federal-state working relationships to achieve national preparedness the cdc perspective

Department of Health and Human Services

Centers for Disease Control and Prevention

Agency for Toxic Substances and Disease Registry

Federal-State Working Relationships to Achieve National Preparedness

The CDC Perspective

National Governors Association Center for Best PracticesRegional Policy Workshop on Bioterrorism

New Orleans, March 15, 2004

Centers for Disease Control and Prevention (CDC)Agency for Toxic Substances and Disease Registry (ATSDR)

2 People Protected – Public Health Prepared.

Outline

CDC’s Strategy Best PracticesWorkforceFunding



CDC’s Strategy



All-Hazards Approach

Science

Ser

vice

Sys

tem

s

Biological

ChemicalNuclear

Radiological

Trauma/Nat’l.Disasters

OUR VISIONOUR VISIONPeople Protected – Public People Protected – Public

Health Prepared.Health Prepared.

OUR GOALOUR GOALTo combine our strengths in To combine our strengths in

times of crisis to reduce times of crisis to reduce suffering and death.suffering and death.

Strategy



Dimensions of Public Health Readiness

Nu

mb

er o

f C

ases

1

1,000s – 100,000s

Level of E

ffort

Assess – Diagnose – Isolate – Treat – Manage

Report – Mobilize Response – Investigate – Prophylaxis

Communicate to stakeholders and public – enhance surveillance & reporting

Deliver mass intervention – call up reserve workforce

Manage high volume of data and information

Activate community-wide mass care system – manage the dead

Command and control – vital to assure containment

Time

Reso

urces

Local

Global

PREPARE DETECT REPORT RESPOND CONTAIN RECOVER

Strategy



Strategy

PreparednessDetection & Reporting RecoveryResponse &

Containment

Planning

Exercising

Partnering

Training

System Building

Testing

Surveillance

Clinician Training

Laboratory Diagnostics

Electronic reporting systems

Communicating

Clinicians

Public Health

General Public

Responders

Intervention

Therapies

Education

Quarantine

Contact tracking

Coordination

Monitoring community mental health

Apply Lessons learned – continuous response improvement

Workforce Activities



Early detection/warning is critical to allow for early intervention.

The sooner we know the sooner we can intervene!

Key Services & Efforts – Detection

Strategy




Hospitals

DoD& VA

Vital Records

Environmental(BioWatch)

PharmacyData

Veterinary

Laboratory

Cargo/Imports

Immigration

International

Schools

Employers

Law Enforcement

ACTION POINTIntersection of Information &

Analysis

Media

Clinicians

Public

First Responders

Quarantine Stations

Border States

Current State

Strategy



Hospitals

DoD& VA

Vital Records

Environmental(BioWatch) Pharmacy

Data

Veterinary

Laboratory

Cargo/Imports

Immigration

International

SchoolsEmployers

Law Enforcement

Media

Clinicians

Public

First Responders

Quarantine Stations

Border States

ACTION POINTIntersection of Information &

Analysis

Key Services & Efforts – DetectionDesired State

Strategy



Key Services & Efforts – Detection Improving Laboratory Diagnosis and Detection Capabilities

– Smallpox – Tularemia– Anthrax – Radiation - Plague– Botulinum Toxin – Chemicals in blood and urine

Improving Connectivity for Diagnosis and Detection– 24x7 Clinical Information Hotline – Media and public outreach– Clinician outreach and communication – Blended-media educational programs– Epi-X (2-way communication network) – Other critical channels and audiences– Health alerting – MMWR Dispatch

CDC Laboratories– Biological: Antimicrobial resistance assays; Continuity of Operations Plan (COOP);

Throughout Capacity, BSL-4 containment lab, scientific depth– Chemical: Rapid Toxic Screen (150 agents); Blood and Urine Samples; State Labs

Quarantine Stations– New York – Chicago – Miami –

Atlanta– Los Angeles – San Francisco – Seattle – Honolulu

Strategy



Laboratory Response Network (LRN)


Strategy



Strategic National Stockpile (SNS)

Repository of antibiotics, chemical antidotes, antitoxins, life-support medications, IV administration, etc., etc.

