key: cord-0857127-naavpb4v
authors: Khan, Ali S
title: Public health preparedness and response in the USA since 9/11: a national health security imperative
date: 2011-09-01
journal: Lancet
DOI: 10.1016/s0140-6736(11)61263-4
sha: 77fa92a8807379e0067570f2b4a9745b2e5c0b7e
doc_id: 857127
cord_uid: naavpb4v

nan

national stockpile of medical assets, and a novel laboratory diagnostic network for bioterrorism agents. Since 9/11, the US public health system has received unprecedented national investment in recognition of its importance to the national security. These investments have resulted in increased capacity that is most evident in well populated states and large urban areas where new resources were mostly directed. The terrorist attacks also led to a cultural shift in the way state and large city health departments work and interact with other agencies and sectors. Health departments are now becoming increasingly accepted as equal partners by traditional fi rst responders, such as law enforcement agencies, fi re departments, and emergency medical services. These interactions are supported by the incorporation of public health components into the National Response Framework and the National Incident Management System. Public health bodies at the local, state, and federal levels now routinely use this system to ensure that everyone has the same focus, whether responding to daily incidents or major disasters.

Further substantial investments were made in state and local preparedness and response infrastructure, planning, and capability development for routine outbreaks and to help ensure health security in the event of large disasters or epidemics. The US Department of Health and Human Services established several additional resources, including deployable teams from the US Public Health Service that can rapidly assist in a response to a public health emergency. The National Disaster Medical System expanded its mission to include medical treatment for victims of terrorist attacks. Sustained eff orts to leverage technology in advanced research and development of countermeasures to increase protection from radiological or nuclear, chemical, and biological agents have improved diagnostic tests and led to new vaccines and antitoxins for smallpox and botulism, and drugs for anthrax, smallpox, and infl uenza.

CDC's Strategic National Stockpile increased its core formulary to support the prophylaxis of more than 50 million people to prevent anthrax, plague, or tularaemia, and acquired enough smallpox vaccine to immunise every person in the USA. The Stockpile also started the forward placement of lifesaving antidotes for terrorist attacks with chemical or nerve agents (the CHEMPACK programme 5 ). The mission of the Laboratory Response Network has expanded from biological and chemical agents to include emerging infectious diseases and other public health threats and emergencies, and from US borders to international partnerships with Mexico, Canada, the UK, and others. After 9/11, the US Congress passed the USA PATRIOT Act of 2001 6 and the Bioterrorism Act of 2002, 7 which substantially strengthened the ability of the USA to oversee select agents and toxins that could pose public health threats. A recent Presidential Executive Order 8 stipulated that the list of select agents will be adjusted to focus on agents of greatest concern. Several US Government programmes (eg, CDC's Global Disease Detection, Department of Defense's Biological Threat Reduction Program, Department of State's Global Threat Reduction Programs, and USAID's Emerging Pandemic Threats Program) have also been involved in enhancing worldwide capacity to rapidly detect and contain emerging health (and bioterror) threats. These programmes increasingly focus on the development of local health capacity to support WHO's revised international health regulations in conjunction with other worldwide and native eff orts directed at epidemic preparedness and response. 9 Although preparedness and response capabilities for public health emergencies have been diffi cult to defi ne and measure 10 (a task that CDC continues to address 11 ), reports from CDC and organisations such as the Trust for America's Health have documented substantial improvements. 12, 13 These reports show that public health departments are now better equipped to identify health threats rapidly and have improved their abilities to respond eff ectively to and communicate emergencies. For example, 48 of 50 states (96%) have shown their ability to activate staff and their emergency operations centres. Similarly, the medical response to a public health emergency has been strengthened. 14 Progress in preparedness made in the past decade (panel 1) has benefi ted routine and large-scale or unexpected responses, therefore saving lives and preventing illness and injuries. 15 Annual investments through CDC's Public Health Emergency Preparedness cooperative agreement with states support crucial everyday systems. These investments support more than 5000 front-line public health workers who routinely assist local and regional responses for incidents 24 h per day 7 days per week, such as outbreaks of foodborne and infectious diseases, and regional environmental disasters, such as wildfi res, fl oods, and ice storms.

Federal investments in public health infrastructure have eff ectively supported several large-scale responses, the most recent being for H1N1 pandemic infl uenza (2009). Within 2 weeks of a novel virus being identifi ed and confi rmed, CDC validated a new PCR assay for rapid defi nitive laboratory diagnosis, manufactured new diagnostic kits, and began distributing them to partner laboratories in the USA and abroad in support of WHO. This response not only led to rapid selection and development of the vaccine strain, which is still used, but also confi rmed early cases in fi eld investigations for rapid characterisation of the geographical spread of the virus, and the patient groups at highest risk of illness complications. Additionally, about 90% of member laboratories in the Laboratory Response Network were mobilised for the 2009 H1N1 infl uenza pandemic (including key partner laboratories in the Department of Defense), and CDC's Strategic National Stockpile deployed 25% of its antiviral drugs and personal protective equipment within planned timelines.

