Michael R. Fraser and Donna Brown
Michael R. Fraser and Donna Brown, Bioterrorism
Preparedness and Local Public Health Agencies: Building Response
Capacity., 115(4) Public Health Reports 326 (July 2000)
THE THREAT OF BIOTERRORIST ATTACKS HAS LED MANY LOCAL public health
agencies to question their capacity to respond to these and other public
health emergencies. While the probability of a bioterrorist attack in
the United States has not been comprehensively assessed, it is clear
that the public health threats facing the nation are growing in
complexity and severity.(1-3) The public health response to these
threats is multifaceted and may include such diverse activities as:
detecting foodborne illnesses associated with the shipment of frozen
strawberries inadvertently contaminated with hepatitis A virus;
controlling the spread of an unseasonably large outbreak of influenza;
reducing water pollution caused by a flood, hurricane, or tornado;
minimizing injury from the willful contamination of food products with
Salmonella; or responding to a terrorist's release of aerosolized
Bacillus anthracis (anthrax) in a city center. While public health
responsibility for responding to these threats differs nationwide,
almost all states rely on local public health agencies to identify and
respond to disease outbreaks to protect the health of their
communities.(4)
Local public health officials serve every day on the front lines in
cities, towns, and counties across the country. The National Association
of County and City Health Officials (NACCHO) is the national
organization representing the nation's almost 3000 local public health
agencies. At the core of NACCHO's
bioterrorism program is a belief that the capacities needed by local
public health agencies to cope effectively with the consequences of an
act of bioterrorism should build on the systems used to respond to
disease outbreaks that are nor the result of acts of terrorism.(1) The
public health response to bioterrorism should allow for the development
of a dual-use response infrastructure that improves the capacity of
local public health agencies to respond to all hazards while taking into
account the unique and complex challenges a bioterrorist event may
present. After all, unless the planned release of a biological agent is
announced prior to the event, the cause of an outbreak will be detected
only after an epidemiologic investigation is initiated.(5,6) The 1999
outbreak of West Nile Virus in New York City, which killed three people
and sickened 59, is testament to the need for local, state, and federal
public health agencies to act quickly and decisively to protect the
public's health regardless of the cause of a disease's introduction and
spread.(7)
Using bioterrorism initiatives to build the capacity of local public
health systems is an efficient and effective use of limited public
health resources. However, local public health agencies do not need to
add a bioterrorism response system to an already large number of
stand-alone reporting systems and response protocols. Instead, NACCHO
has advocated for community-wide surveillance systems capable of
detecting bioterrorist events as
well as other health emergencies. In national forums, Congressional
testimony, and in their communities, local public health officials have
repeatedly stated that an investment in strengthening overall local
public health practice is the best way to address the public health
consequences of bioterrorism.(8)
ADVOCACY
NACCHO has used the public interest in bioterrorism to demostrate the
pressing need for fiscal support of general preparedness activities of
local, state, and federal public health agencies. We are particularly
concerned with maintaining support for the Health Alert Network, a
Centers for Disease Control and Prevention (CDC) program that will equip
and train local public health agencies to use up-to-date and secure
electronic communication technology; provide instantaneous access to
disease surveillance data, laboratory reports, and CDC response
protocols; support the development of model community disease
surveillance systems; support local public health agency planning: and
develop and apply performance standards for local capacity to address
bioterrorism and other health threats. Although the primary reason for
the Health Alert Network is to develop systems for detecting and
responding to bioterrorism, the surveillance, communications, and
training infrastructure the Health Alert Network creates will be used to
respond to any public health emergency.
To date, Health Alert Network
funds have been allocated to 37 state and three urban public health
agencies (in Chicago, Los Angeles, and New York City). NACCHO is urging
Congress to appropriate $40 million in fiscal year 2001 so that the
program can be expanded to all states. A unique feature of the Health
Alert Network program is that 85% of all program funding must be used to
benefit local public health agency capacity. States have used Health
Alert Network funds to electronically link all local public health
departments to the state public health agency, to purchase
decontamination equipment and equipment for secure-communications, and
to develop training materials for the public health workforce on
bioterrorism and emergency response.
NACCHO also supports CDC's efforts to create a National Electronic
Disease Surveillance System (NEDSS), for which the Clinton
administration has requested $20 million for FY 2001. As envisioned,
NEDSS would replace more than 70 different disease reporting systems
currently operated by CDC with a single system. Local and state public
health agencies, laboratories, and other partners would transmit disease
surveillance 'information to CDC using highly secureelectronic linkages
designed to interface with the multiplicity of surveillance and
reporting systems used at the local and state level. NEDSS will be
designed to complement the advances achieved through the Health Alert
Network. Taken together, both are essential capacity
building programs for local public health agencies.
EFFECTIVE COORDINATION OF RESOURCES AND PROGRAMS
The recent interest in bioterrorism preparedness among public safety
officials has stimulated a great deal of activity at the local, state,
and federal levels. Unfortunately, much of this activity has taken place
without the involvement of local public health officials. For example,
states have developed emergency response protocols without the input of
local public health officials, who will most likely be the first to
detect a bioterrorist event and respond to it. Local law enforcement and
emergency management agencies have inconsistently shared their emergency
response and bioterrorism planning activities with partners in the
public health and medical communities. At the federal level,
anti-terrorism programs are spread across many different agencies and
departments, including the Departments of Health and Human Services,
Justice, and Defense, often with overlapping goals and objectives.