Twelve, strategically located, 12-hour push packages

Tailored Vendor Management Inventory (VMI)

VMI deployable within 24 to 36 hours

Technical Advisory and Response Unit (TARU) support

Key Services & Efforts – Containment

Strategy



Key Services & Efforts – Containment Environmental Microbiology

– Water safety research– Detection and survival of select bacterial agents research– Research on remediation of environments and facilities– Exotic bacterial data collection with respect to the environment– Development of lab sampling methods and processes– Studies on the effect of common disinfectants on these agents

Smallpox Readiness– Vaccination of the medical frontline (healthcare, public health, etc.)– Pending licensed vaccine (for those who insist)– Early detection capacity– Rapid control and containment plans– Vaccination of population within 10 days

Strategy

State and Local Efforts– Local, State, and Regional Response Plans– Field services support– SNS Capacity– Drive toward standards-based, federally delivered exercises (Level I to IV)



Upgrading State and Local Capacity

31 Centers for Public Health Preparedness assisting state and local public health emergency preparedness by improving the quantity and quality of the public health and healthcare response workforce.

Increasing the number of state and local public health professionals (1,886) who use Epi-X to share intelligence regarding outbreaks and other emerging health events including those suggestive of bioterrorism.

Cooperative Agreement for 62 state, major city and territory health departments expands epidemiology and surveillance capacity to detect, investigate, and mitigate health threats.

Rapid assessment of surveillance capacities in 8 priority cities.

Forensic Epidemiology training sessions for public health and law enforcement professionals.

Strategy



Key Services & Efforts – Containment

State and Local Cooperative Agreement Program

90% of states have response plans for anthrax(78% exercised)

100% for smallpox (86% exercised)

90% for plague (76% exercised)

85% for botulinum toxin (46% exercised)

92% for RDD/Nuclear events (91% exercised)

75% for Nerve Agents (70% exercised)

25/50 completed their state-wide response plans

50/50 completed their interim SNS plans – work needed!

Strategy



Strategy

Strategic Imperatives and Preparedness Workforce ObjectivesTimely, effective and integrated detection and investigation

Objective 1.2: Increase the number, skills and distribution of investigation professionals

Sustained prevention and consequence management programsObjective 2.3: Provide scientific and technical support for

recovery programs associated with physical, psychological and environmental public health needs.

Coordinated Public Health Emergency Preparedness and Response Objective 3.3: Provide technical assistance and resources to

public health agencies to assure all jurisdictions have a ready emergency response system

Competent and sustainable workforceObjective 5.1: Increase the number and type of professionals that

comprise a preparedness and response workforceObjective 5.2: Deliver certification- and competency-based

training and educationCreative and effective management services

Objective 11.3: Promote leadership and management development across terrorism preparedness and response programs



Best Practices



Site visits by senior CDC management to:

Florida

New Hampshire

New York State

Texas

Washington State

Best Practices



Florida

Developed critical institutional partnerships that will enable long-term readiness that is not dependent on current leaders

Investment in electronic disease mgmt system that will link disease detection-laboratory diagnosis-outbreak investigation-analysis.

Trained 500 lab staff in procedures for handling/transfer of critical agents

Conducted 4 exercises in collaboration with FBI , HAZMAT, state/local law enforcement and fire/rescue

Emphasis on strong corrective action process following exercises

Vaccinated 4,000 persons who will implement mass smallpox vaccination, investigate cases and manage patients.

Best Practices



New Hampshire

Partnerships with hospitals, academic institutions and community stakeholders

All hospitals (26) have submitted emergency response plans

Monitoring OTC medicine purchases enhances detection system

Robust alerting system includes 96% of key response stake holders (hospitals, commercial labs, infection control practitioners, EMS staff, Dept of Education)

Best Practices



New York State

Contracts with local health depts have clear deliverables that cover all aspects of preparedness and response:

— Protocols for isolation and quarantine

— Packaging/transport of lab samples

— Processes for rapid diagnoses and agent confirmation

— Plans to ensure rapid control and containment

— Training of staff and reserve staff as events scale up

— Plan linkage with state and regional plans

Partnerships with State Medical Society, Nurses Assoc, Healthcare Association, Community Health Center Assoc, Hospital Assoc, etc.

Developed sophisticated electronic communicable disease reporting and laboratory information systems

Can test for critical agents: Variola major, vaccinia, tularemia, bot toxin, ricin toxin, brucellosis, glanders, Q fever

Best Practices



Texas

Partnerships include 12 Metropolitan Medical Response Systems, 22 councils of Governments, US-Mexico Border Health Commissions, FBI and state/local law enforcement

3-member epidemiologic response teams assigned in each of the 8 regions

Relationships with 138 labs

Trained 60 Texas Medical Rangers – a reserve corps of the Texas State Guard – through the Center for Public Health Preparedness and Biomedical Research at UT-HSC in San Antonio. Plan to train a total of 1000