The eff ectiveness of responses are judged by accurate communications of emerging health threats in addition to response and health outcomes. CDC's secure, webbased Epidemic Information Exchange (Epi-X) allows state and local public health offi cials to access and share health surveillance information about such events as illnesses associated with a case of human bubonic plague (2010), reports about airline travellers potentially exposed to com municable disease (2010), and the recreational use of designer drugs that were components of items marketed as bath salts (2011). In April 2009, Epi-X reported cases of acute respiratory illness in Veracruz, Mexico, an outbreak that was identifi ed as a novel form of infl uenza A (H1N1). CDC's Health Alert Network (HAN) is another important system of communication for sending messages to health professionals and the public (including media). HAN alerts have featured guidance about use of infl uenza antiviral agents during the 2010-11 season, and updates for detection of increased levels of radioactive material in the USA caused by the 2011 Japanese Fukushima nuclear incident. The US Government is increasingly recognising that preparedness and core (routine) investments in public health are synergistic. Large-scale and unpredictable natural, accidental, or intentionally caused disease outbreaks and environmental disasters need many of the same routine surveillance, laboratory, risk com munication, and other core public health systems. The fl exibility of the Laboratory Response Network shown during the anthrax attacks, for example, has also played a key part in validating BioWatch results, and for responses ranging from severe acute respiratory syndrome (SARS), monkeypox, West Nile virus, and H5N1, to investigations for ricin and saxitoxin poisonings and numerous exposures to mercury. Individuals, families, and communities are also essential partners in building resilience to public health hazards. Development of informed empowered individuals and communities (a cornerstone of the whole-of-nation policy approach 16 ) demands new actions and investment in many sectors to transform the populace from victims to potential responders. Prepared communities understand potential risks and their roles before, during, and after an adverse incident. These communities also have members who are engaged in local decision making, are prepared to take action during an incident, and are committed to their personal preparedness to protect their own health and that of their neighbours until help arrives. A continued public health focus on development of healthy communities can also have ancillary benefi ts to improve preparedness because healthy people are more resilient to health threats.

Although the USA is better prepared to prevent, rapidly respond to, and recover from public health emergencies than it was a decade ago, much more work still needs to be done. Of increased concern are natural emerging infectious diseases caused by novel zoonotic pathogens with pandemic potential like SARS, or known pathogens, such as another pandemic infl uenza virus. A main driver for this convergence is the volume and speed of human travel across the world, which provides infectious agents with unprecedented opportunities for broad geographical reach and new populations of human and animal hosts. Furthermore, technological barriers are continually being overcome for development of modifi ed versions of microbes with new or enhanced virulence traits or even completely new life forms, which can all infl ict great harm. The genomes of thousands of microbes have been sequenced and their blueprints are available for rapid sharing across the internet along with instructions for development of chemical agents. These and other types of advanced technologies are becoming increasingly accessible and easy to use by less-skilled individuals. In 2009, President Obama signed an Executive Order 17 to bridge gaps in the ability of the USA to respond rapidly to a biological attack, and CDC has created an Anthrax Management Team to develop guidelines for preparing for and responding to this threat. In view of its unique biochemical properties and clinical eff ects, anthrax is the most concerning biological agent to the USA.

Another major challenge is the continuing economic crisis and its eff ect on health departments. From 2008 to 2010, more than 44 000 jobs were lost in state and local health departments, and health workers such as public health physicians and nurses, laboratory specialists, and epidemiologists were reduced. 18 Thus, states must grapple with continued declines in funding levels that have already aff ected the ability of the public health system to respond eff ectively to routine and major public health incidents, especially when an increased investment was needed to protect the nation uniformly and address substantial gaps. A 2009 survey 19 found that only 37 state epidemiologists reported substantial-to-full capacity for bioterrorism emergency response-a 10% decline since the peak of federal funding in 2004. Similarly, advances in laboratory reporting are tempered by the reality that in 2010, 12 (24%) states could not submit 90% of Escherichia coli test results to CDC's PulseNet database within 4 working days, compromising rapid identifi cation of outbreaks and subsequent recalls. 12 States cannot adequately meet everyday needs, let alone increased eff orts for emergency incidents that have potential national implications, without reliable, dedi cated, or sustained federal funding. Because all responses are initially local, this limitation is the primary vulnerability to national preparedness.

