsed-field gel Delaware (100%) New York (100%) electrophoresis (PFGE) testing Florida (100%) North Carolina (90.9%) Georgia 100%) North Dakota (100%) for all reported cases of Shiga Hawaii (100%) Ohio (100%) Idaho (90.0%) Oklahoma (100%) toxin-producing Escherichia coli Illinois (92.4%) Pennsylvania (97.7%) (E. coli) O157. Indiana (91.8%) South Carolina (100%) Iowa (93.8%) Tennessee (98.8%) Kansas (97.2%) Texas (96%) Kentucky (97.4%) Utah (100%) Maine (92.3%) Virginia (100%) Maryland (100%) Washington (97.9%) Massachusetts West Virginia (100%) (95.1%) Wisconsin (98.7%) Michigan (100%) Wyoming (100%) Minnesota (99.3%) *Note: Washington, D.C. data were not available; they were awarded a point for the indicator. Information was not reported. Source: CDC, Prevention Status Report, 2015 Every year, an estimated one in six in the United States. Many strains Americans suffer from foodborne of this diverse group of bacteria live illnesses.87 Of those, around one harmlessly in the guts of humans and million will suffer from long-term animals. However, some pathotypes chronic complications, such as of E. coli — known as Shiga toxin- kidney failure and brain and nerve producing E. coli (STEC) — can cause damage.88, 89 Foodborne illnesses acute gastro-intestinal illness that may are responsible for around 128,000 lead to systemic disease. People can be hospital visits and kill approximately sickened by consuming contaminated 3,000 individuals each year.90 Illnesses leafy greens, raw dairy products and would be reduced if prevention-based undercooked meat.91 measures were fully implemented to According to the U.S. Department improve the U.S. food safety system. of Agriculture’s (USDA) Economic These indicators are also important Research Service, E. coli costs the United proxies for outbreak prevention and States over $271 million a year, and a containment policies. 2015 study found that 15 foodborne Escherichia coli O157 is one of the pathogens alone are estimated to cost most common foodborne illnesses the country $15.5 billion per year.92 TFAH • healthyamericans.org 29 unknowingly eat it in many different foods. ■ Information technology is helping investigators in many ■ Unexpected foods have been linked to recent multistate places work together. outbreaks, such as caramel apples and chia powder. ■ Efforts by food industries are helping trace contaminated foods to their source. More multistate outbreaks are being found Multistate outbreaks: less common, but more serious Why? Better methods to detect and Why? The deadly germs Salmonella, E. coli and investigate, and wider food distribution. Listeria cause 91% of multistate outbreaks. . 120 of sicknesses Only 3% 11% Number of outbreaks 79 of all US foodborne outbreaks are multistate, but they cause more of hospitalizations 51 than their share of 34% 34 outbreak sicknesses, hospitalizations and deaths: of deaths 1995-1999 2000-2004 2005-2009 2010-2014 56% SOURCE: CDC National Outbreak Reporting System, 1995-2014. SOURCE: CDC Vital Signs MMWR, November 2015. 2 This estimate includes medical costs independent diagnostics, which provide (doctor visits and hospitalizations) and a quick diagnosis, but do not provide a productivity loss due to premature death bacterial isolate that is needed for DNA and time lost from work.93 fingerprinting to enable public health officials to identify an outbreak. One practice that can help states reduce the rapid spread of foodborne illness Indicator 6’s ratings reflect the extent is increasing the speed of pulsed-field to which each state tested E. coli O157 gel electrophoresis (PFGE) testing cases within four days as determined (DNA fingerprinting) of reported E. by the PulseNet database.95 Forty- coli O157 cases. According to the CDC, five states met CDC’s national “Speed of PFGE testing is defined as the performance target of testing 90 annual proportion of E. coli O157 PFGE percent of reported E. coli O157 cases patterns reported to CDC…within four within four days. Four states tested working days of receiving the isolate between 60 percent and 89.9 percent in the state public health PFGE lab.”94 of reported cases and one state tested Detecting outbreaks quickly not only fewer than 60 percent.96 Quickly prevents new cases of illness, but also detecting E. coli O157 contamination can help the food industry identify serves as a marker for the ability of gaps and minimize adverse economic states to protect their populations and impact. Food safety surveillance faces the nation from foodborne illness. the additional challenge of culture- 30 TFAH • healthyamericans.org 35 states and Washington, D.C. have implemented all four 15 states have implemented three or fewer activities INDICATOR 7: REDUCING activities to build capacity for HAI prevention. (1 point.) to build capacity for HAI prevention. (0 points.) Arkansas New Hampshire Alabama HEALTHCARE-ASSOCIATED California New Jersey Alaska INFECTIONS (HAIs) Colorado New Mexico Arizona Connecticut New York Delaware D.C. North Carolina Florida KEY FINDING: 35 states Hawaii North Dakota Georgia Illinois Ohio Idaho and Washington, D.C. Indiana Oregon Minnesota have implemented four Iowa Pennsylvania Missouri Kansas South Carolina Oklahoma recommended activities to build Kentucky South Dakota Nebraska Louisiana Tennessee Nevada capacity for HAI prevention. Maine Texas Rhode Island Maryland Utah Vermont Massachusetts Virginia Wyoming Michigan Washington Mississippi West Virginia Montana Wisconsin Source: CDC Prevention Status Report, 2016 Approximately one out of every 25 infections, increases if they are having hospitalized patients will contract a invasive surgery, if they have a catheter healthcare-associated infection, which in a vein or their bladder, or if they are is an infection patients can get while on a ventilator or a prolonged course receiving medical treatment in a of antibiotics as part of their care.101 In healthcare facility.97 Healthcare-associated 2011, there were an estimated 722,000 infections not only happen in hospitals, HAIs and 75,000 patients with HAIs but can also occur in outpatient surgery died during their hospitalizations in the centers, nursing homes and other long- United States.102, 103 Of the infections, term care facilities, rehabilitation centers, 157,500 were from pneumonia; 157,500 community clinics or physicians’ offices. from surgical site infections; 123,100 from gastrointestinal illness; 93,300 HAIs cost the country $28.4 billion to from urinary tract infections; 71,900 $33.8 billion in preventable healthcare from primary bloodstream infections; expenditures each year.98 A 2013 meta- and 118,500 from other types of analysis found that central line-associated infections.104 Clostridium difficile, which blood stream infections were the caused 12.1 percent of HAIs, was the most costly HAIs at $45,814 per case.99 most commonly reported pathogen. According to CDC, if 20 percent of these infections were prevented, healthcare This indicator examines whether state facilities could save nearly $6 billion to health departments have implemented $7 billion, and reducing infections by all four activities to build capacity for 70 percent could result in $25 billion to HAI prevention according to data nearly $32 billion in savings.100 from a CDC 2015 survey of state HAI coordinators. These four activities A person’s risk for an HAI, which are: 1) building and maintaining includes a range of antibiotic-resistant TFAH • healthyamericans.org 31 Protect every patient every time. Actions to prevent antibiotic-resistant infections in healthcare. Prevent infections Prevent bacteria Improve from catheters from spreading. antibiotic and after surgery. use. 3 Improve hand hygiene. 3 Get cultures and start antibiotics promptly, especially in the case of sepsis. 3 Use catheters only when needed. 3 Use gloves, gowns, and dedicated equipment for patients who have 3 Use cultures to reassess the need for 3 Follow recommendations for safer surgery resistant bacteria. antibiotics and stop antibiotic treatment as and catheter insertion and care. soon as they are no longer needed. 3 Know about antibiotic-resistant 3 Remove catheters from patient as soon as HAI outbreaks in your hospital 3 When antibiotics are necessary, use the they are no longer needed. and region (e.g. promote coordinated appropriate antibiotic in the proper dosage, action for prevention). frequency, and duration. N AT I O N A L ACUTE CARE HOSPITALS Healthcare-associated infections (HAI) are infections patients can get while receiving medical treatment in a healthcare facility. Working toward the elimination of HAIs is a CDC priority. For more information on HAI prevention progress, visit: www.cdc.gov/hai/progress-report/index.html. CLABSIs SSIs CENTRAL LINE-ASSOCIATED SURGICAL SITE INFECTIONS BLOODSTREAM INFECTIONS 1 in 6 CLABSIs were caused 1 in 7 SSIs were caused by by urgent or serious antibiotic- urgent or serious antibiotic- resistant threats. resistant threats. CAUTIs C. difficile Infections CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 1 in 10 CAUTIs were caused 9 in 10 patients diagnosed by urgent or serious antibiotic- with C.difficile are related resistant threats. to healthcare. SOURCE: CDC Vital Signs, March 2016. Data used for this analysis was reported to CDC’s National Healthcare Safety Network. 3 32 TFAH • healthyamericans.org partnerships (e.g., collaborating with were an estimated 30,800 fewer invasive S TAT E H A I P R O G R E S S ACUTE CARE HOSPITALS quality improvement organizations or Methicillin-resistant Staphylococcus LEGEND 2014 state SIR is significantly lower (better) or Change in 2014 state SIR compared to group in than comparison group in column header column header is not statistically significant 2014 state SIR is significantly higher (worse) 2014 state SIR cannot be calculated Yes than comparison group in column header hospital associations); 2) supporting aureus (MRSA) infections in the United CLABSIs: CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS HAI-related outbreak response by States from 2005 to 2011, with hospital- STATE 2014 Reporting and Validation 2014 State CLABSI SIR # Hospitals State Reporting State HD‡ has Data Checked Additional vs. vs. vs. Reporting Mandate Access to Data for Quality In-Depth Data 2013 2014 2008 to NHSN+ Review State SIR Nat’l SIR Nat’l Baseline building infrastructure to identify onset MRSA decreasing by more than Alabama Alaska 70 11 and respond to reports of outbreaks 60 percent.111 Hospital-onset MRSA Arizona 60 Arkansas 47 California 358 in healthcare settings; 3) conducting decreased 13 percent between 2011 Colorado Connecticut 53 31 or supporting HAI training; and 4) and 2014.112 D.C. 8 Delaware 8 Florida 194 validating HAI data (i.e., analyzing Georgia 108 In addition, CDC updated the annual Hawaii 16 data for quality and completeness and/ Idaho 15 National and State Healthcare-Associated Illinois 150 Indiana 101 or reviewing medical records to check Iowa 61 Infections: Progress Report. It found Kansas 48 data accuracy). Kentucky 70 THIS REPORT IS BASED ON 2014 DATA, PUBLISHED IN 2016 from between 2013 and 2014, 11 states Louisiana 80 Maine 21 Maryland 48 Prevention and education efforts have reduced rates for one of the sentinel Massachusetts Michigan 69 98 been helping to decrease the rates of infections — central line-associated Minnesota Mississippi 48 49 Missouri 76 HAIs. CDC, the Centers for Medicare blood stream infections (CLABSI), + The number of hospitals that reported to NHSN and are included in the SIR calculation. ‡ State Health Department State analyzed 2014 data for quality and completeness. State reviewed medical records to determine 2014 data accuracy. and Medicaid Services (CMS), states including: Arizona, Florida, Indiana, and medical providers have launched North Carolina, New York, Pennsylvania, S TAT E H A I P R O G R E S S ACUTE CARE HOSPITALS LEGEND 2014 state SIR is significantly lower (better) or Change in 2014 state SIR compared to group in a series of provider education and South Carolina, Texas, Utah, Virginia than comparison group in column header column header is not statistically significant 2014 state SIR is significantly higher (worse) 2014 state SIR cannot be calculated Yes than comparison group in column header prevention initiatives.105, 106 In addition, and Wisconsin.113 In addition, 13 CLABSIs: CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS STATE 2014 Reporting and Validation 2014 State CLABSI SIR in 2008, Medicare provided an incentive states had rates that were statistically # Hospitals Reporting to NHSN+ State Reporting Mandate State HD‡ has Access to Data Data Checked for Quality Additional In-Depth Data Review vs. 2013 State SIR vs. 2014 Nat’l SIR vs. 2008 Nat’l Baseline to reduce infections by adopting a “no significantly better than the national rate: Montana 16 Nebraska 27 Nevada 24 pay” rule for infections acquired during Colorado, Hawaii, Illinois, Michigan, New Hampshire New Jersey 24 72 a hospital stay, requiring the hospitals North Carolina, Ohio, Oklahoma, New Mexico 34 New York 168 North Carolina 98 themselves to cover any costs incurred by Pennsylvania, South Dakota, Texas, North Dakota Ohio 8 137 these infections.107 According to a 2012 Virginia, West Virginia and Wisconsin. Oklahoma Oregon 58 50 survey, 80 percent of infection-control Pennsylvania 176 Puerto Rico 16 A central line is a tube that is typically Rhode Island 11 professionals believe the rules have South Carolina 67 inserted in a patient’s large vein, usually South Dakota 13 resulted in a greater focus on reducing Tennessee 105 THIS REPORT IS BASED ON 2014 DATA, PUBLISHED IN 2016 Texas 289 in the neck, chest, arm or groin, to give Utah 27 HAIs. The ACA also requires in-patient Vermont 7 important medical treatment. When Virginia 83 hospitals to report certain infections to Washington 86 not put in correctly or kept clean, West Virginia 43 Wisconsin 96 the National Healthcare Safety Network Wyoming 22 central lines can become a freeway + The number of hospitals that reported to NHSN and are included in the SIR calculation. ‡ State Health Department State analyzed 2014 data for quality and completeness. State reviewed medical records to determine 2014 data accuracy. (NHSN) in order to receive their full for germs to enter the body and cause payment updates, and the information is deadly infections in the blood. These available on the CMS’ Hospital Compare infections are usually serious, often website.108 The NHSN is the largest resulting in the prolongation of hospital healthcare-associated infection reporting stay and increased cost and risk of system in the United States, serving mortality.114 Nationally, the number more than 20,000 healthcare facilities of of CLABSI infections has decreased all types that track HAIs.109 overall — by 50 percent — from 2008 to Many states are seeing decreases in 2014, when the standard infection ratio HAIs. Between 2008 and 2014, there benchmark was established (0.54) to be were 50 percent fewer central line- able track progress over time.115, 116 The associated bloodstream infections and indicator reflects whether healthcare 17 percent fewer surgical site infections systems and providers are aware of related to 10 surgical procedures in infection problems and have taken in-patient healthcare settings.110 There appropriate steps to prevent them.117 TFAH • healthyamericans.org 33 INDICATORS 8 AND 9: 44 state laboratories provided biosafety training and/or 6 state laboratories and Washington, D.C.’s information about biosafety training courses for sentinel laboratory did not provide biosafety training and/ PUBLIC HEALTH clinical labs in their jurisdiction (from July 1, 2015 to June or information about biosafety training courses LABORATORIES 30, 2016). (1 point.) for sentinel clinical labs in their jurisdiction (from July 1, 2015 to June 30, 2016). (0 points.) Alabama Kentucky  North Carolina^  D.C. Alaska^ Louisiana  North Dakota  Idaho KEY FINDING: 44 state Arizona  Maine Oklahoma  Maryland laboratories provided biosafety Arkansas  Massachusetts  Oregon Ohio California  Michigan South Carolina  Pennsylvania training and/or provided Colorado^  Minnesota South Dakota  Rhode Island Connecticut  Mississippi  Tennessee  West Virginia information about biosafety Delaware^  Missouri^  Texas  training courses for sentinel Florida^ Montana^ Utah Georgia  Nebraska^  Vermont  clinical labs in their jurisdiction Hawaii  Nevada Virginia^ Illinois^ New Hampshire^  Washington  (from July 1, 2015 to June 30, Indiana  New Jersey^  Wisconsin  2016.) Iowa  New Mexico^ Wyoming Kansas New York Note: ^Provided both training and information. Source: Association of Public Health Laboratories 2016 survey 47 state laboratories and Washington, D.C.’s laboratory 3 state laboratories reported not having a Key Finding: 47 state reported having a biosafety professional (from July 1, 2015 biosafety professional (from July 1, 2015 to to June 30, 2016). (1 point.) June 30, 2016). (0 points.) laboratories and Washington, Alabama  Louisiana  North Dakota  Alaska D.C.’s laboratory reported having Arizona  Maine  Ohio  Nevada Arkansas  Maryland Oklahoma  Pennsylvania a biosafety professional (from California  Massachusetts  Oregon  Colorado  Michigan  Rhode Island  July 1, 2015 to June 30, 2016.) Connecticut  Minnesota  South Carolina  D.C. Mississippi  South Dakota  Delaware  Missouri  Tennessee  Florida  Montana Texas  Georgia  Nebraska  Utah  Hawaii  Nevada  Vermont  Idaho  New Hampshire  Virginia  Illinois New Jersey  Washington  Indiana  New Mexico  West Virginia  Iowa  New York  Wisconsin  Kansas  North Carolina  Wyoming Kentucky  Source: Association of Public Health Laboratories 2016 survey 34 TFAH • healthyamericans.org Public health laboratories are essential to CDC’s Epidemiology and Laboratory quickly identifying and diagnosing new Capacity for Infectious Diseases (ELC) outbreaks and tracking ongoing outbreaks. Cooperative Agreement distributes char definerizatio resources to U.S. health departments to act Labs require highly expert staffing, itive n detect, prevent and control infectious extensive safety measures, specialized disease threats. Grants are used to equipment, reagents and other strengthen epidemiological, laboratory conftesting biological materials to use for testing and health information systems capacity irma and enough capacity to test for a large tor y at state, local and territorial levels. The threat or multiple threats at once. They ELC cooperative agreement totaled have ongoing responsibilities, such reco e-out over $245 million in awards in FY 2016, r ul er as testing water and environmental gniz ref boosted from 2015 levels by Zika and e conditions, as well as responding to funding for Combating Antimicrobial emergencies and novel threats, such as Source: CDC Resistant Bacteria (CARB).120 an outbreak of Salmonella or a suspicious white powder that could potentially be specimens. They are made up of more These indicators examine two important used as an act of bioterrorism. than 100 state and local public health, components of ensuring safety in labo- military, international, veterinary, ratories. First, according to an annual Since 2001, public health labs have agriculture, food- and water-testing survey conducted by the Association of created networks to be more efficient and laboratories; and Public Health Laboratories (APHL), for effective, so that every state has a baseline the time period of July 1, 2015 to June 30, of capabilities but does not have to invest l S entinel laboratories provide routine 2016, 44 state labs reported that they pro- the resources required to maintain every diagnostic services, rule-out and vided biosafety training and/or informa- type of state-of-the-art equipment or referral steps in the identification tion about biosafety training courses for staffing expertise. For example, samples process. While these laboratories may sentinel clinical labs in their jurisdiction. can be shipped to facilities with the needed not be equipped to perform the same In addition, 47 state labs and Washington, expertise as quickly and safely as possible. tests as LRN Reference laboratories, D.C. reported that they have a profes- they can test samples. The Laboratory Response Network for sional committed to biosafety on staff. Biological Threat Preparedness (LRN-B) Labs not only help detect and diagnose According to the Occupational Safety includes clinical diagnostic and research problems, the information they provide and Health Administration (OSHA), labs with a hierarchy of different helps public health officials track the there are over 500,000 lab workers in capabilities that form an integrated, emergence and spread of different the United States. These workers can supporting network capable of rapidly outbreaks and is an essential part be exposed to a range of chemical, responding to an outbreak and/or of monitoring disease threats and biological and radiological hazards. bioterrorism attack, including:118 understanding how to control them. While lab safety is governed by myriad l N ational laboratories — including In 2010, CDC began funding 57 state, regulations at the national, state and those operated by CDC, U.S. Army local and territorial health departments to local level, OSHA has developed Medical Research Institute for encourage increased electronic reporting standards and published guidance over Infectious Diseases (USAMRIID) and of lab results to help make reporting faster the years to improve safety.121 the Naval Medical Research Center and more complete.119 Data collected since Many workers handle a variety of (NMRC) — are responsible in their then show various improvements. By the biological hazards, including bloodborne role in the LRN-B for specialized strain end of July 2013, 54 of the 57 jurisdictions agents, research animals and federally- characterizations, bioforensics, select were getting some laboratory reports regulated select agents (e.g., viruses agent activity and handling highly through Electronic Laboratory Reporting and bacteria) and toxins that have the infectious biological agents; (ELR), and 62 percent of laboratory potential to pose a severe threat to public reports were being received through ELR l R eference laboratories are responsible health and safety. Select agents and compared to 54 percent in 2012. for investigation and/or referral of TFAH • healthyamericans.org 35 36 TFAH • healthyamericans.org toxins — as well as other infectious agents regulated federally, workers must use It is also important to have well-trained and toxins — must be properly stored PPE and agents must be properly stored laboratorians and labs that have and handled to ensure the safety of the and handled. PPE is selected based on adequate and up-to-date equipment to worker, his or her immediate environment the hazard to the worker and must be be able to respond when new threats and the larger public as a whole. properly fitted, maintained in accordance arise. Strong training helps ensure with manufacturing specifications and that appropriate biosafety precautions A biosafety program requires consistent properly removed and disposed of or are taken. In the past several years, use of good microbiological practices, cleaned to avoid contaminating the labs have had to respond to the rise use of primary containment equipment worker, others or the environment.123 of emerging threats, such as Zika, and proper containment facility design.122 Chikungunga, Dengue and Ebola. It is One of the primary elements of lab safety Properly maintained Biosafety Cabinets also important to have enough trained is personal protective equipment (PPE) (BSCs) are another key component staff to be able to test for emerging — the protective gear workers wear to of laboratory safety. They provide an problems — including to meet surge keep them safe as they carry out their effective containment system for safe needs when the labs get an influx jobs. These include respirators, goggles manipulations of biological agents that of samples, as some states are now and disposable gloves. In working with may produce infectious aerosols.124 managing in response to Zika. the infectious agents and toxins that are LABORATORY SAFETY IMPROVEMENT MEANINGFUL USE The Office of the Associate Director for Laboratory Science and Meaningful use is defined as “the use of certified electronic Safety (OADLSS) was established in 2015 to centralize over- health record (EHR) technology in a meaningful manner (for sight and leadership of laboratory safety and quality following example electronic prescribing); ensuring that the certified reported laboratory safety incidents in 2014. CDC created the EHR technology is connected in a manner that provides for the executive position of the ADLSS, staffed with a senior scientist electronic exchange of health information to improve the quality who directly reports to the CDC Director, to provide agency-wide of care; and that in using certified EHR technology the provider leadership and accountability for laboratory safety and quality; must submit to the Secretary of HHS information on quality of and the U.S. Food and Drug Administration (FDA) hired a safety care and other measures.” Through the Medicare and Med- official to address gaps in FDA labs.125, 126, 127 icaid Programs: Electronic Health Records Incentive Program, CMS is providing incentive payments to eligible hospitals, pro- The creation of OADLSS represents a major success in trans- viders and critical access hospitals that adopt and successfully forming laboratory quality and safety oversight at the agency. demonstrate meaningful use of certified EHR technology.128 By centralizing all laboratory quality and safety functions in a single point of accountability, OADLSS merges the scientific One public health objective for meaningful use is electronic and safety priorities of its diverse laboratories and estab- lab reporting (ELR), transmitting laboratory reports to public lished a framework for effective leadership of CDC’s labora- health agencies on reportable conditions. Its benefits tories. One key accomplishment to enhance safety at CDC include improved timeliness, reduction of manual data entry includes the creation of the Laboratory Safety Review Board, errors and reports that are more complete. The vision for which reviews all new and amended protocols for the transfer ELR — as determined by a task force comprised of experts of biological materials out of Biosafety Level 3 (BSL-3) and from CDC, the Council of State and Territorial Epidemiologists BSL-4 laboratories, and conducts annual reviews of existing (CSTE) and the Association of Public Health Laboratories protocols. Another key accomplishment is the creation of the (APHL) — is that “all labs (public and private) conducting Laboratory Leadership Service (LLS), a fellowship program clinical testing identify laboratory results that indicate a that prepares early career laboratory scientists to become fu- potential reportable condition for the jurisdictions they serve, ture laboratory leaders. LLS is modeled after the Epidemic In- format the information in a standard manner and transmit telligence Service, and it combines competency-based public appropriate messages to the responsible jurisdiction; all health laboratory training with practical, applied investigations. jurisdictions can and do receive and utilize the data.”129 TFAH • healthyamericans.org 37 INDICATOR 10: 10 states have a formal access program or 40 states and Washington, D.C. do not have a formal access a program in progress for getting private program or a program in progress for getting private sector HEALTHCARE sector healthcare staff and supplies into healthcare staff and supplies into restricted areas during a PREPAREDNESS — restricted areas during a disaster. (1 point.) disaster. (0 points.) Florida Alabama** Iowa Nevada ACCESS TO DISASTER Louisiana Alaska Kansas Oklahoma SITES Massachusetts Arizona Kentucky Oregon Mississippi Arkansas Maine Pennsylvania** New Jersey California Maryland** South Dakota Key Finding: 10 states have North Carolina Colorado Michigan Tennessee Ohio Connecticut** Minnesota Texas** a formal access program or a Rhode Island* D.C. Missouri Utah South Carolina Delaware Montana Vermont program in progress for getting Washington* Georgia** North Dakota Virginia private sector healthcare staff Hawaii Nebraska West Virginia Idaho New Hampshire Wisconsin and supplies into restricted Illinois** New Mexico Wyoming Indiana New York** areas during a disaster. Note: *State programs in progress. **City or county programs. Source: Healthcare Ready This indicator examines state access During a disaster, access and re-entry of programs across the United States critical healthcare personnel and supplies for getting critical private sector to the site are essential. Many states healthcare staff and supplies into have disjointed policies for permitting restricted areas during and following a private sector personnel and supplies disaster. Healthcare Ready’s research into disaster sites. This can create delays approach included:130 in healthcare operations — limiting access for patients, deliveries of critical l A comprehensive review of state-level products, employee access to work sites legislation, regulations for provisions and community and economic resiliency. and existing programs addressing entry In healthcare settings, staff shortages and and re-entry, transportation and delivery. delivery delays can cost lives. l A survey of over 120 federal and Coordination with law enforcement state emergency managers, public and emergency responders is one key health officials and private sector component of any disaster response. They representatives on their experiences mitigate dangerous and unsafe conditions and recommendations. and restrict access to protect communities l I nterviews with twenty-five public and and begin to establish stability in the private sector stakeholders, including immediate aftermath. While maintaining emergency management agencies and safety, they must validate identities and business continuity specialists in the roles of individuals requesting access in healthcare, retail, telecommunications order to grant entry only to those who are and logistics industries. essential. If officers manning roadblocks are not aware of access programs in l A nalysis of applicable emergency place and do not recognize the badges declaration language addressing private or credentials that parties will use to gain sector access to restricted sites and/or access, critical operations can be delayed. healthcare operations during a disaster. 