Conducted exercises to test ability to receive and distribute the SNS

Pre-event smallpox preparedness program vaccinated 2,400 hospital and public health staff

Best Practices



Washington

Assessed all local health jurisdictions and hospitals to determine emergency preparedness and response capacity

Expanded public health workforce at the district level

— A new emergency response planners in each of the 9 districts

— 9 new learning specialists to coordinate and evaluate preparedness training

— 17 new epidemiology response and surveillance coordinators

Critical preparedness capacities are included in the comprehensive public health improvement planning process – result is performance-based and outcome-driven planning

Best Practices



Workforce



Public Health Readiness Field Program (PHRFP):

1. Rapidly enhance preparedness of state, local and territorial public health agencies

2. Improve CDC’s ability to respond to terrorism and other urgent health threats

3. Address the long-range need for public health leaders at federal, state and local levels

Workforce



Workforce

Background State and Local authorities concern over their ability to recruit, hire,

train, and retain qualified personnel

Assignment of CDC staff has been a successful model for CDC to assist state and local agencies with program planning and implementation

FY 03 appropriation : “. . . employees of CDC . . . assigned or detailed to States, municipalities or other organizations under the authority of Section 214 of the Public Health Service Act for the purposes related to the homeland security, . . . shall not be included within any personnel ceiling applicable to the Agency . . . during the period of detail or assignment.”

OTPER Field Services Office formed November 1, 2003



Workforce

Background: Existing CDC Field Programs

Career Epidemiology Field Officer (EPO)

NCHSTP (STD, HIV, TB)

Immunization (NIP)

Quarantine Officers (NCID)

BioWatch Laboratorians

Chronic Disease Prevention (NCCDPHP)



Workforce

PHRFP Overview Multidisciplinary and multi-level

Strong training component

Leverage and coordinate readiness activities of other CDC field programs

Assignments within State/Territorial and Local public health agencies

Field Services support by OTPER as necessary



Workforce

PHRFP Basic Principles:

Emphasis on Staff DevelopmentMore than a staffing service for state and local agencies -- a long term professional development program

Expand and enhance

Do not supplant the current federal, state and local public health workforce

Linkage with the BT Cooperative AgreementDuties of CDC field staff paid with BT Cooperative Agreement funds must be within the scope of the BT Cooperative Agreement

Customer FocusAssignments funded by the BT Cooperative Agreement will be in response to a request by a grantee and reflected as a DA award on the Notice of Cooperative Agreement to the grantee



Workforce

PHRFP Training Program:

Rigorous Basic Training “Boot Camp”

Follow-on courses for specified for several career tracks

Competency-based

Utilize/Adapt existing training

Certification and CEUs

Available to State/Local staff also



Workforce

We hope the PHRFP will: Meet state and local public health preparedness needs

Foster the “dual use” concept

Mitigate the silo-effect of categorical programs at federal, state, and local levels

Provide Support and enhance the good work the categorical programs do

Emphasize BT while also support an all-hazards approach Make a dent in long range public health work force needs



FUNDING



Security Improvement

0.14%

Upgrading State & Local

84.10%

Anti-Infectious Agents0.18%

Upgrading CDC13.97%

Anthrax1.61%

* The appropriation amount of $1.16 billion does not include the rescission and indirect costs.

FY04 Appropriation by Budget Line ($1.16 Billion) (compared with $1.54 Billion in FY03)

Funding



FY04 Funding: Upgrading State and Local Capacity

Bioterrorism Cooperative Agreement $872 Million

Centers for Public Health Preparedness $29.4 Million

Advanced Practice Centers $ 5.5 Million

Technical Assistance and Oversight $17.9 Million Epidemic Intelligence Exchange (Epi-X) - $1.8 Million Cooperative Agreement Technical Assistance – $13.8 Million Public Health Field Readiness Program – $2.2 Million

Health Alerting $ 9.4 Million

Total: $ 934.4 Million

Funding



CDC Goals for 2004

Full Development of the Performance Indicators that focus on:

Rapid detection and reporting to allow for early intervention

State and regional plans that are scenario-specific (CBRN) that are developed to take into account a variety of scalable events (100 - >1,000 casualties) that will challenge/stress the response system

Public health workforce (improve the quality and quantity)

Implement the Public Health Readiness Field Program

Partnering with the Centers for Public Health Preparedness

Stronger ties with HRSA and DHS (HSPD 8)

Funding



Funding Concerns

$80 unobligated reported on FSRs (11/1/03)

Draw-down lag

Supplanting

Allocation formula – change?

Funding

federal-state working relationships to achieve national preparedness the cdc perspective

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