The Smallpox Vaccination Program Public Health in an Age of Terrorism (2005) / Chapter Skim
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Appendix G: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #6
Appendix G: Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation Letter Report #6
Pages 285-328
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Committee on Smallpox Vaccination Program Implementation is pleased to offer you the sixth in a series of brief reports. 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.
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review of what public health may learn from disaster research and from the practice of disaster response. INTRODUCTION Charge to the Committee One way to measure public health agencies' performance in achieving preparedness is by performing and evaluating exercises.2 Whereas exercises have been conducted and evaluated in the emergency management field for many years, public health has had less experience with exercises and is currently beginning to assess their value for relationship building, training, and performance measurement.
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Federal coordination efforts should also include the clarifica tion of primary responsibility and authority in bioterrorism events, to ensure that CDC can fulfill its unique role as the nation's public health agency. Recommendation 2: The committee recommends that CDC should collaborate with all of its partners to strengthen preparedness by applying research findings and experience in public health emergency response, bioterrorism pre paredness, and disaster management.
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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. Preparedness drills and exercises should not be evaluated individually, but their cumulative and long-term impact on preparedness, such as generalizability to other potential hazards, must be considered in the evaluation process INTEGRATING PUBLIC HEALTH INTO DISASTER PREPAREDNESS AND RESPONSE: CONCEPTUAL ISSUES The public health community has become an active partner in the world of emergency and disaster preparedness and response, joining other members in the traditional emergency management and response field who have defined roles and established ways of doing work (Landesman et al., 2001)
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Unique Role of Public Health in Disasters, and Primary Role in Response to Bioterrorism Public health generally does not have a formal tradition of disaster preparedness and response. However, notable and instructive exceptions are found in the experience of the following types of public health agencies, some of which have developed varying levels of expertise in planning and exercising for disasters and in managing disasters (e.g., the experience of the state of Georgia described by Werner et al., 1998)
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. In addition to the public health effects of most other types of disasters, attacks with biologic agents, as exemplified by the anthrax attacks of 2001, require that governmental public health agencies serve as primary responders.
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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.
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The category of first responders has typically included personnel from the firefighting, EMS, and law enforcement fields, along with state emergency management agencies and federal agencies (e.g., Federal Emergency Management Agency, Environmental Protection Agency) , and nongovernmental organizations, such as the Red Cross and the Salvation Army.
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. 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 (Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction, 2003; GAO, 2003a; Clements and Evans, 2004)
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This is necessary because of the functional overlap between public health and other state agencies, and because some state public health agencies already plan and execute their bioterrorism preparedness exercises in conjunction with their state emergency management offices. While public health preparedness exercises are needed to assess the unique functions and goals of public health, they will ideally be coordinated with other types of exercises where appropriate.
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The range of partners in preparedness should be conceived broadly, to include local community, health care institutions, voluntary organizations, and others. The committee also heard that state grantees funded by the DHS ODP FY 2004 Homeland Security Grant Program are encouraged to share exercise calendars with other partners and to coordinate or integrate efforts with other state and local exercises (Schweitzer, 2004)
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Preparedness efforts must include discussion and clarification of roles and responsibilities in a way that meets the needs of both public health and law enforcement professionals and undermines neither the disease prevention
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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 (GAO, 2001; Kuhr and Hauer, 2001; Landesman, 2001; FEMA, 2003)
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Speaking the Same Language: the Lexicon Project The DHS has already recognized the need for a baseline understanding of the terms, acronyms, and phrases regularly used by different federal agencies that are involved in preparedness activities. For example, there are often very different understandings of the terms "first responder" and "surveillance." The Homeland Security Advisory Council has created a report for the secretary of Homeland Security on the Lexicon Project -- a project that would create a homeland security lexicon by identifying the terms, acronyms, and phrases (and their associated definitions)
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Such mechanisms may include, but are not limited to, regular meetings to familiarize CDC and ODP program staff with each other's program priorities and activities, a database for informing ODP and other partners of exercises planned by CDC grantees, etc. 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.
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· 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)
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. 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 (Auf der Heide, 1989; Perry, 2003)
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. Although its value has been questioned by some disaster researchers, and there is limited empirical evidence documenting its effectiveness, ICS has been widely embraced by the emergency management field and even in health care and other areas, and forms the foundation of the National Incident Management System adopted by DHS (Tierney, 1993; Quarantelli, 1995; Drabek and McEntire, 2002; NRC, 2003)
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. · Emergency response is sometimes based on myths that research has disproved, with consequences for the success and effectiveness of the response (Auf der Heide, 1989; Tierney et al., 2001)
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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 be 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 public health system; conducting a retrospective analysis of public health agencies' responses to infectious disease and other relevant events in the past 2-3 years; and increasing the emphasis on studying the responses to proxy events and the effect of exercises and publishing findings in the peerreviewed literature.