38 TFAH • healthyamericans.org While having an access program does not Supply chains that deliver critical necessarily result in improved outcomes, medicines and supplies are often global it is an indicator of prioritization, or national and need access across attention and/or resources focused multiple jurisdictions. Yet, emergency on addressing the concerns and issues response operations are run by local around access to healthcare during and emergency management agencies and following disasters. law enforcement. Some companies also contract surge or third party personnel. Three major challenges with access If rules are different at checkpoints in to disaster sites are defining critical every jurisdiction, companies must have personnel, “last mile delivery” and relationships with every jurisdiction jurisdictional challenges. Private along their supply route — a nearly personnel whose roles are considered impossible endeavor. critical (doctors, nurses, etc.) will likely receive access. Unfortunately, what is There are two primary methods of deemed critical varies widely between facilitating access to restricted sites: public and private sectors. Additionally, formal access programs and ad hoc or companies that manufacture and just-in-time methods: distribute medicines and supplies l ormal access programs. These identify F often contract their “last mile” delivery and authorize essential personnel to local third party companies with before an event and are administered unmarked courier vans and drivers either by the state or local jurisdiction unaware of the cargo they are carrying. or by a third-party organization that As contractors, these drivers lack has an access program adopted by the company ID verifying their affiliation. jurisdiction. Vetted personnel are first This hinders law enforcement in registered, and then approved, managed verifying the contents to ensure only the and monitored through a database. most critical supplies gain access. TFAH • healthyamericans.org 39 Eight states currently maintain l d hoc or just-in-time methods A statewide programs. Of these, five are authorize personnel during or managed by the state (Florida, Ohio, immediately following an event. New Jersey, North Carolina and South One type is coordination through Carolina) and three have adopted emergency operations centers programs set up and managed by a (EOCs) and business emergency third-party access program (Louisiana, operations centers (BEOCs), which Massachusetts and Mississippi). Two maintain a large volume of private states (Rhode Island and Washington) sector points of contact in their have statewide programs in databases and serve as hubs during development. In addition, several cities crises to share information between and counties have implemented locally- sectors, coordinating resources and developed or third-party programs in supporting local response operations. eight states: Alabama, Connecticut, Law enforcement can contact the Georgia, Illinois, Maryland, New York, BEOC or EOC with questions or Pennsylvania and Texas. concerns about the validity of an Third-party organizations dedicated access request and, conversely, private to providing governments with sector organizations can contact the customizable ready-to-use systems for BEOC or EOC when they experience defining, managing and enforcing challenges gaining access to a site. access are gaining popularity. Two Another common practice companies major programs include Corporate that routinely require access after a Emergency Access System (CEAS) disaster use is the development of in the Northeast and the Emergency event-specific letters requesting access. Responder--ID Trust Network (ER-ITN) These letters are printed on official in Gulf Coast states. Both programs are letterhead and contain a brief message sustained by fees assessed to companies. explaining the role of the critical CEAS uses pre-issued identification personnel or nature of the supplies cards that can be managed online requiring delivery. They are issued to verify requesting personnel’s to critical employees and shown at affiliation and qualifications to law security checkpoints. enforcement controlling access. Law Emergency declarations have also been enforcement can scan the card with used to facilitate access during disasters, a mobile app to verify the credential but declaration language can vary and track personnel on the scene. widely even within the same jurisdiction. ER-ITN provides a tiered time-phased For example, during Hurricane Sandy, procedure for access and re-entry. Its bridge restrictions were lifted for system assesses the entry tier for which emergency and medical personnel but personnel are approved and other the language was not as effective for response qualifications or certifications, allowing other personnel and delivery which are displayed to law enforcement access. While ad hoc just-in-time scanning their badge or looking them solutions have been proven to work up in the system. The program uses a occasionally, formal programs are more mobile app, vehicle access placards and reliable and should be the standard. letters of access for re-entry. 40 TFAH • healthyamericans.org SECTI O N 2 National NATIONAL HEALTH SECURITY ISSUES AND RECOMMENDATIONS National Health Security Issues and Recommendations Health The nation’s health security policy needs to be built to expect Security Issues new emergencies. Health crises are not a question of if, but & when. Preparing requires maintaining a stronger steady defense that is able to more effectively manage ongoing Recommendations public health needs while being ready and able to respond to emerging and emergency priorities. Investments have helped significantly E. nnovating and Modernizing I improve many areas of preparedness Infrastructure, Including Wide over the past 15 years, but they have Implementation of Faster fallen short of what is needed to Diagnostics, Biosurveillance and address some major gaps and ensure a Medical Countermeasures; consistent and strong level of readiness F. aintaining a Robust, Well-Trained M across the country. In addition, budget Public Health Workforce; cuts have actually eroded gains that had G. Rebooting and Developing a New been made, including sustaining some Strategy for Hospital and Healthcare basic capabilities. Emergency Preparedness — Surge TFAH has identified a set of concerns Capacity for Major Emergencies; and recommendations for improving Healthcare Associated Infections; America’s preparedness for health and Integrated Public Health and emergencies, including: Healthcare Response; A. eforming Baseline Abilities to R H. upporting Community Resilience — S Diagnose, Detect and Control Health for Communities to Better Cope and Crises: Foundational Capabilities; Recover from Emergencies — With Better Behavioral Health Infrastructure B. Supporting Stable, Sufficient and Capacity; Funding for Ongoing Emergency Preparedness — and Funding a I. eadying for Climate Change and R Permanent Public Health Emergency Weather-Related Threats; Fund for Immediate and “Surge” J. topping Superbugs and Antibiotic S Needs During an Emergency; Resistance; C. Supporting Global Health Security; K. Improving Vaccination Rates — for D. mproving Federal Leadership I Children and Adults; and DECEMBER 2016 Before, During and After Disasters; L. Fixing Food Safety. BACKGROUND REVIEW OF MAJOR RECENT FEDERAL DIRECTIVES, STRATEGIES AND REPORTS In recent years, the federal government — DHS, including FEMA, health preparedness to provide a concrete vision for state and and HHS, including the Office of the Assistant Secretary for local governments on recommended actions and the essential Preparedness and Response (ASPR) and CDC — has released elements for success. These reports also examine current trends a number of strategies and reports on disaster and public and progress and outline necessary improvements for the future. PRESIDENTIAL POLICY DIRECTIVE-8 AND NATIONAL HEALTH SECURITY STRATEGY In March 2011, President Obama issued the Presidential Policy Directive-8 (PPD- “A secure and resilient Nation with the capabilities required across the 8): National Preparedness, which laid whole community to prevent, protect against, mitigate, respond to and out the country’s approach to preparing for acts of terrorism (including cyber recover from the threats and hazards that pose the greatest risk.”132 attacks), disease outbreaks and natural disasters.131 Requirements While the language of the Goal itself did in 2016 to provide greater visibility on of the directive include a National not change, a new core capability, Fire firefighting capabilities and operations. Preparedness Goal; a National Management and Suppression, was added Preparedness System that includes a series of National Planning Frameworks and Federal Interagency Operational Plans; an annual National Preparedness Report; and a Campaign to Build and Sustain Preparedness. DHS, through FEMA, released an updated National Preparedness Goal in September 2011, which set the vision for preparedness in five mission areas — prevention, protection, mitigation, response and recovery. In November 2011, DHS/FEMA released the National Preparedness System as integrated guidance, programs and processes need to implement the National Preparedness Goal. The National Preparedness Goal (Goal) — updated in 2015 based on lessons learned and real-world events — defines what it means for the nation to be prepared for all types of disasters and emergencies. Source: FEMA 42 TFAH • healthyamericans.org NATIONAL PREPAREDNESS SYSTEM The National Preparedness System Within the National Preparedness System, outlines an organized process for there are Federal Interagency Operational The National Preparedness every person — individuals, families, Plans (FIOPs) for each preparedness mis- Frameworks set the strategy and communities, the private and nonprofit sion area that describe how the federal doctrine for realizing the Goal, with sectors, faith-based organizations, and all government aligns resources and delivers one framework for each mission levels of governments — to achieve the the core capabilities. area — prevention, protection, National Preparedness Goal. It comprises mitigation, response and recovery.133 Given the whole community approach to a capabilities-based approach to They define objectives for the core the System, a Comprehensive Campaign to preparedness planning that is applicable capabilities and the critical tasks Build and Sustain National Preparedness is to all five mission areas. necessary to meet them. another essential piece of the ongoing effort It has six parts: 1) Identifying and of preparedness. FEMA built a website Assessing Risk; 2) Estimating Capability soliciting the public to post on a number of Requirements; 3) Building and Sustaining topics. This public feedback will ultimately Capabilities; 4) Planning to Deliver help FEMA more effectively increase Capabilities; 5) Validating Capabilities; outreach efforts and encourage everyone to and 6) Reviewing and Updating. take actionable steps to be prepared. FEMA’S NATIONAL PREPAREDNESS • Increasing the number of fusion centers by encouraging resilient building prac- REPORT — first released in March 2012 that meet designated standards for tices through post-disaster funding. and most recently in March 2016 — gathering, receiving, analyzing and • xpanding efforts to plan for and adapt E summarizes progress made in building, sharing threat-related information. to hazards posed by climate change. sustaining and delivering the 32 core • xpanding training and support to E • eveloping the Federal Flood Risk D capabilities in the Goal’s five mission enhance capabilities for chemical, Management Standard. areas. FEMA collects and analyzes biological, radiological, nuclear and quantitative and qualitative information explosive threats. l R esponse (saves lives, protects gathered from more than 450 data property and the environment and sources and 190 stakeholders, including l P rotection (secures the homeland meets basic human needs after an 66 non-federal organizations. 134 against acts of terrorism and manmade incident has occurred) or natural disasters) The 2016 report’s findings related to • xtending the coverage of an integrated E • mproving resilience to cyber-security I set of public alert and warning capabili- public health and medical services — the risks through increased availability of ties to a larger portion of the country. fifth report in the series — demonstrates training and resources and increased that the nation has achieved significant • reating new — and improving existing C information sharing between the fed- improvements in national preparedness — active-shooter response planning eral government and the private sector. since 2011. Improvements highlighted in and training resources. the Report in the five mission areas include: • ecuring vulnerable nuclear and radio- S • roviding a unified approach to deliver P logical materials around the world. l P revention (to avoid, prevent or stop mass care services through the • mproving abilities to detect and ad- I National Mass Care Strategy. an imminent terrorist attack within the dress chemical, biological, nuclear and United States) l R ecovery (maintains and restores im- radiological threats. • xpanding the use and accuracy of E portant community assets after an in- terrorist and criminal biometric identifica- l M itigation (reduces loss of life and prop- cident, such as housing, infrastructure, tion capabilities through the achievement erty by lessening the impact of disasters) businesses and health and social ser- of full operational status for the FBI’s • nhancing the connection between the E vices, as well as ensures consideration Next Generation Identification Program. Mitigation and Recovery mission areas for natural and cultural resources) TFAH • healthyamericans.org 43 erational Coordination, Logistics and Supply Chain Management, Fire Management and Suppression, and Situational Assessmen n 2015, wildland firefighting operations successfully coordinated the deployment of local, regional, national, and nternational resources to support response efforts. The U.S. Forest Service worked with jurisdictions to mobilize heir All-Hazard Incident Management Teams, which are multi-agency, multi-jurisdiction teams activated for major or complex incidents. For example, a team from San Diego helped coordinate structural firefighting resources from five states to protect communities in Washington State threatened by wildland fires. To help responders allocate resources, the Civil Air Patrol flew 163 missions to provide aerial photography of wildland fires in five states. • trengthening federal coordination of re- S in North Carolina highlight the need for covery assistance, including environmen- mitigation strategies to reduce loss of erational Communications and Situational Assessment tal and historic preservation reviews, in life and property. n January 2015, the Federal Communications Commission (FCC) process. rules that improve location information order to expedite the recovery adopted l major avian or “bird” flu outbreak and A obtained from 9-1-1 calls made indoors. Additionally, National Disaster Recov- and tribal wildfire season since at least to take • pplying the A Federal, state, local, the worst authorities continued steps to implement Next Generation 9-1-1, which will provide aincidents ery Framework in real-world nationwide, 1960 demonstrated the importanceemergency Internet Protocol–based of communications infrastructure that allows and familiarizing national stakeholders for voice and multimedia communications and improve emergency quick and effective response activities. services for the public, dispatchers, and first with its principles. January 2015, FCC orrential flooding task force,Maryland, issued responders. In l T chartered a in Louisiana, which our reports with recommendations for how ntegrating Safety Answering Points (i.e., 9-1-1 centers) Virginia demon- their •I Public research and lessons learned North Carolina and West can optimize security, operations, and funding as they migratereal-world incidents to improve out- from to Next Generation 9-1-1. strated the need for community capabili- comes in health and social services for ties to recover by quickly restoring critical ss Care Services disaster-affected communities. infrastructure and essential services. From October 1 to December 31, 2015, over 17,000 unaccompanied children crossed into the United States, more In 2015, federal agencies supported Despite increased capabilities, disasters con- han double the number who arrived over the same period in 2014. To ensure sufficient shelter, the Office of Refugee of shelter providers from disaster survivors by assisting in: Resettlement within HHS increased the capacitychallenge the nation through 2016: 7,900 beds to approximately 8,400 beds tinued to n November, and added 1,400 temporary shelterattacks in December. l yber C beds on private and public l 3 major disaster declarations across 4 systems and multiple active-shooter inci- 32 states, territories and tribes. nning dents tested protection capabilities. l 4 instances of fire management across 3 Catastrophic planning received renewed attention weather events like the historic year, nine states. l evere in 2015. Throughout the S FEMA conducted various events with state, local, and private-sector partners (e.g.,winter storm in New England and Hur- orientations, planning meetings) l rought declarations for 1,000+ counties in building towards a four-day exercise D n June 2016 that will address a 9.0-magnitude earthquake in the Cascadia subduction zone—a 700-mile seismic fault ricane Matthew’s destructive flooding across 35 states and territories. ine off the Pacific Northwest coast. In addition, a high-profile media article echoed this priority by detailing the potential devastation resulting from a large earthquake in the Cascadia subduction zone and subsequent tsunami. As shown in Figureefforts to strengthen several efforts to improve catastrophic planning and preparedness. In 2015, 1, this was one of catastrophic preparedness occurred in each of FEMA’s 10 regions Source: FEMA National Preparedness Report 44 Figure•1: In 2015, efforts to strengthen catastrophic preparedness occurred in each of FEMA’s 10 regions. TFAH healthyamericans.org 2016 National Preparedness Rep Several lessons learned from the 2014 development and initiate clinical trials of Ebola outbreak are outlined in the National vaccines, therapeutics and diagnostic tests Preparedness Report. The $5.4 billion in for Ebola. It is expected that candidates emergency funding awarded in December may soon be mature enough for inclusion 2014 supported progress in 2015 on in the Strategic National Stockpile. assessing and increasing hospital capabil- HHS also funded 31 research projects to ities and the development of diagnostics, support post-Hurricane Sandy recovery vaccines and therapeutics for Ebola. efforts, generating best practices and Ebola highlighted that not every major tools to enhance future recovery, such hospital could build and sustain the capa- as insights into mental health services bilities to handle Ebola identification, bio- provision and coordination between local containment and treatment. HHS worked health departments and non-governmental with states to assess hospitals’ prepared- organizations. ness and designate those with the best ASPR, in partnership with CMS, completed capabilities as Ebola Treatment Centers. two studies that followed treatment pat- The Ebola response also highlighted the terns and outcomes of 13,000 dialysis essential need for rapid development patients in New York City and New Jersey. of medical countermeasures. ASPR’s The studies identified mitigation measures Public Health Emergency Medical that protected patient’s health, while min- Countermeasures Enterprise worked imizing stress on the healthcare system closely with suppliers to accelerate the before, during and after the storm.135, 136 FOCUS ON COMMUNITY RESILIENCE National Health Security Strategy National Health Security Review (NHSS) (NHSR) In December 2009, HHS released the The national health security goals National Health Security Strategy (NHSS) of the inaugural NHSS 2010-2014 to help galvanize efforts to minimize included: build community resilience; the health consequences associated and strengthen and sustain health and with significant health incidents. The emergency response systems.  