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Contents of Letter Report
Pages 1-32

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From page 1...
... This report may seem like a departure from the committee's previous work, which focused on smallpox vaccination as a part of public health preparedness. However, this report responds to a CDC request for guidance as the agency moves toward comprehensive preparedness for bioterrorism and other public health disasters, and toward broad smallpox preparedness efforts.
From page 2...
... examine conceptual issues and challenges related to integrating public health into disaster preparedness and response; (2) review some of the evidence base from disaster research and practice that is germane to public health preparedness; (3)
From page 3...
... In order to strengthen the evidence base for public health preparedness, CDC should: Strengthen the link between public health research and practice; Participate in and promote interdisciplinary research about preparedness; Support a system to assure the ongoing collection, synthesis, and sharing of lessons learned and best practices from public health preparedness exercises and public health response to proxy events; and In coordination with the appropriate federal-level partners, such as the Agency for Healthcare Research and Quality, evaluate the effectiveness, design, and opportunity costs of preparedness strategies, such as exercises. Recommendation 3: The committee recommends that CDC should use the Evidence-Based Performance Goals for Public Health Disaster Preparedness to develop standards against which CDC, states, and localities may regularly measure their performance in exercises and in response to proxy events.
From page 4...
... The re-emergence of infectious diseases in part related to demographic change and globalization has elevated interest in public health's role as both a responder to and a preventer of epidemics and infectious disease outbreaks. Public health agencies have the ongoing responsibility to prevent disease outbreaks and other emergencies through measures such as immunization, sanitation, and community education.
From page 5...
... . In addition to the public health impacts of most other types of disasters, attacks with biological agents, as exemplified by the anthrax attacks of 2001, require that governmental public health agencies serve as primary responders.
From page 6...
... For public health agencies, responding to major crises has been the exception from their usual work, therefore, conducting regular drills and training to prepare for disaster response has generally not been a common practice. Also, even when public health agencies have gained experience dealing with disease outbreaks, these events do not typically reach the scale of a disaster, and response is largely limited to the public health and health care communities.
From page 7...
... . Given the large number of federal, state, and local agencies involved in preparedness efforts, establishing adequate coordination across federal, state, and local levels is proving to be a challenge (Clements and Evans, 2004; Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction, 2003; GAO, 2003a)
From page 8...
... 2004 Homeland Security Grant Program and FY 2004 Urban Area Security Initiative Grant Program, states and some local emergency management offices receive funding to conduct exercises that test many of the same capacities and interagency collaborations expected by HRSA and CDC (DHS, 2003)
From page 9...
... Since state emergency management offices will be following the HSEEP guidelines, and some state public health agencies may be participating in exercises that follow these guidelines, a certain level of coordination is necessary between CDC's public health preparedness exercise guidelines and the HSEEP guidelines. In order to maximize the knowledge, skills, and relationship-building that states and local jurisdictions gain from participating in preparedness exercises supported by limited federal resources, the committee encourages CDC to work closely with ODP (as well as HRSA)
From page 10...
... The committee was unable to find a comprehensive resource describing all of the funding streams available for emergency preparedness activities, their purpose, funding amounts, and intended recipients. Such a tool would aid coordination of funding at the state and local level, and would also facilitate coordination of all-hazards preparedness activities among national, state, and local partners in the academic, non-profit, and business sectors.
From page 11...
... Common Definitions and Terminology Are Needed The emergency and disaster management field and federal agencies associated with it have developed a great deal of experience planning for disaster response and designing and conducting exercises to promote relationship-building and training (Landesman, 2001; GAO, 2001; FEMA, 2003; Kuhr and Hauer, 2001)
From page 12...
... To the extent that it is not involved already, the committee encourages CDC to work with the Department of Homeland Security to ensure that the commonly used public health preparedness terms and the relevant CDC documents are incorporated into the Lexicon Project, and that knowledge of this effort is shared broadly across CDC and HHS. In the preceding pages, the committee has outlined challenges and opportunities inherent in integrating public health into a broader field.
From page 13...
... Federal coordination efforts should also include the clarification of primary responsibility and authority in bioterrorism events, to ensure that CDC can fulfill its unique role as the nation's public health agency. THE EVIDENCE BASE FROM DISASTER RESEARCH AND PRACTICE Nature of the Evidence Although quantitative evidence (with randomized controlled trials as the gold standard)
From page 14...
... · Studies of the preparedness activities of local emergency management agencies show that they are diverse in structure and operate in ways that make them well adapted to local conditions (Quarantelli, 1994)
From page 15...
... . An emergency response plan does little good if the participants in the plan have not developed a relationship with their partners, have not practiced the plan, or have not updated the plan as circumstances have changed (Perry, 2003; Auf der Heide, 1989)
From page 16...