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Unfortunately, there is no systematic, comprehensive agenda for public health preparedness research to provide a structure for public health emergency preparedness and response research. Such an agenda would be a part of the broader public health research agenda that has recently begun to take shape, but it still requires infrastructure and funding (Council on Linkages between Academia and Public Health Practice, 2004)
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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, ill-intentioned introduction? What if the number of cases of an unusual new disease was not a handful, but a few thousand?
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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.
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As CDC's Evidence-Based Performance Goals for Public Health Disaster Preparedness, currently under development, are disseminated and implemented, it is important that CDC and its state and local partners take steps to link these with a system for capturing lessons learned from the response to proxy events. The committee has described some of the knowledge available from the practice of disaster response and from disaster research and the need to strengthen public health preparedness research.
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Once it is determined how sensitive the outcome is to the different input parameters, preparedness efforts can be focused on the factor that is estimated to have the greatest effect on the outcome. This also will help policymakers determine the factors for which indicators should be developed.
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. Other models have examined an individual's risk-benefit profile for pre-or postexposure smallpox vaccination (Meltzer, 2003)
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Of the three models created under the aegis of the Smallpox Modeling Working Group, one is a deterministic model, since it uses single point estimates for each of the input parameters, whereas the other two are stochastic models, using probability estimates for the different input parameters (Borio, 2004)
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, exercising reveals flaws in planning, clarifies roles, improves individual performance, and tests and evaluates plans, policies, and procedures. Moreover, exercises have become an institutionalized strategy for planning in homeland security.
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shows that hospitals and public health agencies conduct exercises and find them useful in evaluating the quality of training, the smoothness of emergency operations, and other aspects of disaster response, but there seems to be little or no empirical study of the validity or effectiveness of exercises themselves as a strategy for public health and health care preparedness. The Agency for Healthcare Research and Quality (AHRQ)
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. This graphic outlines an incremental set of techniques or methods for preparedness planning and training, from the minimal complexity of a seminar to the significant complexity of functional or full-scale approaches.
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Together, ODP and FEMA are responsible for HSEEP, Radiological Emergency Preparedness (REP) Program, Community Hazards Emergency Response Capability Assurance Program (CHER-CAP)
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. 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.
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The committee also suggests several areas for further study: · A systematic assessment of all lessons learned in the course of the smallpox vaccination program (which could be considered a national-level, multisite, months-long preparedness meta-exercise) ; · Determine what knowledge is available about public health preparedness and about conducting exercises (and drills)
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In the case of public health preparedness for bioterrorism and other events with significant public health impact, outcomes are occasioned by actual events themselves, and the infrequency and huge variation among these events (including the proxy events discussed in preceding pages of this report) make it difficult or nearly impossible to gauge, for example, a decrease in rate of disease from contaminated water or other reductions in mortality and morbidity attributable to the disaster.
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Ensuring Compatibility Between the DHS Exercise Doctrine and Public Health Preparedness Exercises The DHS HSEEP describes a yearly cycle of planning and development, followed by training, exercises, and the development and implementation of an improvement plan. The committee has learned that CDC intends to implement a similar cyclical process (target goals exercise target goals, etc.)
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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 inter-agency levels, as part of a process of continuous quality improvement in preparedness planning and response.
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Gebbie, Committee Vice Chair Robert B Wallace, Committee Vice Chair Committee on Smallpox Vaccination Program Implementation REFERENCES Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction.
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Presented at the Meeting of the IOM Committee on Smallpox Vaccination Program Implementation on March 29, 2004. Drabek T, McEntire D
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2003a. Review of the Centers for Disease Control and Prevention's Smallpox Vaccination Program Implementation: Letter Report #5.
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2004. Transcript from the IOM's Committee on Smallpox Vaccination Pro gram Implementation Meeting Five on March 29, 2004, Washington, DC.
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2004. Transcript from the IOM's Committee on Smallpox Vaccination Program Implementation Meeting Five on March 29, 2004, Washington, DC.
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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 mea sure 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.
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REP Radiological Emergency Preparedness Program WMD Weapons of Mass Destruction Glossary All-hazards: generally contrasted with "agent-specific," refers to a broad preparedness and response approach to all possible hazards to population health and safety, whether the complete range of known disasters, or specifically the complete range of public health disasters (from naturally occurring to deliberately introduced)
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Emergency responder/first responder/traditional emergency responder: term refers to a set of disciplines and responsibilities, including, but not limited to Emergency Medical Services (EMS) , fire, law enforcement, hazardous materials specialists, etc.
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