Since strategy is built on a foundation of 2010, progress has been made in community resilience.137 In May 2012, achieving both of these goals, while HHS released the NHSS Implementation the greatest improvement involved Plan, which describes the outcomes integration of public health, healthcare desired in order to meet the strategic and emergency management systems; objectives of the NHSS, and identifies planning at all levels of government priority implementation activities, and coordination within government including fostering informed, empowered and between it and the private sector; individuals and families and developing and building national health security and maintaining the workforce needed workforce capabilities in disaster for national health security. medicine and public health.138  TFAH • healthyamericans.org 45 CDC’S 15 PUBLIC HEALTH PREPAREDNESS CAPABILITIES139 In 2011, CDC identified 15 core capabilities in six domains as the basis for state and local public health preparedness to assist health departments in their strategic planning: Biosurveillance Information Management mal medical infrastructure, and to survive l P ublic health laboratory testing is the l E mergency public information and warn- a hazard impact and maintain or rapidly re- ability to conduct rapid and conventional ing is the ability to develop, coordinate cover operations that were compromised. detection, characterization, confirmatory and disseminate information, alerts, l V olunteer management is the ability to testing, data reporting, investigative warnings and notifications to the public coordinate the identification, recruitment, support and laboratory networking to ad- and incident management responders. registration, credential verification, train- dress actual or potential exposure to all l I nformation sharing is the ability to con- ing and engagement of volunteers to sup- hazards, including chemical, radiological duct multijurisdictional, multidisciplinary port the public health agency’s response. and biological agents in clinical, food exchange of health-related information and environmental samples. Countermeasures and Mitigation and situational awareness data among l M edical countermeasure dispensing is l P ublic health surveillance and ep- all levels of government and the private the ability to provide medical counter- idemiological investigation is the sector in preparation for and in response measures in support of treatment or ability to create, maintain, support and to public health incidents. prophylaxis to the identified population strengthen routine surveillance and Surge Management in accordance with public health guide- detection systems and epidemiological l F atality management is the ability to lines and/or recommendations. investigation processes, as well as to coordinate with other organizations to l M ateriel management and distribu- expand these systems and processes in ensure the proper recovery, handling, tion is the ability to acquire, maintain, response to public health emergencies. identification, transportation, tracking, transport, distribute and track medical Community Resilience storage and disposal of human remains materiel during an incident and to re- l ommunity preparedness is the ability of C and personal effects; certify cause of cover and account for unused medical communities to prepare for, withstand and death; and facilitate access to mental/ materiel, as necessary, after an incident. recover from public health incidents in the behavioral health services to the family l N on-pharmaceutical interventions short and long term, through engagement members, responders and survivors. are the abilities to recommend to the and coordination with emergency manage- l M ass care is the ability to coordinate applicable lead agency and implement ment, healthcare organizations and provid- with partner agencies to address the strategies for disease, injury and expo- ers, community and faith-based partners, public health, medical and mental/behav- sure control, such as quarantine, social and state and local governments. ioral health needs of those affected by an distancing and hygiene. l C ommunity recovery is the ability to col- incident and gathered together. This ca- l R esponder safety and health is the ability laborate with community partners follow- pability includes ongoing surveillance and to protect public health agency staff re- ing an incident to plan and advocate for assessment as the incident evolves. sponding to an incident and support the the rebuilding of public health, medical l M edical surge is the ability to provide ad- health and safety needs of hospital and and mental/behavioral health systems equate medical evaluation and care during medical facility personnel, if requested. to a functioning level or better. events that exceed the limits of the nor- Incident Management l E mergency operations coordination is Through its annual Public Health Preparedness National Snapshot, CDC highlights the ability to direct and support a public national, state and local progress in the 15 public health preparedness capabilities health or medical incident by establishing as the basis for state and local public health preparedness. Its 2016 report high- a standardized, scalable system of over- lights how CDC strengthens the nation’s health security to save lives and protect sight, organization and supervision con- against public health threats within the context of its 2014-2015 Ebola response and sistent with jurisdictional standards and its three overarching priorities: 1) improving health security at home; 2) protecting practices and with the National Incident people from public health threats; and 3) strengthening public health through collab- Management System. oration. Each state profile reflects the five capabilities with the largest Public Health Emergency Preparedness (PHEP) cooperative agreement investments.140 46 TFAH • healthyamericans.org 2017-2022 HEALTH CARE PREPAREDNESS AND RESPONSE CAPABILITIES141 The Hospital Preparedness Program (HPP) Capability 1: Foundation for Health Care the face of damaged or disabled health- distributes grants to 62 state and territorial and Medical Readiness care infrastructure. Healthcare workers departments of public health to support the Goal of Capability 1: The community’s are well-trained, well-educated and well- building of healthcare capabilities outlined in healthcare organizations and other stake- equipped to care for patients during the recently released 2017-2022 Health Care holders — coordinated through a sustain- emergencies. Simultaneous response and Preparedness and Response Capabilities. The able HCC — have strong relationships, recovery operations result in a return to program is managed by ASPR, which pro- identify hazards and risks and prioritize normal or, ideally, improved operations. vides programmatic oversight and works with and address gaps through planning, train- Capability 4: Medical Surge its partners in state, territorial and municipal ing, exercising and managing resources. Goal of Capability 4: Healthcare organi- government to ensure that the program’s Capability 2: Health Care and Medical zations — including hospitals, EMS and goals are met or exceeded. Grant awards Response Coordination out-of-hospital providers — deliver timely help state and local governments, healthcare Goal of Capability 2: Healthcare organiza- and efficient care to their patients even coalitions (HCCs) and ESF-8 planners identify tions, the HCC, their jurisdiction(s) and the when the demand for healthcare services gaps in preparedness, determine specific ESF-8 lead agency plan and collaborate to exceeds available supply. The HCC, in priorities and develop plans for building and share and analyze information, manage and collaboration with the ESF-8 lead agency, sustaining the capabilities. These capabil- share resources and coordinate strategies coordinates information and available ities aim to help patients receive the care to deliver medical care to all populations resources for its members to maintain they need at the right place, at the right during emergencies and planned events. conventional surge response. When an time, and with the right resources, during emergency overwhelms the HCC’s col- emergencies; decrease deaths, injuries, and Capability 3: Continuity of Health Care lective resources, the HCC supports the illnesses resulting from emergencies, and Service Delivery healthcare delivery system’s transition to promote healthcare delivery system resil- Goal of Capability 3: Healthcare organiza- contingency and crisis surge response and ience in the aftermath of emergencies. The tions, with support from the HCC and the promotes a timely return to conventional four healthcare preparedness and response ESF-8 lead agency, provide uninterrupted, standards of care as soon as possible. capabilities include: optimal medical care to all populations in TFAH • healthyamericans.org 47 U.S. INTERNATIONAL HEALTH REGULATIONS (IHR) JOINT EXTERNAL EVALUATION (JEE)142 The first U.S. International Health JEE Technical Area Indicator (abridged) Regulations (IHR) Joint External Evaluation Score Antimicrobial Resistance Antimicrobial stewardship activities 3 (JEE) was conducted on May 23-27, Zoonotic Disease Surveillance for zoonoses 3 2016. Led by ASPR, 23 federal agencies Real-Time Surveillance Interoperable, electronic real-time event reporting 3 participated in a self-assessment in the Emergency Response Operations High-risk patient transportation and case management 3 months leading up to the JEE using the Risk Communication Crisis communication with affected communities 3 evaluation tool approved by the World Radiation Emergencies Detection and response to radiation hazards 3 Radiation Emergencies Policies, plans and workforce 3 Health Organization (WHO). Fifteen Antimicrobial Resistance Detecting emergence of antimicrobial resistance 4 external assessors from 11 countries Antimicrobial Resistance Surveillance of community-acquired AMR infections 4 visited the United States to review the Antimicrobial Resistance Surveillance for healthcare associated infections 4 self-assessment and conduct detailed Zoonotic Disease Veterinary workforce 4 Zoonotic Disease Responding to zoonoses 4 interviews with more than 120 national Food Safety Responding to outbreaks and contamination 4 subject matter experts. The JEE Tool is now Biosafety and Biosecurity National biosafety/biosecurity system 4 being used by numerous other countries as Biosafety and Biosecurity Biosafety/biosecurity training and oversight 4 a part of the Global Health Security Agenda National Laboratory System Specimen referral and transport system 4 to evaluate the performance of core public Real-Time Surveillance Syndromic surveillance system 4 Reporting Reportable disease system 4 health capacities required by the IHR and Workforce Development Workforce development strategy 4 to guide the development of national and Preparedness Public health risk assessments and priorities 4 regional roadmaps and strategies for Emergency Response Operations Health emergency plans and procedures 4 supporting global health security. The Emergency Response Operations Health emergency operations programs 4 MCM and Personnel Deployment Deploying/receiving emergency medical teams 4 United States JEE, conducted at the federal Risk Communication Risk communication plans 4 level, indicated a number of nationwide Risk Communication Public health communication 4 gaps and challenges. Among the 19 Risk Communication Dynamic listening and rumor management 4 technical areas of the JEE Tool, there are Points of Entry Preparedness plans at all points of entry 4 48 capacity indicators that are ranked on Chemical Events Detection and response to chemical emergencies 4 National Legislation, Policy, Financing Federal legislation supports implementation of IHR 5 a scale from 1 (lowest) to 5 (highest). The National Legislation, Policy, Financing National policies and procedures 5 United States received a score of 5 in 20 IHR Coordination, Communication National systems support multisectoral coordination 5 indicators (41 percent), a score of 4 in 21 and Advocacy indicators (43 percent) and a score of 3 in Immunization Adequate vaccine coverage for measles 5 Immunization National vaccine access and delivery 5 7 indicators (15 percent). Despite the fact National Laboratory System Confirmatory testing for priority diseases 5 that the United States has consistently National Laboratory System Point of care and laboratory based diagnostics 5 demonstrated its ability to detect, assess National Laboratory System Laboratory testing quality system 5 and report public health emergencies Real-Time Surveillance Indicator and event based surveillance systems 5 — the U.S. IHR National Focal Point in Real-Time Surveillance Analysis of surveillance data 5 Reporting System for efficient reporting to WHO, FAO and OIE 5 ASPR has notified WHO of 95 potential Workforce Development Human resources are available to implement IHR 5 public health emergencies of international Workforce Development Applied epidemiology training programs 5 concern since the IHR went into effect in Preparedness National health emergency plans 5 2007 — there are still numerous areas Emergency Response Operations Capacity to activate emergency operations centers 5 Linking Public Health and Security Public health and law enforcement authorities are for improvement within the health security 5 Authorities linked scope of the JEE. MCM and Personnel Deployment Receiving/deploying public health countermeasures 5 Communication among internal and external stake- The following table lists examples of the Risk Communication 5 holders indicators (abridged) and the scores from Emergency response systems in place for points of Points of Entry 5 the 2016 U.S. JEE. entry Chemical Events Policies, plans and workforce 5 The external assessors’ mission report for the U.S. IHR JEE has been posted online at https:// www.ghsagenda.org/docs/default-source/jee-reports/united-states-jee-report.pdf and the U.S. IHR JEE Self-Assessment Report is published on the ASPR website as www.phe.gov. 48 TFAH • healthyamericans.org A CDC FRAMEWORK FOR PREVENTING INFECTIOUS DISEASES: SUSTAINING THE ESSENTIALS AND INNOVATING FOR THE FUTURE CDC has identified strategies and fun- surveillance, laboratory detection and l D eveloping and advancing policies such damental capabilities that should be epidemiologic investigations; as integrating clinical infectious disease in place to fight infectious diseases in preventive practices into U.S. health- l I dentifying and implementing high-impact a Framework for Preventing Infectious care systems; educating and working strategies — such as vaccinations, infec- Diseases: Sustaining the Essentials and with the public to understand how to tion control, rapid diagnosis of disease Innovating for the Future. Core elements limit the spread of diseases; and work- and optimal treatment practices — to of the framework include focusing on: ing with the global health community limit the spread of diseases and sys- to quickly identify new diseases and l S trengthening public health funda- tems to reduce the diseases transmitted reduce rates of existing diseases.143 mentals, including infectious disease by animals or insects to humans; and A. Reforming Baseline Abilities to Diagnose, Detect and Control Health Crises: Foundational Capabilities Americans deserve and should expect basic health protections, no matter where they live. Yet, while there have been many improvements in national health security in the 15 years since the anthrax and terrorist attacks of 2001 and 11 years since the landfall of Hurricane Katrina, funding has been unstable and insufficient to maintain baseline capabilities. As a result, fundamental public health services intended to protect our health and the funding of these programs often vary dramatically from state to state and among communities and territories. And disease and death rates vary significantly from city to city and region to region. While many public health agencies are A leading recommendation by the localities. The foundational capabilities able to prepare for and respond to many Health and Medicine Division of approach would complement and helps small scale emergencies, such as isolated the National Academies of Science, provide a backbone to build and expand foodborne outbreaks and some types Engineering and Medicine (formally the capabilities that are supported by of natural disasters, the instability of the Institute of Medicine) and other PHEP, HPP, FEMA and other homeland maintaining a strong base level defense experts is to establish and maintain a security grants and programs for states. for more significant health crises leaves clear, consistent set of key foundational The expert-defined foundational first responders without adequate capabilities — that focus on performance services should include: 1) tools and systems to respond and an outcomes in exchange for increased communicable/infectious disease unsteady foundation to build upon when flexibility and reduced bureaucracy.144, 145 prevention; 2) chronic disease and significant emergencies arise. In addition, These foundational capabilities injury prevention; 3) environmental unstable funding means that public health would help support preparedness and public health; 4) maternal, child and must reorient its resources and operations readiness, helping provide a stronger family health; and 5) access to and when a major disaster hits, resulting in core, more consistent foundation for linkage with clinical care.146, 147 gaps in basic public health functions. public health activities in states and TFAH • healthyamericans.org 49 In addition, 20 state, 141 local, one The defined foundational capabilities l B uilding new models that integrate integrated and one tribal health include: clinical and population health; department have been accredited l A ssessment (surveillance, epidemiology l C ultivating leadership — along through the voluntary national and laboratory capacity); with organization, management accreditation program (as of and business — skills needed to l D eveloping policy to effectively November 2016) — a measurement build and sustain an effective health promote and improve health; of health department performance department and workforce to against a set of nationally recognized, l U sing integrated data sets for effectively and efficiently promote practice focused and evidence-based assessment, surveillance and evaluation and improve health; standards.148 The Public Health to identify crucial health challenges, best practices and better health; l D emonstrating accountability for Leadership Forum has recommended what governmental public health that there should be financing l C ommunicating with the public and does directly and for those things that mechanisms to help all states and other audiences to disseminate and it oversees through accreditation, localities achieve accreditation and receive health-related information in continuous quality improvement and the ability to deliver foundational an effective manner, including health transparency; and public health services, either directly promotion opportunities, access to or through cross-jurisdictional care and prevention; l P rotecting the public in the event of collaboration.149  an emergency or disaster, as well as l M obilizing the community and forging responding to day-to-day challenges or partnerships to leverage resources threats, with a cross-trained workforce. (including funding); RECOMMENDATION: l P rioritizing and fully funding a founda- • or instance, many current grants F demonstrate their ability to meet the tional capabilities approach for public for epidemiological, laboratory and foundational capabilities could be given health departments at all levels of surveillance support are administered greater flexibility in their use of federal government. More than perhaps any separately and for specific diseases. A support for core public health functions. other role of health departments, the foundational capabilities model includes Ensuring the workforce is well trained foundational capabilities model is key to the ability and flexibility for communities to carry out these capabilities and that strengthening preparedness for public to build upon foundational capabilities to a mechanism for continuous quality health emergencies. These core func- meet their specific needs and concerns, improvement and stable, sufficient tions of modern public health — such contingent on additional available funding are in place are all inherent to as modernized laboratory, workforce resources. Jurisdictions that could the success of this model. and surveillance capabilities — are the cornerstone to a community’s capacity to track and contain disease outbreaks VISION FOR A BASELINE PUBLIC HEALTH SYSTEM: or respond to disasters. This approach To Address Emergencies and Ongoing Health Concerns means changing siloed grant and bud- Surveillance & Data/ Laboratory Capacity Epidemiology/Investigations get structures that often fund different Information Systems aspects of these core capabilities sepa- Trained, Expert Workforce + Research/Evidence-Informed Strategies rately and do not focus on performance, Accountability + Continuous Quality Improvement capabilities or outcomes for the overall integrated, coordinated system. Sustained, Stable Funding 50 TFAH • healthyamericans.org EXAMPLES OF STATES ADOPTING FOUNDATIONAL CAPABILITIES A number of states, including Colorado, additional $21.8 million and local health Oklahoma and Washington, have taken jurisdictions in the state would need an steps to move toward a foundational ca- additional $78.0 million (2013 dollars) pabilities approach within their state and (totally $99.9 million statewide) to fully local public health departments. and effectively implement foundational capabilities.151 For instance, Washington State has en- gaged stakeholders (such as hospitals, Ohio has also been developing strategies community health organizations, service for implementing foundational capabilities providers and laboratories) to partner with and has moved forward to consolidate public health departments and improve or some local health departments and increase health information exchange; re- cross-jurisdictional services and programs viewed state public health laws to identify and to prioritize funding streams.152, 153 governing power and regulations across Colorado legally defined foundational jurisdictions; reviewed funding streams “minimum quality standards,” and within to determine what mandatory services two years has shown significant increases may or may not be attached to funding; in the delivery of several programs and identified which services can be provided service areas.154 by state health departments versus local The Public Health Cost Estimation Work health departments; and engaged with Group has developed a methodology to policymakers to gain support of legisla- help state and local health departments tive changes needed to fully develop and determine the cost of adopting founda- implement foundational public health tional capabilities and the data will be services.150 The state’s Department of used to generate national estimates.155, 156 Health estimated it would require an TFAH • healthyamericans.org 51 SOME KEY CDC HEALTH SECURITY PROGRAMS l C DC’s Epidemic Intelligence Service (EIS): EIS officers serve as expert “disease detectives” who conduct investigations, research and surveillance — around the United States and abroad. EIS is a two-year post-graduate training program for November 12 physicians, nurses, veterinarians, PhD-trained scientists and other health professionals.157 The facts l C DC’s Division of Global Health Protection: The Division works in over 70 countries to build global public health capacity to rapidly detect, fight and control disease outbreaks. This in- Pneumonia is the #1 infectious disease killer of children under 5 99% cludes the Global Disease Detection (GDD) Program, the Field Epidemiology Training Program (FETP), National Public Health of pneumonia deaths in children under 5 occur in low & middle income countries Institutes Program, Global Health Security, and Emergency Re- sponse and Recovery.158 The GDD program works to strengthen Pakistan global health security — especially supporting countries with USA 71,000 300 China limited capabilities — in order to rapidly detect, accurately 33,000 identify and promptly contain emerging infectious diseases and Ethiopia 35,000 intentional bioterrorist threats that occur. 159 FETP trains field epidemiologists globally to become “disease detectives” in their home countries and quickly identify causes of communicable and non-communicable outbreaks. CDC has begun providing Nigeria India technical support to 50 countries through the Global Health Se- 121,000 DRC 174,000 curity program to better prevent, detect and respond quickly and 48,000 effectively to public health threats in accordance with the Global Health Security Agenda (GHSA).160 Simple, proven solutions WORLD IMMUNIZATION WEEK 2016 Exclusive breastfeeding Vaccination Safe drinking water for baby’s first 6 months and good sanitation Frequent hand Good nutrition, Adequate indoor washing with soap especially for kids ventilation aged 6 months to 2 years 50 Years of Global Every breath counts. Stop pneumonia now. Immunization Success www.worldpneumoniaday.org Sources: CDC. “Deaths: Final Data for 2011.” National Vital Statistics Report. www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_03.pdf WHO. 2013. Pneumonia: Priority diseases and reasons for inclusion. www.who.int/medicines/areas/priority_medicines/Ch6_22Pneumo.pdf CS256813-AB November 2014 52 TFAH • healthyamericans.org l P ublic Health Emergency Preparedness mass care; medical countermeasure use during a major disease outbreak, (PHEP) Cooperative Agreement dispensing; medical materiel bioterror or chemical attack, or other Program: PHEP provides formula- management and distribution; public health emergency.163 Twelve- based cooperative agreement funds medical surge; non-pharmaceutical hour Push Packages of medicines and to states, territories and urban areas interventions; public health laboratory supplies are kept in secure locations to build and sustain the ability to testing; public health surveillance around the country and are available for prepare for and respond to all types and epidemiological investigations; deployment within 12 hours of a federal of major health emergencies.161 PHEP responder safety and health; and decision. The federal government also focuses on 15 key capability areas, volunteer management. 162 can employ systems to work with some including community preparedness; private pharmaceutical distribution l S trategic National Stockpile: The community recovery; emergency companies and pharmacies to be able stockpile is a national repository of operations coordination; emergency to distribute vaccines or medicines antibiotics, chemical antidotes and other public information and warning; facility during an outbreak. medicines and medical supplies for management; information sharing; TFAH • healthyamericans.org 53 l W HO Collaborating Center: CDC’s and non-infectious diseases and Influenza Division has served as a WHO conditions.164 NNDSS has undergone an Collaborating Center for Surveillance, initiative to modernize the systems and Epidemiology and Control of Influenza processes used to receive nationally in Atlanta, Georgia since 1956 and notifiable disease data that will is the largest global resource and improve public health decision making reference center supporting public health and interventions by providing more interventions to control and prevent comprehensive and higher quality data pandemic and seasonal influenza. As in a more timely manner. a WHO Collaborating Center, CDC’s l N ational Syndromic Surveillance Influenza Division plays a major role in Program: This program is a year-round surveillance for early detection collaboration among public health and identification of antigenically agencies for timely exchange drifted seasonal influenza viruses as of syndromic data to improve well as novel influenza A viruses that national situational awareness and may have pandemic potential. The responsiveness to hazardous events Influenza Division collects and analyzes and disease outbreaks.165 Syndromic influenza viruses from around the world surveillance uses syndromic data and for epidemiological, antigenic (immune statistical tools to detect, monitor response), antiviral susceptibility and and characterize unusual activity for genetic characterizations. further public health investigation or l N ational Notifiable Diseases response. Syndromic data include Surveillance System (NNDSS): The patient encounter data from emergency system is a nationwide collaboration departments, urgent care, ambulatory that enables all levels of public health care and inpatient healthcare settings, — local, state, territorial, federal and as well as pharmacy and laboratory international — to share notifiable data. Though these data are being disease-related health information captured for different purposes, they are allowing health officials to monitor, monitored in near real-time as potential control and prevent the occurrence indicators of an event, a disease, or an and spread of selected infectious outbreak of public health significance. 