Federal-State Working Relationships to Achieve National Preparedness The CDC Perspective

1. Department of Health and Human ServicesCenters for Disease Control and PreventionAgency for Toxic Substances and Disease Registry Federal-State Working Relationships to Achieve National PreparednessThe CDC Perspective National Governors Association Center for Best Practices Regional Policy Workshop on Bioterrorism New Orleans, March 15, 2004

2. Outline • CDC’s Strategy • Best Practices • Workforce • Funding

3. CDC’s Strategy

4. Science Biological Service NuclearRadiological Chemical Trauma/Nat’l.Disasters Systems Strategy All-Hazards Approach OUR VISION People Protected – Public Health Prepared. OUR GOAL To combine our strengths in times of crisis to reduce suffering and death.

5. PREPAREDETECTREPORTRESPONDCONTAINRECOVER Strategy Dimensions of Public Health Readiness Global 1,000s – 100,000s Command and control – vital to assure containment Activate community-wide mass care system – manage the dead Manage high volume of data and information Number of Cases Deliver mass intervention – call up reserve workforce Level of Effort Resources Communicate to stakeholders and public – enhance surveillance & reporting Report – Mobilize Response – Investigate – Prophylaxis 1 Assess – Diagnose – Isolate – Treat – Manage Local Time

6. Strategy Workforce Activities Detection & Reporting Response & Containment Preparedness Recovery • Planning • Exercising • Partnering • Training • System Building • Testing • Communicating • Clinicians • Public Health • General Public • Responders • Intervention • Therapies • Education • Quarantine • Contact tracking • Coordination • Monitoring community mental health • Apply Lessons learned – continuous response improvement • Surveillance • Clinician Training • Laboratory Diagnostics • Electronic reporting systems

7. Strategy Key Services & Efforts – Detection • Early detection/warning is critical to allow for early intervention. • The sooner we know the sooner we can intervene!

8. ACTION POINT Intersection of Information & Analysis Strategy Key Services & Efforts – Detection Current State Law Enforcement Environmental (BioWatch) DoD & VA Border States Pharmacy Data Schools Public Employers Media Cargo/ Imports Laboratory Immigration Clinicians First Responders International Vital Records Veterinary Quarantine Stations Hospitals

9. ACTION POINT Intersection of Information & Analysis Strategy Key Services & Efforts – Detection Desired State DoD & VA Law Enforcement Environmental (BioWatch) Pharmacy Data Border States Public Schools Employers Media Cargo/ Imports Laboratory Immigration Clinicians First Responders Hospitals Veterinary Vital Records International Quarantine Stations

10. 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 • Quarantine Stations – New York – Chicago – Miami – Atlanta – Los Angeles – San Francisco – Seattle – Honolulu • 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

11. Strategy Key Services & Efforts – Detection • Laboratory Response Network (LRN)

12. Strategy Key Services & Efforts – Containment • Strategic National Stockpile (SNS) • Repository of antibiotics, chemical antidotes, antitoxins, life-support medications, IV administration, 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

13. 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 • 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)

14. Strategy 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.

15. 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!

16. Strategic Imperatives and PreparednessWorkforce Objectives Timely, effective and integrated detection and investigation Objective 1.2: Increase the number, skills and distribution of investigation professionals Sustained prevention and consequence management programs Objective 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 workforce Objective 5.1: Increase the number and type of professionals that comprise a preparedness and response workforce Objective 5.2: Deliver certification- and competency-based training and education Creative and effective management services Objective 11.3: Promote leadership and management development across terrorism preparedness and response programs Strategy

17. Best Practices

18. Best Practices • Site visits by senior CDC management to: • Florida • New Hampshire • New York State • Texas • Washington State

19. 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.

20. 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)

21. 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

22. 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

23. 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

24. Workforce

25. 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

26. 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

27. 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)

28. 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

29. Workforce • PHRFP Basic Principles: • Emphasis on Staff Development • More 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 Agreement • Duties of CDC field staff paid with BT Cooperative Agreement funds must be within the scope of the BT Cooperative Agreement • Customer Focus • Assignments 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

30. 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

31. 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

32. FUNDING

33. Funding FY04 Appropriation by Budget Line ($1.16 Billion) (compared with $1.54 Billion in FY03) * The appropriation amount of $1.16 billion does not include the rescission and indirect costs.

34. 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

35. 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 CDC Goals for 2004

36. Funding • Funding Concerns • $80 unobligated reported on FSRs (11/1/03) • Draw-down lag • Supplanting • Allocation formula – change?