Seeing National Preparedness Through the Public Health Lens

As is required by the Presidential Policy Directive 8 – better known as the 2011 “National Preparedness” Directive – the Federal Emergency Management Agency (FEMA) is required to develop and release an annual National Preparedness Report (NPR). That report summarizes the areas not only where the nation has made significant progress but also where there are still major challenges that must be faced – particularly with regard to the various elements of preparedness outlined in the 31 core capabilities postulated in the National Preparedness Goal.

The first NPR, issued in 2012, showed that there has been significant progress in the preparedness and response capabilities that the United States has focused on since the 9/11 terrorist attacks. The 2013 NPR, released in May, focuses primarily on the preparedness and response accomplishments either achieved or reported during 2012. It also: (a) reviews the nation’s overall progress in strengthening national preparedness; and (b)entifies several areas where preparedness gaps remain.

The overall state of public health and its various preparedness components were discussed at length in the 2012 NPR. Among the specific initiatives and areas highlighted were the nation’s biosurveillance capabilities, the progress achieved in surge planning, the federal coordination of medical countermeasure efforts, and – last but certainly not least – current and future funding realities. The 2013 NPR touches on many of the same areas of public health preparedness, and highlights both the additional progress made and the numerous challenges remaining.

Successes: Closer Coordination, Biowatch & Fatality Management 

The “Overarching Findings” section of the 2013 NPR spells out one of the more interesting findings specific to public health: “Whole community partners continue to use preparedness assistance programs to maintain capability strengths and addressentified gaps, while key federal sponsors areentifying strategies to improve program effectiveness and efficiency.” The same section outlines the improved collaborative effort between grantors – specifically, the Office of the Assistant Secretary of Preparedness and Response within the U.S. Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) – to better define essential public health and healthcare preparedness capabilities.

That effort led to Hospital Preparedness Program applicants and Public Health Emergency Preparedness applicants having the ability, since May 2012, to submit a single application for both cooperative agreements at the same time. This improved program alignment not only fosters closer coordination among public health and healthcare system partners at all levels of government but also improves efficiency in grant administration.

Among the other key findings specific to public health in the report are the following:

• The national biosurveillance system, also known as Biowatch, is a system designed toentify releases of aerosolized biological threat agents – specifically including anthrax, tularemia, and other pathogens. The Biowatch system, already in place in more than 30 large metropolitan areas, relies heavily on collaboration between federal, state, and local partners. One of the most important successes of the program, as noted in the 2013 NPR, is the 15-hour operational response time achieved to answer biosurveillance queries – less than one-third of the performance target of 48 hours. That remarkable achievement translates directly into a more rapid notification of the possibility of a biological release – and, therefore, significantly more time to respond.
• The 2012 NPR noted that the overall number of states with state-level fatality management plans had increased from 64 percent to 96 percent. However, some of those plans were not yet adequate or fully actionable, so there was still a potential reliance on the use of federal assets to cope with certain incidents. The 2013 NPR shows that additional progress in this area was made in 2012, specifically including the fact that HHS had finalized its own fatality management concept of operations (which involves, among other things, the management of mass fatalities in disasters that result in fewer than 5,000 fatalities). HHS took another step forward by hiring its first national program coordinator for fatality management. These accomplishments, combined with the inclusion of fatality management in the CDC’s own public health preparedness capabilities, focus additional and much needed attention on fatality management.
• One of the operationally based successes described in the 2013 NPR outlines the public health response elements specific to Hurricane Sandy, including the speed at which assets were moved to the affected areas. Traditionally, HHS has postulated a 24- to 48-hour time frame for deploying National Disaster Medical System (NDMS) resources – personnel and equipment, primarily – following a major incident. However, in the case of Sandy, the report stated that two NDMS Disaster Medical Assistant Teams arrived onsite in New York within four hours, well ahead of the time frame usually projected.

Nursing Home Challenges 

The report is not all positive, though – and also highlights certain areas that require improvement or could prove to be an issue in the future. One such area involves the emergency readiness of nursing homes, and is described as follows: “While a large majority of nursing homes met federal emergency planning and preparedness requirements in 2011, experiences during recent disasters indicate that many nursing homes may not be as prepared as these figures suggest.”

In the past, nursing homes have not been as much of a focus as they have been during recent events. Some unique challenges that nursing homes face in developing realistic and actionable emergency plans include the ability to: carry out facility evacuations, establish pre-incident communications with other emergency partners, and complete pre-established transportation contracts for residents. There have been some incidents in which it was difficult to track residents who had been evacuated to other nursing facilities. Following Sandy, various nursing homes reported experiencing some of the aforementioned issues as well as other concerns related to family notifications and ensuring the availability of adequate food and medical supplies.

Funding Realities & Future Problems 

There is an important cautionary tale in the report as well – one that is specific to the reality of how reductions in public health funding and personnel could affect the progress already achieved. Here it is important to remember that most state and local public health agencies pay for their public health preparedness efforts primarily with federal funds. As such, cuts to these funding streams, combined with the job actions that may result from furloughs or layoffs, could substantially impact the progress that will be reported in the 2014 NPR.

Several major organizations – for example, the Association of State and Territorial Health Officials, the National Association of City and County Health Officials, and the Trust for America’s Health – have repeatedly made it clear that the job cuts that state and local public health agencies already have experienced will have an adverse impact on the nation’s overall public health preparedness realities. This impact will no doubt lead to some difficult consequences in future real-life incidents where public health plays a critical role in disease surveillance and detection, the mass prophylaxis of populations with anti-virals, pandemic response, and other areas.

Nonetheless, public health agencies across the United States still stand at the ready to play a significant role in preparedness and response to all types of emergencies. Daily threats, whether a naturally occurring event – for example, H7N9 and the still evolving Middle East Respiratory Syndrome – and/or manmade incidents, continue to make headlines and highlight the need for a robust, well-prepared, and highly capable public health work force.

The latest NPR shows that, although local and state health departments are now better prepared for emergencies than ever before in the nation’s history, there is now an ever-present concern that the funding cutbacks seen in the various public health preparedness grants will adversely impact the agencies that sit at the tip of the spear in protecting the American people during future public health emergencies.