54 TFAH • healthyamericans.org B. Supporting Stable, Sufficient Funding for Ongoing Emergency Preparedness — and Funding a Permanent Public Health Emergency Fund for Immediate and “Surge” Needs During an Emergency and Expedited Emergency Funding Every year, millions of Americans are impacted CDC’S RESPONSE TO ZIKA by infectious disease outbreaks and other WHAT WE KNOW health emergencies. Infectious diseases alone — including the regular seasonal flu — cost the country more than $120 billion each AND WHAT year.166 Baseline funding for public health WE DON’T and healthcare preparedness and response KNOW. is not sufficient to address ongoing needs, yet alone emerging new problems. Over the What we know past 15 years, federal funds to support and maintain baseline state and local preparedness have been cut by about one-third (from $940 million in FY 2002 to $660 million in FY 2016) Zika can be passed Infection during Zika is spread mostly by the and hospital emergency preparedness funds from a pregnant pregnancy can cause bite of an infected Aedes woman to her fetus. certain birth defects. species mosquito. have been cut in half ($515 million in FY 2004 These mosquitoes are aggressive daytime biters. to $255 million in FY 2016).167 They can also bite at night. As new crises arise, they pull funding and attention from ongoing needs. Major problems may cause enough disruption to demonstrate the need for emergency supplemental funding. This type of support usually is The mosquitoes that can Because the mosquitoes There is no vaccine or considered after an emergency has reached a critical mass, carry Zika are found in some that spread Zika virus are medicine for Zika. areas of the US. found throughout the tropics, but the funds are often too little to address all of the needs outbreaks will likely continue. and expenses, too late by delays in bureaucratic processes to be used when they are immediately needed. This means the funds and attention that were diverted for use during What we don’t know the time of emergency take away from the ability to carry out other important functions. The supplemental funds are often then used to pay back expenses that were incurred during the emergencies but they typically do not also cover all the costs of the diverted money — or the consequences of neglecting other ongoing public health problems. Budget If there’s a safe time during If you do travel and are bitten your pregnancy to travel to cuts over time — or when money is diverted during an an area with Zika • How likely you are to get Zika • How likely it is that your baby will have emergency — leads to layoffs of highly trained public health birth defects from the infection experts, many of whom cannot be hired back with short- term emergency funds. The Zika outbreak has illustrated how the erratic nature of For more information: www.cdc.gov/zika CS263014D funding for infectious disease capacity impacts our ability July 29, 2016 to respond. For instance, the country made significant TFAH • healthyamericans.org 55 investments to respond to vector- the nation at unnecessary risk when police, firefighters and FEMA personnel. borne diseases after West Nile virus new threats emerge and hampers the However, under the current systems outbreaks, but then overtime, the ability to tackle ongoing problems — and approach, they do not currently funding and priority for those efforts like HIV, antibiotic-resistant infections have the ongoing support — resources, were cut and eroded — resulting in or even the seasonal flu. Currently, supplies and training — needed to a decline in that capability at many without sufficient support for be able to effectively manage crises. health departments.168 When Zika emergencies, funds and personnel end Maintaining a steady public health emerged, the cycle had to start again, up being diverted from other public system is analogous to having a ready rebuilding much of the capacity health priorities to respond to a new military defense — where the country that had once existed — and served problem, like the Zika outbreak. maintains a standing, trained force on a ongoing purposes for protecting consistent basis, but additional resources Public health and healthcare against West Nile and other diseases and support are needed to fight a war. professionals are first responders, like — but had been lost. This cycle puts CDC OFFICE OF PUBLIC HEALTH PREPAREDNESS AND RESPONSE FUNDING TOTALS AND SELECT PROGRAMS FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014^ FY 2015^^ FY 2016 CDC Total* $1,747,023,000 $1,533,474,000 $1,507,211,000 $1,622,757,000 $1,631,173,000 $1,472,553,000 $1,479,455,000 $1,514,657,000 $1,522,339,000 $1,415,416,000 $1,329,479,000 $1,231,858,000 $1,323,450,000 $1,352,551,000 $1,405,000,000 State and Local Preparedness $940,174,000 $1,038,858,000 $918,454,000 $919,148,000 $823,099,000 $766,660,000 $746,039,000 $746,596,000 $760,986,000 $664,294,000 $657,418,000 $623,209,000 $655,750,000 $661,042,000 $668,200,000 and Response Capability** SNS $645,000,000 $298,050,000 $397,640,000 $466,700,000 $524,339,000 $496,348,000 $551,509,000 $570,307,000 $595,661,000 $591,001,000 $533,792,000 $477,577,000 $535,000,000 $534,343,000 $575,000,000 * CDC Total also includes CDC Preparedness and BioSense ** May include Public Health Emergency Preparedness (PHEP) cooperative agreements, All Other State and Local Capacity, Centers for Public Health Preparedness, Advanced Practice Centers (FY2004-09), Cities Readiness Initiative, U.S. Postal Service Costs (FY 2004), and Smallpox Supplement (FY 2003) ^ FY2014 numbers are enacted levels. Beginning in FY14, CDC moves funds from each budget line to the Working Capital Fund for business services, resulting in different operating budgets from enacted levels Source: http://www.cdc.gov/fmo/topic/wcf/index.html ^^ Totals do not include Ebola funding Source FY 2016: https://www.cdc.gov/budget/documents/fy2016/fy-2016-cdc-operating-plan.pdf Source FY 2015: https://www.cdc.gov/budget/documents/fy2015/fy-2015-cdc-operating-plan.pdf Source: FY 2014: http://docs.house.gov/billsthisweek/20140113/113-HR3547-JSOM-G-I.pdf Source: FY 2012-13: http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY2013_CDC_Full-Year_CR_Operating_Plan.pdf Source: FY 2010-11: U.S. Centers for Disease Control and Prevention. “2011 Operating Plan.” http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan_cdc.pdf Source: FY 2002-09: http://www.cdc.gov/phpr/publications/2010/Appendix3.pdf OFFICE OF ASSISTANT SECRETARY FOR PREPARDNESS AND RESPONSE FUNDING TOTALS AND SELECT PROGRAMS FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015^^ FY 2016 ASPR Totals -- -- -- -- $632,000,000 $694,280,000 $632,703,000 $788,191,000 $891,446,000 $913,418,000 $925,612,000 $897,104,000 $1,054,375,000 $1,112,559,000 $1,396,828,000 HPP^ $135,000,000 $514,000,000 $515,000,000 $487,000,000 $474,000,000 $474,030,000 $423,399,000 $393,585,000 $425,928,000 $383,858,000 $379,639,000 $358,231,000 $254,555,000 $254,555,000 $254,555,000 BARDA** $5,000,000 $54,000,000 $103,921,000 $101,544,000 $275,000,000 $304,948,000 $415,000,000 $379,639,000 $415,000,000 $415,000,000 $415,000,000 $511,700,000 BioShield Special -- -- $5,600,000,000* -- -- -- -- -- -- -- -- -- $255,000,000 $255,000,000 $520,000,000 Reserve Fund * One-time Funding Source FY 2012: http://www.hhs.gov/budget/safety-emergency-budget-justification-fy2013.pdf ^ HPP moved from HRSA to ASPR in 2007 Source FY 2010-11: http://www.hhs.gov/asfr/ob/docbudget/2011operatingplan_phssef.pdf ** BARDA was funded via transfer from Project BioShield Special Reserve Fund balances for FY2005-FY2013 Source FY 2008-09: http://www.hhs.gov/asfr/ob/docbudget/2010phssef.pdf, p. 8 ^^ Totals do not include Ebola funding Source FY 2007: http://www.hhs.gov/budget/09budget/budgetfy09cj.pdf, p. 288 Source FY 2016: https://www.hhs.gov/sites/default/files/budget/fy2016/fy2016-public-health-social-services- Source FY 2006: http://www.hhs.gov/asfr/ob/docbudget/2008budgetinbrief.pdf, p. 109 emergency-budget-justification.pdf Source BARDA FY 2005-06: http://www.hhs.gov/asrt/ob/docbudget/2010phssef.pdf, p. 45. Source FY 2015: http://rules.house.gov/sites/republicans.rules.house.gov/files/113-1/PDF/113-HR- 83sa-ES-G.pdf Source HPP FY 2005: http://archive.hhs.gov/budget/07budget/2007BudgetInBrief.pdf, p. 20 Source FY 2014: http://www.hhs.gov/budget/fy2015/fy2015-public-health-social-services-emergency-budget- Source HPP FY 2004:http://archive.hhs.gov/budget/06budget/FY2006BudgetinBrief.pdf, p. 16 justification.pdf Source HPP FY 2003: http://archive.hhs.gov/budget/05budget/fy2005bibfinal.pdf, p. 16 Source FY 2013: http://www.hhs.gov/budget/fy2015/fy2015-public-health-social-services-emergency-budget- Source HPP FY 2002: http://archive.hhs.gov/budget/04budget/fy2004bib.pdf, p. 14 justification.pdf 56 TFAH • healthyamericans.org RECOMMENDATIONS: l S upporting stable, sufficient funding (section 319 of the Public Health preparedness through programs like for ongoing preparedness. There is Service Act (42 U.S.C. § 247d)) that PHEP and HPP and funding for medical a need to rethink how health security allows the Secretary of HHS to access countermeasures development, as well is funded — to maintain a steady, funds when a public health emergency as cross-cutting programs that support ongoing defense, as well as having is declared, but it has not received capacity. Without this base of support, the ability to quickly ramp up to meet resources since FY 1999. the cost of ramping up quickly during an surge needs and cover the costs emergency is significantly higher than if • uch a fund would need to be S when major new emergencies arise. a solid foundation is maintained. And maintained and replenished at a Public health programs require stable in major disasters, supplemental funds funding level sufficient to respond to an and sufficient funding to be able to are often still needed to support the emerging public health threat. Providing address ongoing public health and long-term needs — such as vaccine contingency resources for a public healthcare readiness priorities. development — to contain an emergency health emergency fund would bridge after the initial response has concluded. l F unding a permanent Public Health the gap between the smaller-scale Emergency Fund and expedited emergency response that public health • xisting structures for funding public E emergency spending processes to be conducts on a day-to-day basis and the health — at the federal and state level ready when crises arise. In addition arrival of supplementary emergency — are also not built for supporting an to ongoing investments, the federal appropriations, if the crisis rises to the emergency response. Health emergency government needs immediate, flexible level of health problems like Ebola, H1N1 response funding — whether through funds to respond to significant crises. or Superstorm Sandy. Federal agencies a permanent fund or supplemental Delays in appropriation of emergency could release the emergency funds dollars — requires greater speed and funds for Zika, for example, has to aid the immediate state and local flexibility than is often allowable under meant health departments, healthcare response and jumpstart research and existing federal and state authorities and providers and researchers were ill- development until additional funds arrive. practices. CDC and other grantmaking equipped to respond to a complex, And such a contingency fund, if deployed health agencies should be given the multipronged outbreak, while federal early in a crisis, could help prevent an needed authority to distribute emergency agencies were forced to reallocate funds event from becoming a disaster. Rules funding to partners as quickly as possible from other important health programs, around a contingency fund should include after approval by Congress (or through like the Ebola response and the all- transparency and accountability, including disbursement from an emergency fund). hazards PHEP cooperative agreement. triggers and guardrails that govern In the midst of a crisis, HHS — as well as Supporting a standing Public Health access to the fund. states — should have authorities to use Emergency Fund as a complement flexible hiring, contracting and transaction • standing Public Health Emergency A to ongoing funding streams is an mechanisms. Emergency funding Fund would complement ongoing important step to be able to provide announcements also should require plans preparedness, but cannot replace “surge” resources and immediately and by grantees for how and when states will ongoing funds to support baseline effectively respond to a new serious distribute the money to local jurisdictions, preparedness. This Fund would need threat when it emerges. A Public Health partners and other subgrantees. to be paired with ongoing support for Emergency Fund is currently authorized Hurricane Katrina (2005) Delays in Funding for Public Health Emergencies* 1 Day Ebola Virus (2014-2015) H1N1 Influenza (2009) 42 Days 51 Days 53 Days 235 Days Hurricane Sandy (2012) Zika Virus (2016) * Time between Presidential request and Congressional approval TFAH • healthyamericans.org 57 C. Supporting Global Health Security Global health security — an effort to make the world safe from infectious disease and other health threats — is integral to the health of those nations as well as to domestic health security. The Ebola outbreak in West Africa connectivity, these diseases can travel American businesses are dependent illustrated the dangers that an infectious around the world quickly if left upon trade, supply chain and travel disease can pose in countries with little unchecked. And often, these responses with these regions. The Global Health public health infrastructure. The costs are complicated, with diplomatic, public Security Agenda is an international, in lives and money were much more health, healthcare, national security and multisector commitment by the United severe than they would have been had economic components and implications. States and over 50 nations, international the outbreak initiated in a country with Outbreaks and other health emergencies organizations and non-governmental a stronger health system — as illustrated can cause political and economic stakeholders to build countries’ capacity in the rapid response to Ebola flareups instability in a region, with global to protect against infectious disease in these nations after response systems implications. These outbreaks can threats before they become severe.169 were established. Due to worldwide cause ripples in the U.S. economy, as RECOMMENDATION: l M aintaining a long-term investment in the Global Health supplemental, expires in FY 2019. The United States should Security Agenda (GHSA) framework and global preparedness reemphasize its ongoing commitment to global health security and and response programs. The United States is a key partner in other programs through CDC’s Center for Global Health, the State the GHSA and must maintain its leadership in the effort. The Department, Department of Defense, ASPR and NIH that seek to current U.S. commitment to GHSA, funded through the Ebola build local public health capacity and response capabilities. In November, 2016, President Obama signed an Executive for the GHSA Interagency Review Council, tasked with issuing Order Advancing the Global Health Security Agenda to Achieve a policy guidance for GHSA implementation; committing the United World Safe and Secure from Infectious Disease Threats.170 The States to another Joint External Evaluation in three to four executive order was intended to strengthen the U.S. commitment years, providing time for the United States to address gaps and to the GHSA, including roles and responsibilities of U.S. agencies challenges; and designating the National Security Council staff to like State, HHS, CDC, USDA and DoD; outlining responsibilities serve as the convener for the Review Council. One Health Initiative: Unifying Human and Veterinary Medicine Recognizing that human health, animal health and ecosystem health are inextricably linked, the One Health Initiative was developed as a global effort to promote and improve health by enhancing cooperation and collaboration across physicians, veterinarians and other scientific health and environmental professionals.171 Worldwide, more than 850 leading scientists, physicians and veterinarians have endorsed the initiative. Some partners include: American Medical Association, American Veterinary Medical Association, American Academy of Pediatrics, American Nurses Association, American Association of Public Health Physicians, American Society of Tropical Medicine and Hygiene, CDC, USDA and the U.S. National Environmental Health Association. Some efforts include joint educational and communications efforts and improved coordination of tracking of health problems and concerns. Source: One Health Initiative 58 TFAH • healthyamericans.org D. Improving Federal Leadership Before, During and After Disasters In addition to funding, recent disasters have illustrated gaps in federal leadership. In particular, emergencies that cross federal agencies’ jurisdictions and/or have both an international and domestic component, such as the Ebola and Zika outbreaks, have demonstrated the lack of clear roles and responsibilities and the need for cross-cutting national leadership, as well as coordinated national/state/local leadership. RECOMMENDATIONS: l D esignating a senior White House-level Study Panel on Biodefense and the position to advise the President on American Academy of Pediatrics.172, 173 health security. There is an ongoing l I mproving federal, state, local and need for a White House position to interstate coordination during multi- provide leadership and coordination agency responses. At the federal level, for a government-wide approach to in addition to White House leadership preparedness, response and recovery and engagement, there must be efforts. While the appointment of improved interagency synchronization emergency coordinators — such as and integration in response to health the Ebola or pandemic flu response emergencies. There must be improved coordinators — has been important, coordination across levels of government; there is an ongoing gap in the agencies within government; across permanent structure of the White House regions, states and jurisdictions; and to prepare for and respond effectively across the public health, healthcare and to emerging and ongoing threats. A other emergency responder sectors. In White House-level leader could ensure addition, there is a need to review the ongoing preparedness planning and roles and responsibilities across the capabilities remain a sustained federal agencies (with national, state priority — even in times between and local stakeholder participation) emergencies — in addition to the ability involved in emergency health response — to trigger and coordinate a multi-agency including ASPR, CDC, CMS, the agencies response, identify the lead agency and within DHS, FDA, NIH and U.S. Agency be the ultimate arbiter for contested for International Development (USAID) decisions. A permanent position would — to ensure efforts are as efficient also ensure a major focus on the and effective as possible, roles and national security risks posed by health responsibilities are clear and bureaucracy emergencies and bring health expertise is limited. Additionally, there must be to the role, and help provide day-to-day better use of existing authorities, such leadership, cross-government strategic as roles outlined in the Public Health alignment, effectiveness, efficiencies Services Act (PHS), and an agreed-upon and accountability. White House-level framework for response — including the leadership in health security has also use of a Public Health Emergency Fund.174 been supported by the Blue Ribbon TFAH • healthyamericans.org 59 NATIONAL GOVERNORS ASSOCIATION: IMPROVING STATE EFFORTS TO PREPARE AND RESPOND TO PUBLIC HEALTH EMERGENCIES175 and end up being ineffective to act upon. Governors should institutionalize internal communication practices among key players through frequent cabinet briefings or having selected public health officials nominated for security clearances so they can serve in homeland security fusion centers. States also must relay clear and consistent messaging to the public and healthcare workers during emergencies to put them at ease, minimize confusion and keep them safe. Governors must determine who should address the public and how often. States can use social media to disseminate messages quickly While overarching federal-level preparedness health officials may have the authority to and also gather information for situa- is essential because diseases and disas- declare public health emergencies or issue tional awareness. A Joint Information ters do not follow state lines, governors and quarantines. Governors should consult System can integrate all information their state officials must also be prepared to with their legal counsel to ensure their pertaining to an incident and deliver a act quickly and decisively when crises strike. actions are within scope and familiarize coordinated response to the public. CDC Emergency response is resource-intensive themselves with the legal authorities of and ASPR also have many existing com- and costly and a solid planning infrastruc- cabinet officials and other staff. munication toolkits that can be leveraged ture can save time, money and lives. by states during an emergency. l Coordination. As with disaster response In an Improving State Efforts to at any level, coordination among key l C apability Gaps and Available Resources. Prepare and Respond to Public Health players is essential. Governors must Emergencies are resource intensive and Emergencies Issue Brief, the National understand the way homeland security, state executives are not always aware of Governors Association (NGA) provided emergency management and public what resources are needed, how to obtain recommendations for states to health agencies interact with one another them and how to best use them during an improve their efforts to prepare and and coordinate with the private healthcare emergency. Gap analyses among public respond to emergencies, focusing sector. The governor can institutionalize health, homeland security and emergency on four components: legal authority, these relationships through task forces management can determine existing re- coordination; communication; and or routine meetings to ensure roles and sources and capabilities to leverage in an capability gaps and resources. responsibilities are established before a emergency and assess limitations to iden- crisis. They can also foster collaboration tify improvements to prioritize. In an era l L egal Authority. NGA recommends that of funding cuts, paying for the costly staff, through training exercises which can help governors ensure that they and those training and equipment required to main- all players understand where they fit in involved in response — like public tain a sufficient level of preparedness is the overall response. health officials — understand their a constant challenge — exacerbated ever legal authorities and expected roles l Communication — both internal and ex- more by the urgent needs during an actual and responsibilities. Often governors ternal — can make or break a response. crisis. Governors must identify, leverage must take immediate action and their It can be difficult to identify and share and coordinate available state and federal authorities can vary depending on the relevant information across all level of funding mechanisms at the state and state’s constitution, laws and extent of governments. Incoming information can local levels to allocate funds effectively the governor’s emergency powers. Public be insufficient, overwhelming, or delayed and minimize duplication. 60 TFAH • healthyamericans.org Recent Actions through Governor Authority Executive Orders mosquito season, the task force was l ndiana Governor Mike Pence signed an I responsible for ensuring coordination executive order in response to an HIV across state and local mosquito outbreak to coordinate a multiagency re- surveillance and control programs. sponse and to provide additional resources Emergency Declaration and tools for addressing the outbreak. l owa Governor Terry Branstad requested a I l lorida Governor Rick Scott signed F major disaster event declaration from the executive orders declaring a state President to allow the Federal Highway of emergency around the Zika virus Administration to issue a waiver for weight outbreak to provide for state funding and limits to help accelerate the disposal authorities for state officials to respond process for birds infected with Avian Flu. to the virus and request additional Budgetary Authority resources and information from the CDC l labama Governor Robert Bentley A to prepare for the Zika virus. authorized more than $235,000 in l irginia Governor Terry McAuliffe created V emergency funding for testing and a multi-agency, statewide task force treatment services in response to a to prepare for the Zika virus. Prior to tuberculosis outbreak in 2016. The CDC also has many existing a critical tool for disseminating timely communication toolkits that can public health information to state and be leveraged by states during an local health departments, healthcare emergency. For instance, CDC’s Morbidity providers and scientists during a public and Mortality Weekly Report (MMWR) is health response. A NATIONAL BLUEPRINT FOR BIODEFENSE: LEADERSHIP AND MAJOR REFORM NEEDED TO OPTIMIZE EFFORTS176 In October 2015, the bipartisan Blue Wainstein. The Blueprint for Biodefense Ribbon Study Panel on Biodefense is- recommendations included: institutional- sued a Blueprint identifying the need ization of centralized federal biodefense for increased leadership to elevate co- leadership; development of a compre- ordination and collaboration and drive hensive national biodefense strategy and innovation to improve the nation’s pre- plan; modernization of biodetection and paredness for biological threats. Panel biosurveillance systems that meet the members included high-level former threat; incentivization of public-private federal officials including: Senator Joseph partnerships to support medical counter- Lieberman (co-chair), Governor Thomas measure development; support for Ridge (co-chair), U.S. Secretary of HHS building and maintaining coordinated and Donna Shalala, Senator Tom Daschle, functional hospital preparedness; and Representative James Greenwood and sufficient and sustained support for state U.S. Homeland Security Advisor Kenneth and local preparedness capacity. TFAH • healthyamericans.org 61 REPORT OF THE INDEPENDENT PANEL ON HHS EBOLA RESPONSE177 In June 2016, an independent panel included: implement the Global Health of experts, led by Jonathan Fielding, Security Agenda; improve coordination MD, published its review of the HHS between HHS and other government response to the Ebola outbreak. The partners, including clarifying roles report found that the U.S. government and responsibilities; ensure effective was not well prepared to respond to communications with the public; and a crisis that had both domestic and provide sustained funding for emergency international elements and did not preparedness, as well as contingency effectively use existing plans during funding for initial response activities. the outbreak. The recommendations AMERICAN ACADEMY OF PEDIATRICS’ BLUEPRINT FOR CHILDREN In 2016, the American Academy of Pediat- improve its ability to support state and rics released a Blueprint for Children: How local public health preparedness before the next president can build a foundation emergencies occur. for a healthy future. 