Determination of appropriate priorities for public health preparedness for state and local health departments is also a key challenge, as is measurement of preparedness. 10 years ago, recommendations indicated that necessary investments be made to ensure optimum local, state, and national preparedness in the context of a defi ned set of Panel 2: Issues to be addressed in public health preparedness within the next decade • Increase the focus on communities and better defi ne and enhance community and local resilience and personal preparedness • Ensure a robust state, territorial, local, and tribal public health infrastructure with a special focus on biosurveillance to ensure accurate and complete data collection and analysis enabled by electronic medical and laboratory records and new data fusion and visualisation devices • Increase the focus on vulnerable populations that need additional assistance in emergencies, including mental and behavioural health needs • Leverage the full range of investments in crucial infrastructure made across the US federal enterprise, including the Department of Homeland Security • Improve coordination of public health, health care, emergency medical services, and the private sector • Improve linkages between domestic health security and global health security • Improve the evidence base for preparedness activities, including measurement standards for recognition of diseases and bioterrorist activities. 20 CDC continues to work to have a better defi nition of what it means to be prepared for all hazards, and to develop and implement standardised measures to assess progress. For the fi rst time, in spring 2011, CDC released national standards 11 for preparedness to guide state and local health departments in assessing needs, building 15 capabilities, measuring outcomes, and directing preparedness funds to priority areas.

Lessons can be learned from other national eff orts for pandemic infl uenza preparedness, both in the benefi ts of preparedness and in the existing shortfalls. Many national self assessments document their improved H1N1 response because of their preparedness activities, and Israel presents a model of civilian-defence partnership. 21, 22 However, despite years of preparation, communities worldwide were still challenged by short comings in communication; access to reliable infor mation; access to quality care; health-care worker skills, quality, density, and distribution; access to essential medicines; and poor organisational infra structure for emergency response. 23 After the H1N1 pandemic, WHO asserted that "the world is ill-prepared to respond to a severe infl uenza pandemic or to any similarly global, sustained, and threatening public-health emergency". 24 For the next decade, specifi c issues in public health preparedness should be further addressed (panel 2). Public health threats increasingly have substantial potential for political, economic, and social infl uence. To ensure health security in the USA and worldwide-a crucial component of a nation's overall national security-and cumulatively our global health security, new commit ments from the local to the national levels are needed.

I am Director of the Offi ce of Public Health Preparedness and Response at the Centers for Disease Control and Prevention. I declare that I have no confl icts of interest.

National Commission on Terrorist Attacks upon the United States. The 9/11 commission report

Injury and illness among New York City Fire Department rescue workers after responding to the World Trade Center attacks

Emerging infections: microbial threats to health in the United States

BioHazard: the chilling true story of the largest covert biological weapons program in the world-told from inside by the man who ran it

Public health preparedness: strengthening CDC's emergency response

Uniting and strengthening America by providing appropriate tools required to intercept and obstruct terrorism (USA PATRIOT Act) Act of

Public health security and bioterrorism preparedness and response act of

Executive Order 13546-optimizing the security of biological select agents and toxins in the United States

Developing national standards for public health emergency preparedness with a limited evidence base

Public health preparedness capabilities: national standards for state and local planning

Public health preparedness: 2011 update on laboratory capabilities and response readiness planning

Ready or not? Protecting the public's health from disease, disasters, and bioterrorism

Hospitals rising to the challenge: the fi rst fi ve years of the US hospital preparedness program and priorities going forward

Ten great public health achievements-United States

Presidential policy directive/PPD-8: national preparedness

Executive Order 13527: establishing federal capability for the timely provision of medical countermeasures following a biological attack

National Association of County and City Health Offi cials

2009 national assessment of epidemiology capacity: fi ndings and recommendations

Ready or not-preparedness for bioterrorism

Pandemic risk prevention in European countries: role of the ECDC in preparing for pandemics. Development and experience with a national self-assessment procedure

Pandemic infl uenza preparedness and response in Israel: a unique model of civilian-defense collaboration

Pandemic response lessons from infl uenza H1N1 2009 in Asia

Report of the review committee on the functioning of the international health regulations (2005) in relation to pandemic (H1N1)

I thank Peter Rzeszotarski for drafting the initial outline of this Viewpoint; Denise Casey for doing related research, assembling and editing drafts, and compiling comments; and Daniel Jernigan, Richard Kellogg, Stephen Redd, Daniel M Sosin, and Jay Wenger for reviewing the manuscript and providing helpful comments. The fi ndings and conclusions in this Viewpoint are those of the author and do not necessarily represent the offi cial position of the Centers for Disease Control and Prevention.