NACCHO has urged law enforcement, military, and public safety officials
to make the specific contributions of public health agencies part of
their planning efforts.
The contributions of local public health practitioners to emergency
response planning will vary widely across jurisdictions and may include:
* the ability to rapidly assess the health of populations in affected
areas; * the expertise needed to
implement surveillance systems to monitor the health status of
populations following an event; * the resources to produce and
distribute health education materials to medical providers, affected
populations, and the 'worried well'; * the authority to control disease
outbreaks and identify and mitigate any resulting environmental health
hazards; * the experience of providing for the needs of special
populations, such as the disabled or elderly, during and after a
disaster event.
Through the National Public Health Performance Standards Program, a
CDC-sponsored initiative to create national standards for state and
local public health systems, NACCHO and other national organizations are
working with CDC to develop a set of performance measures for local and
state public health agencies; a subset of these performance measures
will focus on bioterrorism and emergency response capacity.(9) These
measures will set the standard for effective planning and coordination
among local, state, and federal public health and public safety
agencies. The bioterrorism performance standards will also guide
communities that have not yet integrated bioterrorism into their
comprehensive emergency response plans. In a recent NACCHO survey, 84%
of the responding local health officials reported that their
jurisdictions had community disaster plans that defined the roles of
local public health entities in disasters, but only 24% of the local
health officials surveyed reported that their jurisdiction's disaster
plan addressed bioterrorist events.(10)
NEW COLLABORATIONS
The development of Metropolitan Medical Response Systems across the
country with federal support has brought diverse stakeholders together
to develop local response plans and practice these plans using field
exercises and 'table-top' simulations. These stakeholders include police
and other law enforcement authorities, fire departments, poison control
centers, local National Guard units, and local and state public health
officials. Clearly, the missions and priorities of civilian and military
public health agencies differ substantially.(3) The idea of working with
the National Guard, the Department of Defense, and other military groups
may seem foreign to many public health practitioners, but these groups
can provide important resources for the front line response to a
bioterrorist event or other natural disaster. These resources include
decontamination equipment, stockpiles of pharmaceuticals and medical
devices, expertise in crowd control, and back-up medical personnel.
In the case of a bioterrorist attack--or even a hoax--the Federal
Bureau of Investigation will take immediate control of the situation and
coordinate the local response. It is important to emphasize that local
public health agencies are not seeking to duplicate the crisis
management function of the FBI or
the post-incident management function of the Federal Emergency
Management Agency, which would include treatment of infected individuals
and provision of shelter and other services for the affected population.
Instead, local public health agencies want to contribute to a
coordinated and effective local response that will benefit and protect
the health of their communities during and after the event. Therefore,
local public health officials need to coordinate with the FBI and other
law enforcement agencies in advance to understand the responsibilities
of various partners. At the federal level, NACCHO has a role to play in
making the needs and contributions of local public health known to the
FBI and other emergency management agencies, and in developing clear
lines of communication.
LOCAL PUBLIC HEALTH AGENCY NEEDS
NACCHO's survey of local public health agencies' preparedness
Capacity(10) makes clear that disaster preparedness activities at the
city and county level vary tremendously nationwide. Several local public
health departments, typically those in large urban centers such as New
York City or Kansas City, have well-developed response plans that serve
as modes for communities across the country(10) These plans have taken
an 'all-hazards' ('dual-use') approach, meaning that the plan can be
used for responding to either bioterrorism attacks or other public
health emergencies. Working with
CDC, NACCHO is tracking the progress of three Centers for Public Health
Preparedness (DeKalb County Board of Health, Georgia; Denver Health,
Colorado; Rochester-Monroe County Health Department, New York) that were
funded to develop their bioterrorism and emergency response
infrastructure and share the lessons learned in their preparedness
planning with other local public health agencies.
The majority of county and city public health agencies have not
devoted resources to developing bioterrorism preparedness plans. Many
local public health agencies are looking for guidance and sample
documents such as bioterrorism response plans or state emergency
management policies that could be customized for their use. Other
jurisdictions are looking for equipment standards and evaluations of new
technologies before spending limited resources on items such as radios,
cellular telephones, surveillance software, or decontamination devices.
A number of local agencies-have asked for a centralized listing or
'clearinghouse' of federal, state and local resources for information on
bioterrorism and emergency response preparedness. Others are looking to
their peers and national associations for guidance and support in
efforts to improve working relationships with health care facilities,
state health departments, and voluntary associations such as the Red
Cross. An important objective of NACCHO's bioterrorism program is to
help local public health officials
share their successes and failures by fostering peer exchange networks
among practitioners across the country.
The need for further education of the public health workforce about
bioterrorism is a major concern among local public health officials
nationwide. Only 5% of local public health agency directors that were
surveyed as a part of a NACCHO bioterrorism needs assessment(10)
reported that all appropriate members of their staff had received
comprehensive bioterrorism training. The survey also found a need for
detection and decontamination equipment as well as a need for funding to
build the surveillance and communications capacity to respond
appropriately in an emergency.
Local public health agencies serve on the frontlines in responding to
as well as to other public health crises of all sorts. Everyday
outbreaks of diseases such as measles, hepatitis, or tuberculosis
require local public health agencies to build their capacity to respond
quickly to reduce injury and prevent future outbreaks. Building this
capacity will require sustained planning and resources and close
collaboration among local, state, and federal public health officials.
NACCHO will continue its efforts to build local response capacity and to
maximize limited public health resources to benefit and improve the
health of communities nationwide.