178 Among the report’s l C lose the gaps in medical countermea- health security recommendations: sures for children — National stockpiles l P rovide Leadership — The next pres- of medical countermeasures (vaccines, ident must be able to effectively coor- pharmaceuticals and medical devices dinate the response to an infectious (such as personal protective equipment disease outbreak across all federal for children (e.g. face masks and ven- agencies. tilators)) lack pediatric formulations, dosing and safety information.) Federal l E nsure that hospitals are prepared for agencies need to collaborate with indus- public health emergencies — Conduct try, academia and Biomedical Advanced a top-to-bottom review of the HPP and Research and Development Authority CDC’s emergency program to ensure (BARDA) to develop pediatric medical they address the needs of children. countermeasures. Grantees showing poorer performance should be granted technical assistance; l C ongressional Actions — Reauthorize pediatric medical home providers must HPP and add capability measures for be included in all healthcare coalitions. state and local pediatric healthcare pro- viders. Congress should also reauthorize l K eep children safe during disasters and the National Advisory Committee on chil- other emergencies — To assist with dren and Disasters within HHS. pediatric preparedness, the next admin- istration should continue to activate and l F unding Priorities — Restore lost fund- utilize the subject expertise of (CDC’s) ing to HPP, restoring emergency capa- Children’s Preparedness Unit. It should bilities. There’s a need for emergency also consider making the unit perma- “bridge” funding that doesn’t force nent, to expand its role beyond respond- agencies to reallocate money from other ing to a public health emergency, and important health functions. 62 TFAH • healthyamericans.org NATIONAL PEDIATRIC READINESS PROJECT (PEDS READY)179 Historically, assessments of emergency The Peds Ready online assessment was departments’ (EDs) readiness have launched in 2013 and 82.7 percent not been comprehensive and have of America’s hospitals participated, shown relatively poor pediatric representing 4,149 EDs and 24 readiness.180 The National Pediatric million annual pediatric ED visits. The Readiness Project is a “multi-phase assessment was re-launched in quality improvement initiative to ensure November 2015 — allowing a new that all U.S. EDs have the essential opportunity for more hospitals to guidelines and resources in place participate and for 2013 participants to to provide effective emergency care assess their progress. States vary widely to children.”181 It is a collaboration in their participation. Only 3 States and between the federal Emergency Washington, D.C. (Connecticut, Maryland Medical Services for Children and West Virginia) have 100 percent of program, the American Academy of their EDs participating in the assessment. Pediatrics (AAP), the American College Conversely, eighteen states have fewer of Emergency Physicians and the than 5 percent of their EDs participating. Emergency Nurses Association. About half of ED respondents reported missing certain policies, procedures and Comprised of a 55-question web-based protocols. Specifically, only 47 percent assessment sent to ED nurse managers, of EDs reported having a disaster plan the project has three primary purposes:182 that addresses the specific needs of 1) To establish a composite baseline of children.184 the nation’s capacity to provide care In 2015, in its feedback on the to children in the ED; newly proposed Healthy People 2020 2) To create a foundation for EDs preparedness topic under consideration, to engage in an ongoing quality American Academy of Pediatrics, improvement (QI) process that the American College of Emergency includes implementing the Guidelines Physicians and the Emergency Nurse for the Care of Children in the Association strongly recommended Emergency Department;183 and a new objective — to increase the number of EDs that have completed the 3) To establish a benchmark that National Pediatric Readiness Project measures an ED’s improvement reassessment, with a target of 100 overtime. percent participation.185 TFAH • healthyamericans.org 63 E. Innovating and Modernizing Infrastructure, Including Biosurveillance, Medical Countermeasure Development and Wider Implementation of Faster Diagnostics A range of public health systems are outdated and have not kept pace with current technologies. Some key areas that are lagging include: upgrading the biosurveillance systems to be real-time and interoperable; expanding research and development for medicines and vaccines to counter infectious diseases and bioterror threats; and supporting investments to be able to use and implement modern diagnostic technologies around the country. l isease Surveillance. U.S. health D l M edical Countermeasures surveillance systems on many levels Development. The government are often disjointed and out-of-date. is often the only real customer for Public health departments tend to certain medical countermeasure have different, unconnected systems products, such as anthrax and tracking different health problems, smallpox vaccines. As a result, the which often contributes to a significant U.S. government has invested in time lag in the collection, analysis and the research, development and reporting of information, including stockpiling of emergency medical of new infectious or foodborne illness countermeasures for a pandemic, outbreaks. Health departments are bioterror attack, emerging infectious often burdened with redundant, siloed disease outbreak, or a chemical, disease reporting systems. radiological or nuclear event. A successful domestic medical There are around 300 different health countermeasure enterprise is an surveillance systems or networks important aspect of preparing supported by the federal government, for new threats, expected or according to a review in 2011.186 Most unexpected, by building the science, of the systems are not interoperable policy and production capacity in and serve an array of different advance of an outbreak. purposes. The lack of cross-cutting surveillance capacity has led to serious • ongress created Project BioShield (in C gaps in visibility on pressing health 2004) and authorized the Biomedical crises. For instance, there has been Advanced Research and Development a lag in a number of communities in Authority (BARDA) in 2006. HHS tracking and recognizing hepatitis C created a multi-agency Public Health outbreaks — stemming from a rise in Emergency Medical Countermeasures heroin use — which has exacerbated Enterprise (PHEMCE) partnership the spread of the disease and (in 2006) to speed the development constrained the ability to use early of medical countermeasures by containment and prevention strategies. supporting advanced research, A foundational capabilities approach development and testing; working could help address these types of gaps. with manufacturers and regulators; and helping companies devise large- 64 TFAH • healthyamericans.org scale manufacturing strategies.187 The Project BioShield Special Reserve Fund (SRF) was originally established as a $5.6 billion fund over 10 years, to guarantee a market for newly developed vaccines and medicines needed for biodefense that would not otherwise have a commercial market.  The investment has supported 190 new candidate projects and 21 new medical countermeasures for purchase under Project BioShield.188 Six have achieved FDA approval and a number have pediatric dosing recommendations. After the initial investment was depleted, Congress began funding BioShield by an annual appropriation for purchase of products, appropriating $520 million in FY 2016. The FDA also launched the Medical Countermeasures Initiative (MCMi) in 2010 to coordinate medical countermeasure development, to send a five-year spend plan to Scientists are working on similar preparedness and response.189 Congress for the enterprise based on technologies for other pathogens. • bola supplemental funding E anticipated needs. However, recent Other emerging technologies, such as also helped BARDA to develop budget requests and funding levels metagenomics, hold the potential to 12 potential Ebola vaccine and have not kept up with estimated advance the ability to better diagnose therapeutic candidates.190 Thus needs, including replenishing and track patients for diseases ranging far in 2016, some promising areas expiring products already in the from Zika to Ebola to new strains of under development with HHS Strategic National Stockpile.192 antibiotic-resistant superbugs. investments include: assisting Zika l W ider Implementation of Faster Being able to use and scale these vaccine advancements, a new anthrax Diagnostics. New technologies, advances around the country will vaccine and diagnostic, new broad such as whole genome sequencing, require an investment to upgrade spectrum antibiotics and pathogen are increasingly used by CDC, the the technology, as well as training reduction technologies for blood military and other state-of-the- for how to use the technology and products.191 Once a new medical art national laboratories to more to conduct these different types of countermeasure is developed, the quickly and effectively identify the epidemiological (disease detective) FDA can expedite the ability to use reason for and extent of a disease investigations. The underlying the product if needed and if there is outbreak. The leading current use public health system would also no other alternative available under of these technologies is in the area of need to adapt to match a faster pace the Emergency Use Authorization foodborne illnesses — in some cases and different types of investigations (EUA) authority. speeding up investigations by several and containment strategies. These • n 2015, ASPR released an I days or being able to determine the scientific changes provide an updated PHEMCE Strategy and cause of an outbreak that would not important new opportunity to “leap Implementation Plan for the next have been possible using the last frog” to overcome longstanding gaps five years. Federal law requires them generation of investigative tools. and problems within the system. TFAH • healthyamericans.org 65 RECOMMENDATIONS: l M odernizing to real-time, interoperable health problems or outbreaks lawmakers to address barriers in disease surveillance. One of the most and to effectively identify trends electronic disease surveillance while fundamental components of disease and contributing factors to many maintaining patient privacy. prevention and control is the ability health inequities, which cannot be • o help overcome fragmentation in T to identify and track new or ongoing discerned through county or state health information systems, reduce outbreaks and threats. level data. For instance, mapping the burden in reporting and better projects have helped identify at-risk • ealth information technology is H analyze existing data, CDC, ASTHO and populations during the seasonal transforming the way healthcare other groups explored the creation of flu, including people who have life- is delivered, and public health a Public Health Community Platform maintaining medical and assistive must adapt just as quickly to take based on shared infrastructure and equipment. advantage of these advancements. services. The goal is to provide a These transformations mean public • chieving a modern biosurveillance A forum for common data exchange, health must also envision public- system would help faster, more analysis and visualization through an private partnership in new ways and effective identification and tracking interoperable system where common more effectively leverage healthcare of outbreaks and other health data can be exchanged, analyzed and data. New data systems and problems, while making surveillance visualized.193 With RWJF leadership, sources, electronic health records and less burdensome on state and local public health departments (including electronic case reporting, electronic public health departments and CDC) have partnered with the laboratory reporting, mapping systems, healthcare providers. It will require healthcare industry and developers cloud-based disease reporting upgrading hardware and software; of electronic medical records to systems and relational databases maintaining these technologies begin a phase one implementation have the ability to significantly around the country; standardizing scalable demonstration in a few states improve the dissemination of real- efficient reporting standards; to notify state health departments time, interoperable and interactive and hiring and training staff with automatically when cases of information across public health, computer science and information reportable diseases are detected healthcare providers and other technology skills, including in how to in the healthcare system. This first systems. It is essential to ensure use systems and to interpret data. electronic case reporting service (on a systems are built to protect privacy In addition, there will need to be community public health platform) in a and incorporate strong cyber-security effective integration with electronic few states sets the way forward for a measures. health records and electronic host of needed services to exchange laboratory reporting. Supporting and data between healthcare and public • here is growing capability to T incentivizing real-time and two-way health for prompter action. connect health trend information communications between healthcare with risk factor data sources — • Funding at the federal, state and providers and health departments to look at the impact of different local level remains a significant are critical components. There are factors on health and better identify challenge. From 2012 to 2014, the also significant barriers in changing outbreaks or the potential causes federal government released a series the culture and practice of how of health problems in particular of biosurveillance strategies and road disease surveillance is conducted neighborhoods or regions. Any new maps to help consolidate systems, at all levels of public health. system should be able to identify eliminate redundancies and reduce Agencies may have to discontinue health trends at a neighborhood unnecessary reporting burdens. legacy systems, while public or zip code level to be able to help These focus on the ability to integrate health may have to work with state quickly identify locally concentrated with electronic health record systems 66 TFAH • healthyamericans.org and other emerging health information surveillance, they identified policy • ONC should set standards for the technologies, including a call for initiatives including that: nation’s HIT system that ensure partnerships across private and public • ublic health departments should P better coordination with public health healthcare systems and state and have the right workforce and departments as they develop the local public health departments.194, technology to advance surveillance capability to work in the HIT system, 195, 196 However, most of these plans and ONC should work with CDC and and epidemiological functions, do not include funding estimates for other public health agencies to ensure including by aligning CDC programs to the coming years. Currently, there interoperability of their systems. support foundational capabilities; and is insufficient funding to carry out all of the aspects of these plans. Implementing a modern disease surveillance system will require CDC’S SURVEILLANCE STRATEGY up-front investments in technology In 2014, CDC released a Surveillance notifiable diseases. Standardizing and and a trained workforce, as well as Strategy to help facilitate work to harmonizing the data will significantly the political will to let go of legacy consolidate systems, eliminate unnec- reduce the burden of reporting on state systems. There must also be a long- essary redundancies in reporting and re- and local health departments and, at a term funding strategy for federal, state duce the reporting burden on state and future date, will lead to the retirement and local public health to achieve local health departments.198 Once such of older, less efficient legacy systems. the goal of a modernized system. initiative is the NNDSS Modernization Several of these new message mapping An investment in modernization Initiative (NMI), which would move all guides (data standards) are expected would save money in the longer case notification reporting to a standard to begin production rollout in December term by reducing duplicative and format (HL7) for over 100 nationally 2016 and continue throughout 2017. work-intensive legacy systems and preventing avoidable outbreaks. • ational Academy of Medicine’s N Vital Directions for Health and SHARING DATA TO IMPROVE CLINICAL CARE AND PUBLIC Health Care paper on Information HEALTH: THE DIGITAL BRIDGE INITIATIVE199 Technology Interoperability and Use for Better Health Care and Evidence RWJF, Public Health Informatics Institute including a wide range of infectious identified that “it managed more and Deloitte Consulting convened a wide diseases and infections, would be effectively, federal investment in range of public health, healthcare and automatically generated from EHRs and HIT (whether through the [Office health information technology partners to transmitted to public health agencies. of National Coordinator for Health develop the Digital Bridge initiative. The In 2017, the Digital Bridge will help Information Technology (ONC)] or initiative aims to identify a consistent, coordinate eCR implementation in through CMS, which is now actively nationwide and sustainable approach to at least five sites to test technical encouraging states to develop all- using electronic health records data to specifications, demonstrate the viability payer data systems) and public- improve public health surveillance. The of eCR for public health and healthcare, health surveillance … could achieve effort focuses on advancing electronic and determine what assistance health better outcomes without necessarily case reporting (eCR) to move toward a departments will need to receive and requiring new resources.”197 To help more real-time, interoperable and secure incorporate eCR data effectively. improve the integration and alignment process where reportable conditions, of public health and healthcare TFAH • healthyamericans.org 67 RECOMMENDATIONS: l I ncentivizing and supporting medical • n addition, ongoing funding should I countermeasure research, develop- be considered to restock and upgrade ment, stockpiling and distribution. the Strategic National Stockpile so medical countermeasures are avail- • chieving a strong medical counter- A able and not expired in the event measure strategy in the United States they are needed. Also, there must be that continues to support research and better established systems to support development of vaccines, antivirals and public-private partnerships for distrib- other countermeasures requires contin- uting and administering vaccines and ued support for incentives for biophar- medicines, including insurer support maceutical companies to invest in the for medical countermeasure payment research and development of medical when appropriate and possible. And, countermeasures, particularly due to the without a robust public health in- limited funding for purchase under Proj- frastructure to ensure the Strategic ect BioShield. Unpredictable short term National Stockpile and other medical emergency and annual funding, discour- countermeasure products reach the age innovation by being inconsistent with individual patient, research and devel- industry planning standards and creating opment on its own is not enough to uncertainty if the government will be an ensure products are used effectively. assured partner for the long-term. ALTERNATIVE MODELS TO SPUR RESEARCH & DEVELOPMENT l lobal efforts in vaccine development G Bacteria (CARB), HHS partnered with are long, expensive processes. A academic and philanthropic entities recently formed collaboration — the to form the Combating Antibiotic Coalition for Epidemic Preparedness Resistant Bacteria Biopharmaceutical Innovations (CEPI) — seeks to Accelerator, or CARB-X. The provide an alternative model for partnership seeks to refill the pipeline funding vaccine development. The of products against bacterial threats, public, private and philanthropic including therapeutics, vaccines, partners seek to stimulate, finance diagnostics and devices through and coordinate vaccine development funding for research and development against priority threats, particularly and technical assistance for when market incentives alone are companies with promising solutions unlikely to result in development. to antibiotic resistance.201 BARDA The partnership, which is in the has committed up to $250 million start-up phase, is between the over five years and other entities Government of Norway, Government have promised funding. CARB-X is a of India, Wellcome Trust, Bill and partnership between BARDA, NIAID, Melinda Gates Foundation and World the AMR Centre, Wellcome Trust, Economic Forum.200 California Life Sciences Institute, MassBio, The Broad Institute, Boston l s part of the National Action Plan A University and RTI International.202 on Combating Antibiotic Resistant 68 TFAH • healthyamericans.org l U pgrading to modern molecular technologies. Advances in diagnostic technologies allow scientists to identify the causes of outbreaks and connections between different cases much faster. This helps identify how widespread an outbreak may be and how to treat it. In public health, the revolution in DNA sequencing technologies over the past decade is having a dramatic impact on the detection of, and response to, infectious disease outbreaks. However, historically the public health system has not had built-in mechanisms to support and incorporate developments in science and technology. For many years, there had not been a meaningful investment toward upgrading many of the basic Source: Bavarian Nordic systems used by public health laboratories — which hampered the ability to incorporate new technology, identify both emerging and ongoing health problems in a community and track patterns to better discover the causes and cures of diseases. • ew diagnostic technologies; changes N in data-management capabilities to more quickly identify and track outbreaks and problems; and the ability to develop new vaccines, diagnostics and antivirals — particularly for emerging diseases — and to counter growing antibiotic-resistant threats all hold tremendous promise. This will not be realized unless there is continued investment and a fundamental change Source: Alliance for Biosecurity in how the country thinks about and invests in public health. TFAH • healthyamericans.org 69 CDC’S ADVANCED MOLECULAR DETECTION (AMD) PROGRAM CDC’s Advanced Molecular Detection To explain the technology in general terms, breaks and improve health. With improved (AMD) program was established in 2014 CDC has said, “imagine doing a 10,000- funding and reduced price points, the tech- to bring DNA sequencing (“next-genera- piece jigsaw puzzle in the time it takes to nology could be used to support disease tion sequencing” (NGS) which enables finish a 100-piece puzzle. Apply that to investigations of many infectious diseases. “whole-genome sequencing” (WGS)), bio- infectious disease control, and that is AMD While this means that more outbreaks are informatics and related technology into at work. Now imagine putting together that being detected and detected earlier, it has public health in the United States. With 10,000-piece puzzle when key pieces are also increased the need for epidemiologic funding through the AMD program, these missing, disease is spreading and people “boots on the ground” to investigate possi- technologies are now being brought to are dying. AMD gives CDC scientists the ble sources of illness. On top of this, the bear against a wide range of infectious ‘key pieces’ to protect people from ev- revolution in sequencing technology and disease threats across the United States er-changing infectious disease threats.”203 analysis is continuing, with sequencing and are rapidly transforming the monitoring costs decreasing, automation increasing AMD technologies are now being applied in of these threats, as well as the response and analytic methods improving, all of which many areas, such as food safety, influenza to outbreaks. Three years ago, U.S. public are continuing to open up opportunities to prevention and tuberculosis control. While health agencies were behind in the adop- prevent disease, intervene earlier in out- CDC has this technology, it is starting to tion of these technologies, but now they breaks and, ultimately, to save costs. Scal- scale broader use to targeted public health are now leading the world in many areas. ing these and other emerging technologies labs to be able to test for certain patho- Roll out of NGS to all 87 PulseNet labs requires a long-term strategy and an invest- gens. With assistance from CDC, state (which includes all 50 states and Washing- ment in the technology and the training of health laboratories are now acquiring the ton, D.C.) is currently underway. scientists to use equipment effectively. technology and applying it to detect out- EXAMPLES OF CDC INVESTIGATIONS USING ADVANCED MOLECULAR DETECTION (AMD) AMD Helps Trace Connections in HIV health workers to target prevention efforts HCV identifies communities at risk for and HCV Outbreak204, 205 and researchers to use additional AMD introduction of HIV. The major anticipated In January 2015, there were 11 confirmed tools to predict how fast the outbreak impact of GHOST as a new surveillance cases of HIV in one county in rural could grow.  