... . · The emergency management field has frequently grappled with the question of whether to ensure generic or specific preparedness capabilities and processes (NRC, 2003)
From page 17...
... Given the importance of disseminating knowledge, and the currently limited avenues that exist to facilitate such sharing, CDC and its state and local public health partners may wish to consider the DHS mechanism for sharing lessons learned and develop a similar and connected mechanism to support public health preparedness goals. Such a database may involve, but not limited to the following activities: developing and gathering after action reports based on public health preparedness exercises and responses to actual events that tested the capacity of the 17
From page 18...
... However, public health has its own rich knowledge base, which includes lessons from recent public health emergencies such as food-borne disease outbreaks, emerging infectious diseases, and the anthrax attack of 2001. Unfortunately, there is no systematic, comprehensive agenda for public health preparedness research to provide a structure for public health emergency preparedness and response research.
From page 19...
... In significant proxy events, public health agencies should constantly ask themselves: what if the lead in drinking water, the monkeypox cases traced back to exotic pets, the appearance of SARS, or the occurrence of hepatitis A virus in restaurant food were the result of deliberate, illintentioned introduction? What if the number of cases of an unusual new disease was not a handful, but a few thousand?
From page 20...
... CDC is the lead public health agency not only as a standard-setter and funder, but also as an important part of public health practice and of public health response to emergencies and disasters. Proxy events test CDC's resources and ability to respond to crises rapidly, expertly, and in coordination with state and local agencies.
From page 21...
... In order to strengthen the evidence base for public health preparedness, CDC should: Strengthen the link between public health research and practice; Participate in and promote interdisciplinary research about preparedness; Support a system to assure the ongoing collection, synthesis, and sharing of lessons learned and best practices from public health preparedness exercises and public health response to proxy events; and In coordination with the appropriate federal-level partners, such as AHRQ, evaluate the effectiveness, design, and opportunity costs of preparedness strategies, such as exercises. USEFULNESS OF MODELING Role of Modeling in Policy Decisions For public health preparedness, models can be useful tools to assist in decisionmaking, focusing preparedness efforts, and analyzing different response options.
From page 22...
... . These models used slightly different assumptions for most of the key input parameters, resulting in different conclusions.
From page 23...
... To overcome some of the reasons for differing conclusions of previous models (Ferguson et al., 2003) , the Smallpox Modeling Working Group decided that a standardized set of biologically realistic input parameters for smallpox natural history and transmission needed to be agreed upon (Borio, 2004)
From page 24...
... In fact, the DHS HSEEP materials assert that exercises "provide a risk-free environment for jurisdictions to assess if they have the plans, policies, procedures, resources, and agreements in place to enable homeland security personnel to perform critical tasks required to prevent, respond to, or recover from a terrorist attack" (DHS/ODP, 2003:iii)
From page 25...
... shows that hospitals and public health agencies conduct exercises and find them useful in evaluating 25
From page 26...
... . The committee hopes that the experience of public health agencies with exercises and drills will not only be reported to CDC, but that there will be increased emphasis on more in-depth studies of the effectiveness of public health preparedness exercises, and more frequent publication of such studies in the literature.
From page 27...
... Program, Community Hazards Emergency Response Capability Assurance Program (CHER-CAP) , and the Chemical Stockpile Emergency Preparedness Program (CSEPP)
From page 28...
... . Sample Questions, Strategies, and Methodologies for Evaluation Research on Public Health Preparedness Exercises and Proxy Events The committee has identified several possible questions, strategies, and methodologies that could be considered by CDC in evaluation and experimental research in public health preparedness.
From page 29...
... For example, it may be instructive to compare the engagement of public health in emergency and disaster response in states where EMS is part of public health to states where the two agencies are separate. · Systematically assess the lessons learned by state and local public health agencies (perhaps organized by type according to characteristics such as size, urban or rural location, structure and governance)
From page 30...
... For example, in the area of exercises, some exercises may be external, conducted in coordination with other agencies at the federal, state, and local level (refer to the section on Coordination Issues) , while others will be strictly internal exercises on such issues as how to move from normal to emergency operations, including decisions about closing or curtailing planned clinics, outreach, or investigation; decisions about and use of personal protective equipment under various circumstances; establishment of databases for unexpected investigations or unusual outbreaks.
From page 31...
... The committee recommends that CDC should use the Evidence-Based Performance Goals for Public Health Disaster Preparedness to develop standards against which CDC, states, and localities may regularly measure their performance in exercises and in response to proxy events. Public health agency performance in exercises and proxy events should be used to identify gaps in preparedness and to improve planning, communication, and coordination at the agency and interagency levels, as part of a process of continuous quality improvement in preparedness planning and response.
From page 32...
... Wallace, Committee Vice Chair Committee on Smallpox Vaccination Program Implementation 32


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