Going one step further, CDC tool, is enabling state laboratories to southeastern Indiana — by May there scientists also used a novel state of independently conduct sustainable, were 135 HIV-infected people connected the art technology, known as the Global cost-effective and real-time molecular to this community, which had a large Hepatitis Outbreak and Surveillance surveillance of hepatitis C in support number of injection drug users.  In Technology (GHOST), to determine of implementing timely public health addition to traditional epidemiological hepatitis C virus (HCV) transmission interventions. approaches, CDC scientists helped patterns and links, which helped public health officials strategically assign Identifying Enterovirus D68 in Indiana by using AMD methods — additional resources to reduce further Children with Respiratory Illness206 combining demographic data gathered from labs and genetic sequences of HCV and HIV infections.  Genetic data In summer 2014, hospitals in Missouri each individual’s HIV strain — to find from 392 HCV cases tested concluded and Illinois were experiencing increased the links between the infected and how that while the HIV outbreak was new, the admissions of children with severe the virus was spreading.  This enabled large number of co-circulating HCV strains respiratory illness — some children were researchers to quickly, in near real-time, indicate that HCV had been introduced so ill they needed intensive care and identify where the most transmissions into the community multiple times over ventilators to breathe. The hospitals were occurring, thereby allowing public a period of several years. Tracking quickly tested specimens from the 70 TFAH • healthyamericans.org children and found enterovirus. After that there was a common source of the With AMD methods and whole genome being notified, CDC confirmed the finding outbreak. Through patient interviews, sequencing, quickly identified that source and identified enterovirus D68 (EV-D68) it became evident that most had eaten of the outbreaks were contaminated Granny in most specimens. Soon thereafter, caramel apples before becoming ill, tracing Smith and Gala apples and likely prevented CDC began to test specimens from the apples back to a single supplier. many additional illnesses. across the country, discovering EV-D68 in almost every state. Along with some state public health labs, CDC used AMD methods to gain more information on the virus. As a result, in little over three months, CDC and the state labs had identified 1,116 people across 47 states who had suffered respiratory illness that was caused by EV-D68. With the AMD program’s resources, CDC was able to quickly map the entire genomic sequence of the virus along with six other viruses representing the three known strains. The program also helped develop a rapid lab test. This work improved the capacity of public health laboratories to perform molecular typing tests that more rapidly identify and detect enteroviruses and thus enhance outbreak investigations and response. Source: Centers for Disease Control and Prevention Whole Genome Sequencing Pinpoints Source of Listeriosis Outbreak207, 208 Whole genome sequencing prevents Listeria illness In the fall of 2014, seven people died and 34 were hospitalized during a multi- state listeriosis outbreak. Since the outbreak was spread over several states, researchers needed to quickly identify which cases were related. Using the traditional laboratory technique, scientists found the DNA of the germs, identifying two different strains. In addition, scientists began using WGS and other AMD methods, allowing them to investigate one cluster a week earlier than if they had used Before using whole genome sequencing (WGS) (Sept 2012–Aug 2013) Year 1 of WGS (Sept 2013–Aug 2014) only traditional methods. Researchers Year 2 of WGS (Sept 2014–Aug 2015) soon found one individual infected with Source: Centers for Disease Control and Prevention both strains, leading them to conclude TFAH • healthyamericans.org 71 F. Maintaining a Robust, Well-Trained Public Health Workforce Many leading experts — including initiatives led by the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), the Association of Public Health Laboratories (APHL), the de Beaumont Foundation, schools of public health and other expert groups — are focused on the need to recruit and retain a next generation of public health workforce. The public health workforce is 38 percent of state and local public health professionals plan to leave experiencing major challenges. The governmental public health by 2020 current state and local public health workforce is not large enough nor professionally diverse enough to meet community needs, and there are major gaps in the training and capabilities of the existing workforce to meet modern health problems. The size of the workforce has been 48 percent of state and local public health professionals are over 50 years old cut over the past 35 years — and there needs to be greater training to match the skills of the workforce to the most pressing, current public health needs.209, 210 l T he public health workforce experienced significant job losses Some key issues raised in the Public Health l T here is a need to expand training of during the Great Recession, resulting Workforce Interests and Needs Survey (PH skills and strategies for how to effectively in more than 51,000 job losses from WINS) conducted by ASTHO and the de address principal factors that influence 2008 to 2014; Beaumont Foundation to highlight the health, such as for systems changes that l F rom 1980 to 2000, the ratio of need for cross-cutting skills include that:211 incorporate health into housing and public health workforce to the U.S. economic development and working l R etirements and high turnover rates population has decreased dramatically effectively across diverse populations. present challenges in maintaining from 220 per 100,000 population to experience, leadership and continuity A wide range of reviews and assessment 158 per 100,000 population; in core capabilities; have demonstrated the vital importance l 3 8 percent of state and local public and value of also specifically training l M any public health jobs require health professionals plan to leave for emergencies and disasters — to highly-trained, specialized scientific governmental public health by 2020 be prepared and understand roles skills — such as laboratorians and — 25 percent of state public health and responsibilities.212, 213, 214 Ongoing epidemiologists — and it is important employees plan on retiring and 13 training, including drills and scenario to build career tracks that attract a new percent plan on leaving their job; exercises, help better prepare public generation of experts and retention of health and healthcare professionals l 4 8 percent of state and local public expert professionals. Only 17 percent to respond efficiently and effectively health professionals are over 50 years of the public health workforce has any during crises. old, 15 percent are over 60 years old. kind of degree in public health; 72 TFAH • healthyamericans.org RECOMMENDATION: l B olstering efforts to recruit and on training needs assessments and retain trained and experienced public changing agency and community health professionals. There needs to needs.216 Assessing optimal public be a major push to ensure a strong health workforce needs should be public health workforce with the considered as part of Community capabilities to detect, diagnose and Health Needs Assessment reviews. track health problems and that can • 2013 CDC Public Health Workforce A develop strategies to improve health Summit Report identified multiple and reduce chronic and persistent factors that lead to the public problems. This includes the need to health workforce crisis, including the maintain an ongoing workforce — job insufficient number of current workers cuts over the past two decades have across public health disciplines and left major gaps in the workforce that insufficient investment in training must be addressed. A competent and training evaluations.217 Summit workforce requires being able to work leaders called for public health with a wide range of partners and agencies to develop a plan to recruit sectors to implement the strategies. professionals to enter the public Some priorities for workforce health workforce; including those development include: systems with backgrounds in informatics, thinking; communicating persuasively business and finance management within and outside of public health; and law; and for agencies to influencing and developing policy; encourage mentorship between those business and financial management; in supervisory and non-supervisory the ability to be flexible and manage positions to prepare mid-level staff a changing environment; analytic for leadership positions. and technical skills and informatics; information technology (IT) and • orkforce recruiting should also focus W computer science experts of various on skill sets outside of traditional levels; and being able to work public health. Modern health crises with diverse populations.215 As require experts in communications technological and informatics needs and social media to ensure accurate, of health departments increase, it will direct engagement with the public be especially challenging to sustain a before and during emergencies. In public health workforce when public addition to recruiting highly trained health funding remains unstable. informaticians, HHS and health departments should be able to infuse • o help better train and maintain the T the workforce with highly skilled workforce, NACCHO and ASTHO have technology specialists and data recommended the implementation scientists with experience outside the of a workforce development plan traditional health sciences. tied into quality improvement that is updated on a regular basis based TFAH • healthyamericans.org 73 G. Rebooting and Developing a New Strategy for Hospital and Healthcare Readiness; Improving Healthcare Infection Control Practices HPP, administered by ASPR, was created after September 11, 2001, to help build capabilities in health system preparedness for major emergencies.218, 219 The program is a vital lever in building the readiness of the healthcare system to prepare, respond to and recover from disasters and outbreaks. HPP helps build regional coordination work together to focus on the common and collaboration between healthcare needs of the communities and regions entities, such as hospitals, public that they serve.220 Currently, there health, emergency medical services are nearly 500 HCCs nationwide, with and emergency management to ensure more than 28,000 members, including the healthcare system is able to save hospitals, long-term care facilities, lives and provide care during and after outpatient facilities, emergency medical emergencies. HPP is currently the only services, local health departments and source of federal funding for health others.221 These coalitions vary in size system readiness. The program’s peak and capacity. HHS recently updated the funding was $515 million in 2004 healthcare preparedness and response and has been cut over time to about capabilities that the healthcare system $255 million in 2016. The program should achieve, including a greater establishes regional healthcare focus on building a foundation for coalitions (HCCs) that incentivize healthcare readiness, assessing risks diverse and often competitive healthcare and needs, training the workforce and organizations with differing priorities to ensuring preparedness is sustainable.222 74 TFAH • healthyamericans.org RECOMMENDATIONS: l B olstering the Hospital Preparedness Exchange (TRACIE) and has developed that may have never prepared for Program. There is wide variation and tools for coalition quality improvement, disaster could now have an incentive limited transparency in how well states including a new course curriculum to participate in healthcare coalitions and the coalitions within them are doing focused on healthcare coalition and to ensure their staff is well-trained in achieving capabilities defined by leadership, developed by ASPR for a crisis. CMS and ASPR should HHS. While some have achieved notable and FEMA’s Center for Domestic work together to promote coordination successes, other coalitions are in nascent Preparedness. 223 While all coalitions between healthcare coalitions and stages or lack buy-in from healthcare should avail themselves of these facilities within the coalition’s region in administration within the region. In order resources, ASPR should continue to order to meet both CMS’ requirements to make HPP as effective as possible: conduct targeted outreach to new and and healthcare preparedness and less effective coalitions; response capabilities, such as the • HPP must receive stable, robust resources dedicated to the CMS rule funding to ensure the program can • oalitions should ensure they are C on ASPR TRACIE and a recent joint achieve its goals. The funding is formulated to reflect how healthcare is webinar with the Medical Learning important to support coalitions and really delivered in their region, leveraging Network. CMS could also pilot bonus build and sustain better coordination existing affiliations and assets among incentive payments for performance and connections across key facilities and providers; and outcomes around preparedness. healthcare, public health and other • As the program — and the field of emergency responders before and • nother important preparedness A healthcare preparedness — matures, during crises; asset could be value-based ASPR should continue to strengthen the healthcare models, such as • ASPR should assess how funds focus of HPP on the readiness of the Accountable Care Organizations are spent at the state level and healthcare delivery system as distinct (ACOs).225 Healthcare Ready has confirm adequate funding is reaching from public health preparedness. proposed ACOs, collaboratives to coalitions. HPP awardees (the l E xploring Innovative Mechanisms bring doctors, hospitals and other state and local health departments) to Build Readiness. With its limited healthcare providers to join together should distribute sufficient resources funding base (current total hospital and coordinate high quality care to healthcare coalitions and not spending is around $971 billion per to Medicare patients. This model retain HPP funds for public health or year), HPP cannot be the only driver of would help create a more resilient administrative purposes; health system preparedness. While HPP healthcare system by providing some • As it updates performance measures should continue to play an important care away from a centralized location to align with the new capabilities, leadership, coordination and standard- (thus reducing surge in a disaster), ASPR should make certain the setting role, there also need to be new promoting wellness and helping in measures come with transparency, models and additional resources to coordinating care and tracking of accountability and quality support and augment the program’s vulnerable patients in an emergency.226 improvement. HPP must also focus basic functions and to engage the health • number of additional levers can be A funding and technical assistance delivery system and broader community further explored for engaging the health on meeting gaps identified in those into building and investing in better system — such as tax incentives, the measures. ASPR should assess emergency health plans and strategies. Medicare shared savings program the performance of coalitions on an • ne potential lever is the O and Merit-Based Incentive Payment annual basis, publicly report results recently finalized CMS emergency System, Joint Commission standards and develop strategies to strengthen preparedness requirements for and National Quality Forum measures ineffective coalitions. ASPR has Medicare and Medicaid participating to help support preparedness and created a Technical Resources, providers and suppliers.224 Facilities healthcare coalition participation. Assistance Center or Information TFAH • healthyamericans.org 75 RECOMMENDATIONS: • tate policies and practices governing S beyond the initial start-up funding ensuring equity of distribution and the delivery of healthcare during in order to be maintained.229 A reach into underserved communities. emergencies — including contracting standing regional network system • ince 2012, ASTHO, CDC and S and hiring, healthcare and volunteer would require continuous incentives BARDA have been assessing best liability and adoption of crisis and reimbursement to maintain practices for coordinating pandemic standards of care in the context of supplies, workforce and ensure buy-in vaccination preparedness activities scarce resources — can vary from of hospital leadership. The Report between public health programs and state to state. ASPR should conduct of the Independent Panel on the U.S. pharmacies. Successful strategies, a review of barriers to healthcare Department of Health and Human tactics and operational components, response and recovery and urge states Services (HHS) Ebola Response also identified through stakeholder to clarify laws and policies regarding recommends HHS maintain a national interviews and workshops, were healthcare disaster readiness. network of identified treatment centers incorporated into a template for urgent public health threats, • otential support mechanisms from P memorandum of understanding including standardized requirements broader community institutions, (MOU).  ASTHO, in conjunction with and protocols.230 A standing system of such as universities, economic and CDC, will fund and support up to two regionalization could help to overcome community development agencies state health agencies to implement a barriers to meaningful preparedness and other prominent partners that template MOU for pandemic planning planning — such as concerns over benefit from stability and vitality of and response. The MOU is intended liability, loss of profit and competition their neighborhoods can also serve as to improve coordination between between healthcare systems. levers.227 Non-profit hospitals should state-level public health programs and consider incorporating community- l P ublic-Private Collaboration. A number pharmacies by outline the roles and wide disaster planning participation of examples of health emergencies have responsibilities each plays in planning into their community benefit efforts shown the importance of developing for and responding to flu pandemics. to reflect a recent change in Internal better collaborations between the The best practices from these states Revenue Service (IRS) rules that private sector, including hospitals, will be incorporated into a toolkit. allows community resilience to pharmacies, health systems and public • esilience of the healthcare delivery R count for community benefit.228 And, health agencies. system during and after a disaster communities could also investigate • or instance, during the 2009 H1N1 F is also contingent on the ability of incorporating local health improvement pandemic flu response, the distribution healthcare personnel and supplies partnerships into healthcare coalition and administration of the vaccine to reach affected regions. States planning efforts to ensure health and the dispensing of the antiviral should develop formal access and re- needs and assets of communities are Tamiflu (oseltamivir) and Relenza entry programs so critical healthcare being considered in disaster planning. (zanamivir) medications were through personnel and supplies can reach • Not every individual hospital or facility combinations of public and private restricted areas during disasters. requires the same preparedness distribution, insurer and provider • oth public and private sector health B capabilities, but a community systems. The private sector — organizations are also exploring the should know its health needs will such as large or community-based use of nurse triage lines to reduce the be met during a major emergency. pharmacies — was better be able to strain on the healthcare system during The tiered Ebola response system distribute medical countermeasures in a pandemic or other event. Public demonstrated one model of creating some communities in the midst of a health, healthcare and insurers should regional hubs for care, although that crisis than overstretched public health collaborate on these models before system requires continuous funding agencies, but collaboration is key to 76 TFAH • healthyamericans.org the next event to ensure questions 25 people who are hospitalized each facility working alone cannot prevent, of credentialing, payment and risk year contracts a healthcare-associated track or contain the spread of communications are addressed. infection (HAI), leading to around 75,000 superbugs. Public health needs deaths a year.231 to be the backbone organization l H ealthcare Infection Prevention and in a state or region to coordinate Control. Despite years of progress, • very hospital should have minimum E prevention among competing or healthcare facilities still do not routinely baseline screening practices, disparate healthcare systems and carry out standard infection control including travel history; isolation contain potential outbreaks. Private procedures on every patient so that when capabilities to ensure patients and healthcare also needs to be seen new serious outbreaks occur they are healthcare workers are safe from a as part of a coordinated response. able to safely diagnose and treat patients, potential threat; regular training on Barriers to everyday coordination in and ensure that other patients and the infectious control practices and use the private healthcare system, such as healthcare workers themselves are of protective gear; and procedures competition, should be addressed and protected from exposure. For instance, for removal and disposal of protective managed for emergency preparedness the lack of adherence to best practices gear and waste. and response — which is one of the led to initial mistakes in not admitting • ollaborating on the detection and C roles and values that HCC provides the first initial presenting Ebola patient in control of outbreaks. Each healthcare through regional coordination. the United States. And, one out of every NEW EMERGENCY PREPAREDNESS REGULATIONS FOR MEDICARE AND MEDICAID PROVIDERS AND SUPPLIERS In September 2016, CMS finalized To ensure a consistent foundation 3. ommunication plan: Develop and C a rule to establish consistent of emergency preparedness across maintain a communication plan emergency preparedness the healthcare system, Medicare and that complies with both federal and requirements for healthcare providers Medicaid-participating providers and state law. Patient care must be well- participating in Medicare and suppliers must meet the following four coordinated within the facility, across Medicaid, increase patient safety industry best practice standards, as healthcare providers and with state during emergencies and establish a appropriate for their function: and local public health departments more coordinated response to natural and emergency systems. 1. mergency plan: Based on a E and man-made disasters. 232 risk assessment, develop an 4. Training and testing program: After reviewing the previous Medicare emergency plan using an all-hazards Develop and maintain training and emergency preparedness regulations approach focusing on capacities testing programs, including initial and for both providers and suppliers, CMS and capabilities that are critical to annual trainings and conduct drills found that regulatory requirements preparedness for a full spectrum of and exercises or participate in an were not comprehensive enough to emergencies or disasters specific to actual incident that tests the plan. address the complexities of emergency the location of a provider or supplier. preparedness, including communication 2. olicies and procedures: Develop and P and coordination, contingency planning implement policies and procedures and training of personnel. based on the plan and risk assessment. TFAH • healthyamericans.org 77 EXPERT COMMENTARY: Protecting Health and Saving Lives in Epidemics and Disasters: New Approaches in a New Health Landscape By Eric Toner, M.D., UPMC Center for Health Security Although the healthcare system is undoubtedly better prepared for disasters than before the launches of the Hospital Preparedness and Public Health Emergency Preparedness Programs in 2002, the experience of Hurricane Sandy suggests that important gaps exists in the resilience of our health sectors for large-scale disasters. These disasters, as well as smaller ones, command structure, the geographic are becoming ever more frequent. At scope, time to prepare and duration and the same time, over the last decade cadence of the response will be quite there have been major ongoing different. The nature of the illnesses changes in healthcare, especially the will also be quite different. In natural consolidation of hospitals, physician disasters like hurricanes, most of the practices and outpatient facilities into patients who present after the event are large integrated healthcare networks. not direct causalities of the event but This started well before the Affordable people with chronic health conditions Care Act (ACA) and is likely to continue who have been displaced from their regardless of the fate of the ACA. As normal sources of care. Examples the health landscape has been evolving, include loss of access to medication and our understanding of the intersection services for people with chronic medical, of health and disasters has also been behavioral health and substance abuse evolving. Therefore, now may be an conditions. The most vulnerable in our opportune time to re-think some society, who are the most likely to have aspects of the approach to healthcare these conditions, are also inherently preparedness. With the support of the the least able to be resilient due to lack Robert Wood Johnson Foundation, of resources and supports. Therefore, over the last year the UPMC Center quite often these patients end up in for Health Security has explored this hospital emergency departments seeking question in scores of interviews and care that the ED is not well-prepared meetings with thought leaders and to deliver. For example, think of an subject matter experts. We share some elderly, low-income person with diabetes preliminary insight here. on chronic hemodialysis who relies on public transportation. When her dialysis Different types of disasters stress the center closes or the medication runs out, healthcare system in different ways she is likely to call 911 and end up in a Not all disasters are alike. A hurricane hospital emergency department which differs in important ways from, for has little capacity for outpatient dialysis. example, a terrorist mass shooting, and This surge of patients stresses the hospital both of these are different from an and degrades care for both the patients epidemic. Although there are important who need to be in the hospital and those commonalities, such as a similar incident who would be better served elsewhere. 78 TFAH • healthyamericans.org The health sector preparedness base must be broadened For events that have long-duration impacts and large geographic footprints, the stress on the hospitals could be lessened if the rest of the health sector was more resilient — if clinics, home health providers and all the other entities that support the health of the population were better prepared to resist the stress of a disaster and quickly bounce back. The entire health sector is tightly interrelated and co-dependent so a lack of resilience in any one part places an added burden on the resilience of the health sector as a whole. If every health facility and service were prepared to quickly bounce back from a disaster, patients would be better served and hospitals (that are needed for the acutely ill or injured) would be less burdened. Disaster health resilience requires a much broader health sector involvement than from just hospitals and public health. Andrei Orlov / Shutterstock.com While this was an obvious place to start, approaches to disaster health resilience Big events require broadly resilient it is now clear that the preparedness in (1) Boston, where they have a Chief communities foundation must the broadened. In Resilience Officer with a background in Furthermore, Hurricane Sandy line with the strategy of the Hospital public health emergency preparedness; demonstrated, as did Hurricane Katrina Preparedness Program, new partners in (2) Cedar Rapids, where multiple nearly a decade earlier, that many other must be recruited to join healthcare community-based organizations work segments of society that are needed for coalitions. But beyond that, community- together to improve resilience to disaster-resilient communities are not based organizations that work on many flooding; and in (3) Los Angeles, where adequately prepared, including among other important health issues should the health department has developed many others, utilities, transportation, also be encouraged and incentivized to metrics and applied a rigorous supply chains and fuel. To be able to include aspects of health resilience to quality improvement methodological preserve health and save lives after a disasters in their missions. approach to improving resilience. Every disaster, many sectors of society other community and every community-based than just the health sector need to be Creative grass-root solutions organization is different. There are resilient. Thus, in the same way that are needed likely to be many different novel ways broad cultural changes are needed to to improve resilience at the grass roots Finding ways to create public-private- improve peoples’ health overall, broad level. Letting a thousand flowers bloom philanthropic partnerships that cultural changes are needed to promote may be a needed approach during promote greater resilience to the disaster health resilience. a time of major shifts in healthcare, health consequences of disasters will But for years the focus of preparedness require creativity and a good deal healthcare policy and increasingly programs has been on hospitals, public of flexibility. In this project we have frequent disasters. health and emergency management. seen encouraging examples of novel TFAH • healthyamericans.org 79 H. Supporting Community Resilience — for Communities to Better Cope and Recover from Emergencies — With Better Behavioral Health Infrastructure and Capacity Another of the most difficult challenges in emergency health readiness is how to better prepare communities to mitigate impact and more quickly be able to recover when a disease outbreak, natural disaster or other emergency strikes. Hurricane Katrina provided one of While building resilience is one of the most enduring examples of how two overarching goals identified by vulnerable members of a community HHS in the Biennial Implementation — such as children, the elderly, people Plan for the National Health Security with underlying health conditions Strategy, there is not sufficient funding or disabilities and those who are or other resources available to provide lower-income and/or have limited- broad support for efforts.234 Local English proficiency — are often the health improvement partnerships most affected and least prepared and could be one mechanism for helping protected during emergencies.233 to scale and diffuse strategies and engage additional funding support The next phase of preparedness from the broader health, business and efforts must prioritize how to improve community sectors themselves. the resilience of all communities. Frontpage / Shutterstock.com 80 TFAH • healthyamericans.org RECOMMENDATIONS: l P rioritizing the need to improve the media, beyond the Internet, such as competition with HUD disaster recovery ability of communities to be resilient radio, racial and ethnic publications funds to make the city more capable — to be able to cope and recover from and television. of withstanding future storm surges emergencies.235, 236 Public, private and and sea level rises.237, 238 The winning l D eveloping ongoing relationships nongovernmental stakeholders must designs would not only protect against between health officials and work together to develop innovative flooding but would provide health and members of the community so they approaches to build resilience, environmental benefits to the community are trusted and understood when including leveraging the assets within with green, social and recreational emergencies arise. the community. spaces.239 These kinds of cross-sector l A ddressing ongoing behavioral collaborations are a model for creating l L everaging federal, state and local health resources for communities resilience for people and communities. health data and mapping to better — integrating both mental health anticipate and plan for the needs of the l P roviding job-protected paid sick first aid and long term mental health whole community, including by being leave. Nearly 40 percent of private- treatment into disaster response and able to identify, plan for and respond to sector employees — more than 41 recovery strategies. the needs of at-risk populations. million workers — cannot earn paid l E ngaging members of the community sick days for their own illness or injury l I mproving the overall health status and community-based organizations or to care for an ill family member.240 of communities so they are in better directly in emergency planning efforts. Paid sick days help reduce the spread condition to weather and respond to of contagious illnesses and diseases emergencies. Initiatives and programs l I ncorporating community resilience among workers and their families. When supported by the Prevention and Public considerations into other resilience workers without paid sick leave get sick, Health Fund can assist in these efforts efforts at the local level. For instance, they face the impossible choice of going by promoting health and addressing it should be integrated into efforts to to work and potentially infecting others underlying causes of health disparities. address areas such as climate change or staying home and risking losing adaptation, infrastructure resilience, l A ddressing health equity in disaster their jobs. Employees who are sick and continuity of operations, recovery and recovery planning, with a focus on possibly contagious in the workplace from disasters and transportation and health outcomes. Preparedness grants enable the spread of illness among co- housing planning following a Health in should assess and address gaps in workers and customers alike, and the All-Policies Approach. Communities resilience and preparedness for children, very industries and occupations that should leverage various funding the elderly, people with underlying require frequent contact with the public streams, such as from FEMA, U.S. health conditions or disabilities and are some of the least like to provide Department for Housing and Urban communities of color. paid sick days. This increases the Development (HUD), U.S. Environmental chance of infectious diseases spreading l P roviding clear, accurate, Protection Agency (EPA) and private through contact with food, co-workers straightforward guidance to the public grants to ensure resilience and planning and the general public — and it could in multiple languages via trusted efforts consider the health equity threaten the productivity and safety of sources respecting different cultural needs of the most vulnerable residents. America’s businesses. perspectives and delivered via multiple For example, New York City held a TFAH • healthyamericans.org 81 SAVE THE CHILDREN: GET READYGET SAFE Save the Children launched the Get Hurricane Katrina, they found that ReadyGet Safe initiative to help U.S. only 17 of the 81 recommendations communities and families to prepare to in the 2010 report by the National protect and care for children in times of Commission on Children and crisis. They help generate child-focused Disasters have been fully implemented; emergency plans, provide emergency 44 are in progress; and 20 have not training and ensure emergency resources been addressed at all. In addition, are in place before crisis strikes. 241 only 32 states have met minimum recommended emergency planning In addition, in their 2015 report, Still standards at schools and childcare.242 at Risk: U.S. Children 10 Years After 2015 – Our Annual 2008 Only four states met four minimum emergency planning standards for Disaster Report Card child care and schools later recom- mended by the National Commission on Children and Disasters. minimum emergency planning standards at schools and child care. But a decade after Hurricane Katrina, 18 states and D.C. still fall short. District of Columbia 4 CRITERIA MET CRITERIA NOT MET Alaska Hawaii Source: Save the Children, Still at Risk: U.S. Children 10 Years After Hurricane Katrina 82 TFAH • healthyamericans.org I. Readying for Climate Change and Weather-Related Threats Climate change and extreme weather events have serious health consequences in the United States.244 Health departments have an important role to play in helping communities understand and prepare for the adverse effects of climate change, given their role in building healthy communities. SOURCE: CDC Climate and Health Program243 Public health workers are trained to when there is an emergency, whether develop communication campaigns that it is a natural disaster or an infectious both inform and educate the public disease outbreak. These types of about health threats and can use these emergency preparedness and response skills to educate the public about climate skills are essential as extreme weather change-related disease prevention and events and other effects of climate preparedness. In addition, public health change become more common. departments are also on the frontlines TFAH • healthyamericans.org 83 RECOMMENDATIONS: l P reventing and preparing for the addressing the underlying causes of l I mplementing the Clean Air Act adverse impact of climate change climate change can simultaneously (CAA) in an effective and timely on infectious disease outbreaks, provide important health equity manner. The CAA protects American including Zika. Every state should benefits to vulnerable populations. health against dangerous levels of air have a comprehensive climate Projects aimed at reducing greenhouse pollutants. Investments to comply change adaptation plan that includes gas emissions through city planning with the CAA have provided $4 to $8 of a public health assessment and initiatives promoting active economic benefits for every $1 spent response, including developing transportation options, for example, on compliance.248 Four major rules of sustainable state and local mosquito can play an important role in reducing the CAA alone would yield more than control programs. Public health and existing health inequities by increasing $82 billion in Medicare, Medicaid and environmental agencies should work resilience, physical activity levels and other healthcare savings for America together to implement strategies that social cohesion in communities most through 2021.249 help track concerns, coordinate risk at risk.245 Urban planning policies can l D eveloping sustainable state and management and communications also help vulnerable populations adapt local mosquito and other vector and prioritize key public health to the predicted impacts of climate control programs. A review by ASTHO capabilities needed to address change. Policies ensuring buildings found that many states and local environmental health concerns. are constructed to resist extreme communities are challenged to develop Climate change needs assessments weather events, for example, could and maintain vector control programs, should include an examination of what help mitigate the negative impacts but that these programs are a vital additional capacities are needed and for vulnerable populations located in public health strategy to help control identify vulnerable populations and areas heavily impacted by hurricanes vector-borne diseases.250 communities. or heavy rain.246 l I ncreasing funding for the National l B uilding resilience to climate-related l I ncreasing funding for the CDC’s Environmental Public Health Tracking health effects at the federal, state Climate and Health Program at the Program at the National Center for and local level. Climate change National Center for Environmental Environmental Health at the CDC. preparedness should be a required Health. The program was created Health tracking is important to identify element of PHEP and HPP plans in 2009 to translate climate change the link between environmental factors and grants. Funding also should science to inform states and and their impact on health. The program be significantly increased to expand communities, create tools to build should be expanded and fully funded to CDC’s Climate Ready States and state and local capacity to handle cover every state. Cities Initiative nationwide and to extreme events happening today and in build capacity at the federal, state and the future and lead efforts to mitigate l I mproving coordination and moving to local level to understand the impact of the public health impacts of climate integration across medical care, public climate change and apply this to long- change and extreme weather. For each health and environmental agencies. range health planning. additional $1 million in funds, CDC Public health agencies at all levels must would be able to fund approximately work with environmental, homeland l I ncreasing funding for prevention three additional states or cities security and other agencies to undertake and preparedness measures that under their Climate Ready States and initiatives to reduce known health threats promote health equity and help Cities Initiative.247 A larger, long-term from extreme weather, food, water and protect vulnerable populations from investment will be critical to building air and educate the public about ways to adverse climate effects. Initiatives nationwide resilience. avoid potential risks. 84 TFAH • healthyamericans.org J. STOPPING SUPERBUGS AND ANTIBIOTIC RESISTANCE Inappropriate use of antibiotics has contributed to one of the biggest threats to public health: antibiotic-resistant pathogens or “superbugs.”251 Superbugs are turning infections that were once easily treated — like E. coli and Salmonella — into deadly diseases. More than 2 million people in the United States are annually infected by superbugs and at least 23,000 die.252 Superbugs cause $20 billion in annual direct costs and an additional $35 billion in productivity losses.253 CDC has warned that superbugs are expected to continue to grow dramatically — and has prioritized 18 organisms that that are urgent, serious or concerning antibiotic-resistant threats — ranging from methicillin- resistant Staphylococcus aureus (MRSA) to antibiotic-resistant gonorrhea. Six of those urgent or serious antibiotic- resistant threats, plus C.difficile, can cause healthcare-associated infections.254 l E xperts have found that nearly one-third of the 154 million annual antibiotic prescriptions written in doctor’s offices and emergency departments are unnecessary. Many are prescribed for viral respiratory illnesses that inherently will not respond to antibiotics.255 l I n addition, more than 80 percent of Source: CDC antibiotics sold in the United States are used in agriculture (including Another factor contributing to the rise ionophores not used in human is that there are few market incentives medicine).256 Pathogens can develop for pharmaceutical companies to antibiotic resistance when food invest in new antibiotic research animals — such as poultry, cattle or and development. As of March swine — are exposed to antibiotics.257 2016, only 37 new antibiotics were in They can spread to humans through development, 13 of which had reached consumption of food animal products, phase 3 testing.259 Historically, only direct contact with infected animals or 60 percent of phase 3 drugs will be contact with environmental sources, approved by the FDA.260 such as water and soil contaminated by animal waste runoff.258 TFAH • healthyamericans.org 85 RECOMMENDATIONS: l F ully funding and implementing the l R educing over-prescription of antibiotics will be essential for surveillance (i.e. CARB strategy, including CDC’s through implementation of antibiotic NHSN modules for use and resistance). Antibiotic Resistance Solutions stewardship. The Centers for Medicare Sustained funding and continued support Initiative. The initiative is designed and Medicaid Services (CMS) should to state and local health departments to fully implement the priority public finalize and implement requirements for implementing CDC’s Antibiotic Resistance health actions identified in the National all CMS-enrolled facilities to have effective Laboratory Network (AR Lab Network), Action Plan for Combating Antibiotic antibiotic stewardship programs and work next generation surveillance in PulseNet Resistant Bacteria. with public health to track progress in laboratories and whole genome prescribing rates and resistance patterns. sequencing to rapidly uncover foodborne l I ncentivizing the development of HHS should help develop quality measures drug-resistant bacteria, as well as new antibiotics and new diagnostic that assure appropriate prescribing effective dissemination of data collected, tests for resistant bacteria. There of antibiotics.  HHS, CMS, accrediting will be critical for realizing the impacts of should be investment in antibiotic organizations, healthcare facilities, medical this initial federal investment in antibiotic discovery science, early stage product schools and others should educate resistance surveillance. There should be development and research through providers and patients about the harm of increased coordination between human BARDA, public-private partnerships inappropriate prescribing. health, animal health and agriculture — such as CARB-X and other programs. across public health agencies and USDA Partners should also work together to l P reventing and stopping the spread of and state departments of agriculture. develop a model of delinking antibiotic infections and improve antibiotic use reimbursement from sales so drug in every state. CDC should continue l P reventing infection by improving developers are incentivized to innovate expanding implementation of public vaccination rates for children and despite efforts to conserve antibiotics.261 health-healthcare prevention networks adults. Despite their effectiveness, in every state to improve identification vaccination rates remain low in many l R educing overuse of antibiotics in and response to all emerging threats and communities across the United States agriculture. The FDA should fully implement proven strategies in healthcare — especially among adult populations implement and strengthen guidance to facilities to prevent infections and — and reducing disease rates can lower industry regarding the nontherapeutic transmission across healthcare settings. the need for and use of antibiotics and use of antibiotics in food animals. reducing the rates of viral respiratory Important measures include enforcing l S trengthening surveillance and tracking infections, such as the flu, that are often requirements for the collection and of resistant bacteria and infections. mistakenly treated with antibiotics.262 publishing of species-specific use Congress and CDC must continue to Federal, state and local health officials, data, ensuring medically important invest in our public health infrastructure in partnership with medical providers antibiotics in food animals meet to enable the detection and control and community organizations, should judicious use principles, ensuring of drug resistant outbreaks. National conduct assertive campaigns about adherence to requirements for programs to identify emerging patterns the importance of vaccines. Targeted veterinary oversight on the farm, of both resistance and antibiotic use outreach should be made to high-risk promoting antibiotic stewardship will quantify the magnitude of antibiotic groups and to racial and ethnic minority programs and tracking the impact of use in the United States and inform populations where the misperceptions these policies on trends in resistance new interventions. Requirement of about vaccines are particularly high.263 and antimicrobial use in agriculture. data on antibiotic use and resistance 86 TFAH • healthyamericans.org K. Improving Vaccination Rates — for Children, Teens and Adults Vaccines are the safest and most effective way to manage many infectious diseases in the United States. Some of the greatest public health successes of the past century — including the worldwide eradication of smallpox and the elimination of polio, measles and rubella in the United States — are the result of successful vaccination programs.264 A recent model estimated that from 1994-2013 the Vaccines for Children program in the United States will have prevented as many as 322 million illnesses, 21 million hospitalizations and 732,000 deaths at a net savings of $1.38 trillion in societal costs.265 However, despite the recommendations of the vaccines they need unless they are medical experts that vaccines are effective part of institutions that have vaccine and that research has shown vaccines to requirements, such as being enrolled be safe, on average, an estimated 45,000 in colleges or universities, serving in adults and 1,000 children die annually the military or working in a healthcare from vaccine-preventable diseases in the setting. Significant numbers of adults do United States.266 not have regular well care exams, switch doctors or health plans often or only Millions of Americans are not receiving seek care from specialists who do not the recommended vaccinations. For traditionally screen for immunization instance, more than 2 million preschoolers histories or offer vaccines. This makes do not receive recommended vaccinations; it extremely difficult to establish ways there have been outbreaks of measles, for people to know what vaccinations mumps and whooping cough around they need and for clinicians to track and the country; vaccination gaps put teens recommend vaccines to patients. and young adults at risk for HPV and bacterial meningitis; and more than 38 There are several effective strategies percent of seniors have not received identified by the Community Preventive the recommended pneumococcal Services Task Force to improve vaccination.267, 268, 269 vaccinations, such as use of Immunization Information Systems (IIS).270, 271 While many efforts focus on vaccines for children, it is also important to Improving the nation’s vaccination rates address the fact that currently, there is would help prevent disease, mitigate no real system or structure in place to suffering and reduce healthcare costs. ensure adults have access to or receive TFAH • healthyamericans.org 87 RECOMMENDATIONS: l M inimizing vaccine exemptions. Health and document administration of adult l I ncreasing provider education. Profes- and education sectors should work to- immunizations using an Immunization In- sional medical societies and medical and gether to ensure children receive required formation System. To increase confidence nursing schools should support ongoing vaccinations to help protect themselves, and demand for vaccines, an NVAC com- education and expanded curricula on vac- their classmates and educators from mittee has also recommended an index cines and vaccine-preventable diseases diseases. States should enact and to measure and track vaccine confidence, and expand standard practice for providers enable universal childhood vaccinations consistent communications assessment to discuss and track vaccination histories except where immunization is medically and feedback for vaccine confidence and for all patients — including adults — and contraindicated. Non-medical vaccine a repository of tools for providers to com- offer vaccinations to adults during other exemptions, including personal belief municate with parents.275 Training is also doctor and hospital visits. exemptions (PBE), enable higher rates of needed for providers to ensure they are l B olstering immunization registries exemptions — and reduce vaccination able to effectively educate patients and and tracking. Federal and state coverage — in those states that allow make a strong recommendation for vac- policymakers should take steps to them. School exemption rates should cines across the life cycle. facilitate reporting of immunization also be made publicly available so par- l M aking adult vaccinations routine — encounters and interoperability and data ents and educators understand the risks. including regular recommendations and use between immunization registries The National Vaccine Advisory Committee referrals. Private providers and health and EHRs as well as between state and (NVAC) recommends states with existing systems should have standing orders for jurisdictional immunization registries. PBE policies should strengthen policies vaccinations so every provider of care for This will help track when patients receive so that exemptions are only available adults can assess the need, recommend vaccines, improve information sharing after appropriate parent education and and either provide directly or refer to an- and data integrity across providers, acknowledgement of risks to their child other provider for vaccination. Vaccine remind providers to routinely provide and the community.272 locator systems should be expanded to recommended vaccinations, remind l oosting demand for vaccines. Federal, B build an effective vaccine referral system patients of needed vaccinations and state and local health officials, in part- so providers can ensure the vaccine is address gaps. State health information nership with medical providers and com- administered, just as for mammograms exchanges or hub models may make this munity organizations, should continue to or other preventive services. Electronic process simpler by encouraging integration expand assertive campaigns about the im- health records (EHRs) should provide of registry data into EHRs and enabling portance of vaccines, particularly stress- reminder recalls to patients and providers immunization registries (immunization ing and demonstrating the safety and through text messages or other commu- information system (IIS)) data exchange efficacy of immunizations. Targeted out- nications. A routine adult vaccination between states. Resources should be reach should be made to high-risk groups schedule should be established, where available to build capacity of IIS and and to racial and ethnic minority popu- healthcare providers are expected to pur- conduct outreach to encourage providers lations where the misperceptions about chase, educate, advise about and admin- to participate in registries — and IIS vaccines are particularly high.273, 274 The ister immunizations to patients. systems should be linked to school NVAC Adult Immunization Practice Stan- vaccination reporting. States should also l R educing barriers to alternative deliv- dards should be adopted by all healthcare review and adapt statutes to require ery sites. Vaccination services, partic- providers and systems to ensure all reporting or enable opting-out of adult ularly for adults, should be offered by providers, assess immunization needs of registries. Lifespan registries would also pharmacists and other community im- their adult patients; strongly recommend help better track patients’ medical history munization providers, at the workplace needed immunizations to adults; adminis- to ensure they have received all needed and by providers who care for pregnant ter these needed adult immunizations or vaccinations throughout their lives — to women — and should be covered by refer their patients to providers who can help improve and track vaccination rates public and private insurance. administer these needed immunizations; for both children and adults. 88 TFAH • healthyamericans.org l S upporting expanded research all ACIP-recommended vaccines are cov- l R equiring universal immunization of and use of alternatives to syringe ered without cost sharing requirements. healthcare personnel for all ACIP administration of vaccination. All insurance plans should consider recommended vaccinations. The Alternative delivery methods, such as pharmacies and other complimentary Infectious Diseases Society of intradermal patches, could help address providers as important immunizers and American (IDSA), the Society for issues around vaccine shortages, should be considered in-network and Healthcare Epidemiology of American storage and stability, particularly for receive equal payment for vaccine ad- (SHEA) and the Pediatric Infectious global vaccination efforts. 276, 277 ministration services for their adult and Diseases Society (PIDS) support pediatric populations. universal immunization of healthcare l E nsuring first dollar coverage and personnel (HCP) by healthcare access to all recommended vaccines l R equiring on-time immunizations — employers (HCE) as recommended under Medicaid, Medicare and private based on the medically-recommended by ACIP According to a joint policy . insurance. State Medicaid programs vaccines for a person’s age and health statement by the three Societies, are not currently required to offer all rec- status — as a quality measure for all mandatory immunization programs are ommended adult vaccinations without health plans. the most effective way to increase HCP co-payments. While some states offer l C ontinuing support for vaccine programs: vaccination rates.278 The Societies coverage of all recommended vaccines, The Vaccines for Children (VFC) and also support requiring comprehensive some do not. And, many have co-pay- Section 317 immunization programs educational efforts to inform HCP about ments, which present a significant cost provide a safety net for individuals who the benefits of immunization and risks barrier to getting immunized. Medicare are uninsured or remain outside of the of not maintaining immunizations. also does not consistently provide first traditional healthcare system, such as dollar coverage for vaccines, and the l S upporting the development and use children who are eligible but not enrolled different policies dictate what is covered of maternal immunizations. Consistent in Medicaid/State Children’s Health under Part B and Part D, leaving many with the recommendation of NVAC, Insurance Program (CHIP). Section 317 seniors with gaps in coverage. Benefi- the federal government should quickly grants to states have also been key to ciaries can get flu, pneumococcal, TDAP implement the new law to include building the immunization infrastructure, (for at-risk individuals) and HBV (for at- maternal immunizations in the vaccine including enhancing registries, monitoring risk individuals) vaccine covered under injury compensation program (VICP) in the safety and effectiveness of vaccines, Medicare Part B, but an out-of-pocket order to address a barrier to developing responding to outbreaks and conducting payment may be required, depending and delivering vaccines for pregnant surveillance, outreach and service on the immunization and provider. The women to protect newborns. delivery. rest of the recommended vaccines are covered under Medicare Part D, the pre- scription drug benefit, but the patient must get immunized by an in-network pharmacist or find a healthcare provider EXAMPLES OF VACCINE PREVENTABLE DISEASES who accepts Part D and carries the Anthrax, Cervical Cancer, Sequelae of Measles, Meningococcal disease, needed vaccine and not all beneficiaries Hepatitis B Infection (including Liver Mumps, Pertussis (Whooping cough), have Part D coverage. Those who do Cancer), Diphtheria, Haemophilus Pneumococcal disease, Polio, Rabies, will likely face a co-payment that can influenza type b (Hib), Hepatitis A, Rotavirus, Rubella, Smallpox, Tetanus, vary by plan and vaccine, presenting a Hepatitis B, Human Papillomavirus, Typhoid Fever, Varicella (Chickenpox), significant barrier for seniors. All public Influenza (flu), Japanese Encephalitis, Yellow Fever and Zoster (Shingles). and private payers should ensure that TFAH • healthyamericans.org 89 L. Fixing Food Safety Nearly all foodborne illnesses could be avoided with a stronger U.S. food safety system. There are around 48 million cases of illness each year, with 1 million resulting in long-term complications, nearly 128,000 leading to hospital visits and 3,000 resulting in death.281, 282 The annual estimated economic According to research conducted cost of foodborne illnesses is $15.6 by University of Florida Emerging billion in medical costs and lost Pathogens Institute, the top 10 productivity.283 Major outbreaks can riskiest combinations of food and also contribute to significant economic pathogens include Campylobacter in losses in the agriculture and food- poultry, Toxoplasma in pork, Listeria related industries, which contribute in deli meats and dairy products and $985 billion to the U.S. gross domestic Salmonella in foods such as produce, product (GDP) in 2014, a 5.7 percent eggs and poultry.291 These top 10 share.284 A 2011 CDC study found pathogen-food combinations are that Salmonella infections alone are responsible for more than $8 billion responsible for an estimated $365 in annual economic loss. Of all these million in direct medical costs annually, pathogens, Salmonella is the leading and the number of infections had not cause of hospitalizations and death in decreased in the previous 15 years.285 the United States.292 For example, a 2015 outbreak due to In 2015, FDA finalized several contaminated cucumbers led to more major rules implementing portions than 907 cases, 204 hospitalizations of the Food Safety Modernization and six deaths from Salmonella Poona Act (FSMA): Preventive Controls infections in at least 40 states.286 for Human Foods and Preventive According to CDC, produce is related Controls for Animal Foods, which to the highest percentage of illnesses require covered facilities to analyze (46 percent), but meat and poultry potential hazards and implement cause the most deaths (29 percent).287 risk-based preventive controls in Norovirus is the leading cause of illness their production processes; Produce from contaminated food in the United Safety, which establishes standards States.288, 289 Foodborne norovirus for growing, harvesting, packing and outbreaks result most commonly from holding of produce; and the Foreign the handling of ready-to-eat foods by Supplier Verification Program for food infected individuals, but can also occur importers to assure that imported food due to use of fecally contaminated water meets U.S. safety standards.293 The during production and processing.290 FY 2016 appropriations bills included Cyclospora cayetanensi, a microscopic an additional $104.5 million in new parasite, has caused large outbreaks budget authority for implementing of diarrheal illness linked to fecally FDA food safety rules.294 contaminated imported produce items. 90 TFAH • healthyamericans.org WATER SAFETY AND SECURITY Waterborne illnesses also pose serious l I n Charleston, West Virginia in 2014, a threats to America’s health each chemical spill contaminated the water year. While water-related illnesses are supply for around 300,000 people, underreported, there are at least around where many were unable to use their 30 outbreaks — resulting in around tap water for weeks to months.298, 299 1,000 serious drinking water-related According to CDC, lead exposure remains illnesses and 1,300 recreational-related a health concern for young children in water illnesses.295, 296 the United States. Risk varies across There have been a number of recent the country, but because there are often major water crises that demonstrate no obvious symptoms, the exposure fre- the harmful impact that unsafe water quently goes unrecognized. In addition, can have on health and for communities only around 10 percent of schools with when they do not have access to safe their own water systems are required to water. Some of these have required test for lead (350 of which failed lead coordinated multisector emergency tests from 2012 to 2015), and federal law responses. For instance: does not require schools using local public water suppliers to test the water.300 Even l I n Flint, Michigan, a change in the low levels of lead in children’s blood have water supply led to tens of thousands been shown to affect intelligence, ability to of residents exposed to high levels of pay attention and academic achievement. lead and other toxins that are harmful to health, particularly the health of Security professionals also raise young children and babies during concerns about protecting from pregnancy. The CDC found that young potential biological and chemical children who drank the water had terrorism attacks on water supplies, significantly high blood lead levels. 297 including of agricultural water supplies. TFAH • healthyamericans.org 91 RECOMMENDATIONS: l F ully funding and implementing the FDA l I mproving surveillance of foodborne ill- to help prevent and control infectious dis- Food Safety Modernization Act. Suffi- nesses. Currently, foodborne illnesses ease outbreaks.305, 306 cient funding should be devoted at the are radically underreported in the United l A dopting FDA’s Food Code — a uniform federal and state levels to be able to im- States and the quality of reporting varies system of food safety provisions for food plement and enforce the law. FDA should dramatically by state. For example, CDC service, retail food stores, or food vend- ensure public health is the top priority estimates for every reported case of Sal- ing operations in local, state and federal as it implements FSMA prevention-based monella infection, there are 29 unreported jurisdictions. Data consistently identify rules. FDA should also track implemen- cases, and for every E.coli O157-H7 case five major risk factors that contribute to tation of these rules to ensure that pro- there are an estimated 26 unreported foodborne illness: 1) improper holding posed exemptions do not increase risk cases.301 New standards and require- temperatures; 2) inadequate cooking, from foodborne illness. ments should be put in place to incentivize such as undercooking raw shell eggs; 3) states to improve reporting and penalize l I mproving enforcement and inspection contaminated equipment; 4) food from states for underreporting. Surveillance capacity. FDA should work with states unsafe sources; and 5) poor personal for foodborne illness outbreaks should be to ensure they are ready to enforce FSMA hygiene.307 FDA describes the benefits fully integrated with other HIT systems, regulations, develop an operational strat- associated with the 2013 Food Code’s which will help improve tracking and iden- egy and ensure compliance across states. complete and widespread adoption to tification of the scope of problems as include:308 l M oving toward a more unified govern- well as sources of outbreaks. As public ment food safety approach. The federal health moves toward “whole genome se- • eduction of the risk of foodborne R government currently does not have a quencing” of foodborne pathogens, federal illnesses within food establishments, coordinated, cross-governmental approach and state policymakers should ensure thus protecting consumers and industry to food safety.  Right now, food safety adequate workforce and infrastructure from potentially devastating health con- activities are siloed across a range of agen- investment for the transition to modern sequences and financial losses. cies, and many priorities and practices are detection systems. FDA and CDC should • niform standards for retail food safety U outdated and inconsistent.  Better organi- also have a plan for requiring clinics to that reduce complexity and better en- zation and coordination within and between send cultures from rapid response tests sure compliance. federal food safety agencies would improve showing problems to public health labs to • he elimination of redundant processes T public health.  A 2014 initiative within FDA allow for subtype pathogen testing.302 for establishing food safety criteria. to realign its policy and enforcement arms l S upporting paid sick days. Paid sick • he establishment of a more standard- T should be completed.  In the longer term, days help to ensure workers can comply ized approach to inspections and au- the Administration should develop a plan with science-based guidance on con- dits of food establishments. with a set timeline for how to restructure trolling the spread of an outbreak, which food safety functions across the federal l A ssuring clean water for all Americans: is a particular risk in food service. Ac- government — potentially consolidating Measures should be taken to protect a cording to CDC, handling of food by an them within a single, unified food safety safe water supply for all Americans, in- infected person is a contributing factor agency — to better carry out a preven- cluding addressing the ongoing problem in up to two-thirds of restaurant related tion-focused, integrated strategy.  One part of lead and other toxins in the drinking foodborne outbreaks.303 A 2015 survey of this plan, which is the logical next step water in some communities, and taking found that about half of food workers, after FSMA, should be to modernize the measures, such as those in the Environ- including agricultural and restaurant meat and poultry laws so that they are mental Protection Agency’s Clean Water workers go to work sick, often because more risk-based and science-based and Rule, to reduce the potential for water- they can’t afford to lose pay.304 As of protective of public health. This same type borne illnesses and increase protection November 2016, seven states, 30 cities of coordinated, cross-governmental ap- against potential acts of drinking and and two counties have passed paid sick proach to food safety is also needed within agricultural water-related biological and leave laws. Policymakers should extend each state. chemical terrorism. paid sick leave to private sector workers 92 TFAH • healthyamericans.org Ready or Not: APPENDICES Appendix A: State Public Health Budget Methodology Appendices TFAH conducted an analysis of state state funds (e.g. dedicated revenue, fee spending on public health for the last revenue, etc.), was used. In some cases, budget cycle, fiscal year 2015-2016. For only general revenue funds were used in those states that only report their budgets order to separate out federal funds; these in biennium cycles, the 2015-2017 period exceptions are also noted. (or the 2014-2016 and 2015-2016 for Because each state allocates and reports Virginia and Wyoming respectively) its budget in a unique way, comparisons was used, and the percent change was across states are difficult. This calculated from the last biennium, 2013- methodology may include programs 2015 (or 2012-2014 and 2014-2015 for that, in some cases, the state may Virginia and Wyoming respectively). consider a public health function, but This analysis was conducted from the methodology used was selected to September to October of 2016 using maximize the ability to be consistent publicly available budget documents across states. As a result, there may be through state government web sites. programs or items states may wish to be Based on what was made publicly considered “public health” that may not available, budget documents used be included in order to maintain the included either executive budget comparative value of the data. document that listed actual expenditures, Finally, to improve the comparability estimated expenditures, or final of the budget data between FY 2014- appropriations; appropriations bills 2015 and FY 2015-2016 (or between enacted by the state’s legislature; or biennium), TFAH adjusted the FY 2015- documents from legislative analysis offices. 2016 numbers for inflation (using a “Public health” is defined to broadly 0.984 conversion factor based on the U.S. include all health spending with the Dept. of Labor Bureau of Labor Statistics; exception of Medicaid, CHIP, or Consumer Price Index Inflation comparable health coverage programs Calculator at http://www.bls.gov/cpi/).   for low-income residents. Federal After compiling the results from this online funds, mental health funds, addiction review of state budget documents, TFAH or substance abuse-related funds, WIC coordinated with the Association of State funds, services related to developmental and Territorial Health Officials (ASTHO) disabilities or severely disabled persons, to confirm the findings with each state and state-sponsored pharmaceutical health official.  ASTHO sent out emails on programs also were not included in order October 21, 2016 and state health officials to make the state-by-state comparison were asked to confirm or correct the data DECEMBER 2016 more accurate since many states receive with TFAH staff by November 9, 2016.  federal money for these particular ASTHO followed up via email with those programs. In a few cases, state budget state health officials who did not respond documents did not allow these programs, by the November 9, 2016 deadline. Twelve or other similar human services, to be states did not respond by December 7, disaggregated; these exceptions are 2016 when the report went to print. The noted. For most states, all state funding, most recent publicly available data was regardless of general revenue or other used for the states that did not respond.  Appendix B: PUBLIC HEALTH EMERGENCY PREPAREDNESS (PHP) AND HOSPITAL PREPAREDNESS PROGRAM (HPP) GRANTS TO STATES ALL-HAZARDS PREPAREDNESS FUNDING BY SOURCE AND FISCAL YEAR Fiscal Year 2002 Fiscal Year 2016 Percent Change, CDC-PHEP Fuding, ASPR-HPP Funding, CDC- PHEP Funding, ASPR-HPP Funding, Between FY 2002 Total Total and FY 2016 FY 2002 FY 2002 FY 2016 FY 2016 Alabama $14,900,443 $1,972,833 $16,873,276 $8,282,477 $3,213,182 $11,495,659 -31.9% Alaska $6,395,720 $492,877 $6,888,597 $4,008,961 $946,524 $4,955,485 -28.1% Arizona $16,422,170 $2,237,637 $18,659,807 $10,911,739 $3,802,604 $14,714,343 -21.1% Arkansas $10,951,709 $1,285,691 $12,237,400 $6,249,569 $2,021,657 $8,271,226 -32.4% California $60,816,245 $9,962,905 $70,779,150 $38,570,815 $23,405,491 $61,976,306 -12.4% Colorado $14,575,766 $1,916,334 $16,492,100 $9,094,118 $3,019,385 $12,113,503 -26.5% Connecticut $12,581,705 $1,569,336 $14,151,041 $7,233,738 $2,351,714 $9,585,452 -32.3% Delaware $11,273,558 $721,619 $11,995,177 $6,247,100 $948,679 $7,195,779 -40.0% D.C. $6,744,505 $553,571 $7,298,076 $4,243,150 $1,057,820 $5,300,970 -27.4% Florida $40,581,081 $6,441,669 $47,022,750 $26,833,350 $11,834,415 $38,667,765 -17.8% Georgia $23,225,251 $3,421,481 $26,646,732 $14,662,128 $6,009,692 $20,671,820 -22.4% Hawaii $7,697,208 $719,356 $8,416,564 $4,694,308 $1,253,321 $5,947,629 -29.3% Idaho $7,880,688 $751,285 $8,631,973 $4,694,308 $1,252,520 $5,946,828 -31.1% Illinois $26,201,381 $3,939,374 $30,140,755 $15,294,823 $8,882,060 $24,176,883 -19.8% Indiana $18,536,799 $2,605,616 $21,142,415 $10,526,446 $3,973,603 $14,500,049 -31.4% Iowa $11,514,786 $1,383,675 $12,898,461 $6,385,337 $2,126,090 $8,511,427 -34.0% Kansas $10,985,143 $1,291,509 $12,276,652 $6,355,765 $2,052,547 $8,408,312 -31.5% Kentucky $13,998,067 $1,815,805 $15,813,872 $7,896,874 $2,798,229 $10,695,103 -32.4% Louisiana $14,949,145 $1,981,308 $16,930,453 $8,286,241 $2,899,154 $11,185,395 -33.9% Maine $7,838,322 $743,913 $8,582,235 $4,528,810 $1,080,551 $5,609,361 -34.6% Maryland $16,791,405 $2,301,890 $19,093,295 $10,411,078 $4,911,525 $15,322,603 -19.7% Massachusetts $19,134,801 $2,709,678 $21,844,479 $12,181,742 $4,372,887 $16,554,629 -24.2% Michigan $27,125,655 $4,100,212 $31,225,867 $15,361,777 $6,172,668 $21,534,445 -31.0% Minnesota $15,952,086 $2,155,835 $18,107,921 $10,518,587 $3,546,523 $14,065,110 -22.3% Mississippi $11,332,975 $1,352,037 $12,685,012 $6,312,338 $2,166,456 $8,478,794 -33.2% Missouri $17,456,448 $2,417,618 $19,874,066 $10,067,187 $3,621,262 $13,688,449 -31.1% Montana $7,008,529 $599,516 $7,608,045 $4,203,760 $927,401 $5,131,161 -32.6% Nebraska $8,809,733 $912,954 $9,722,687 $5,119,326 $1,362,493 $6,481,819 -33.3% Nevada $9,448,659 $1,024,136 $10,472,795 $6,372,777 $1,929,769 $8,302,546 -20.7% New Hampshire $7,751,193 $728,751 $8,479,944 $4,624,949 $1,101,804 $5,726,753 -32.5% New Jersey $23,732,611 $3,509,769 $27,242,380 $14,289,117 $5,459,638 $19,748,755 -27.5% New Mexico $9,049,686 $954,709 $10,004,395 $6,475,408 $1,537,475 $8,012,883 -19.9% New York $29,418,122 $4,499,138 $33,917,260 $18,239,925 $9,757,860 $27,997,785 -17.5% North Carolina $22,919,940 $3,368,351 $26,288,291 $13,677,089 $5,908,241 $19,585,330 -25.5% North Dakota $6,429,710 $498,792 $6,928,502 $4,008,961 $886,426 $4,895,387 -29.3% Ohio $30,275,150 $4,648,274 $34,923,424 $16,356,243 $7,210,035 $23,566,278 -32.5% Oklahoma $12,682,086 $1,586,804 $14,268,890 $7,302,035 $2,612,637 $9,914,672 -30.5% Oregon $12,616,956 $1,575,470 $14,192,426 $7,510,978 $2,580,105 $10,091,083 -28.9% Pennsylvania $32,340,936 $5,007,754 $37,348,690 $17,808,098 $8,193,982 $26,002,080 -30.4% Rhode Island $7,333,840 $656,125 $7,989,965 $4,347,166 $945,077 $5,292,243 -33.8% South Carolina $13,931,820 $1,804,277 $15,736,097 $9,225,872 $3,120,729 $12,346,601 -21.5% South Dakota $6,680,486 $542,431 $7,222,917 $4,028,356 $854,218 $4,882,574 -32.4% Tennessee $17,665,877 $2,454,062 $20,119,939 $10,395,677 $4,062,164 $14,457,841 -28.1% Texas $51,421,771 $8,328,119 $59,749,890 $34,065,482 $16,294,177 $50,359,659 -15.7% Utah $9,971,636 $1,115,143 $11,086,779 $6,276,248 $2,288,020 $8,564,268 -22.8% Vermont $6,355,413 $485,864 $6,841,277 $4,008,961 $782,301 $4,791,262 -30.0% Virginia $20,758,682 $2,992,259 $23,750,941 $13,899,895 $6,117,444 $20,017,339 -15.7% Washington $18,121,901 $2,533,418 $20,655,319 $11,184,642 $4,292,040 $15,476,682 -25.1% West Virginia $9,025,861 $950,564 $9,976,425 $5,085,641 $1,411,417 $6,497,058 -34.9% Wisconsin $16,940,986 $2,327,920 $19,268,906 $10,844,792 $3,638,592 $14,483,384 -24.8% Wyoming $6,099,294 $441,296 $6,540,590 $4,008,961 $843,452 $4,852,413 -25.8% State Totals by FY* $842,653,940 $114,390,960 $957,044,900 $513,213,125 $203,838,056 $717,051,181** -25.1% *Note: The totals do not include funds for the three directly funded major U.S. metropolitan areas: Chicago, Los Angeles and New York; U.S. Territories, such as Puerto Rico and Guam and Freely Associated States of the Pacific, such as Marshall Islands. **Note: FY2016 includes $44 million that was reallocated from PHEP for the Zika response, then reimbursed by the Zika emergency supplemental. 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