1 11/02 RAND How Ready Are Health Responders for Terrorist Attacks? Lois M. Davis, Ph.D. June 26, 2003

2 11/02 RAND How Prepared Local Health Responders Are for Terrorist Attacks Has Been an Ongoing Concern  The June 2001 Dark Winter exercise—which simulated intentional release of smallpox in three U.S. cities—raised warning flags “Dark Winter further demonstrated how poorly current organizational structures and capabilities fit with the management needs and operational requirements of an effective bioterrorism response. Responding to a bioterrorist attack will require new levels of partnership between public health and medicine, law enforcement, and intelligence. However, these communities have little past experience working together and vast differences in their professional cultures, missions, and needs.”  9/11 attacks and anthrax attacks in Fall 2001 further called into question how prepared health responders were

3 11/02 RAND Today’s Focus  How prepared are local health responders for biological and chemical terrorism?  RAND nationwide surveys of state and local responders prior to 9/11 and at the one-year anniversary  Results of other survey efforts since 9/11: OIG/DHHS survey and GAO case studies  What role should the media play in informing the public health response to terrorism?

4 11/02 RAND Questions and Answers  How prepared are local health responders for biological and chemical terrorism?  What role should the media play in informing the public health response to terrorism? Questions  Preparedness efforts are improving since 9/11, but fundamental readiness concerns persist Answers

5 11/02 RAND Prior to 9/11, Only 1/3 of Local Public Health Departments Had SOPs for Biological Attacks Have Response Plans or SOPs for......Biological Incidents...Chemical Incidents Overall Large Metropolitan Counties Other Counties Local public health Hospitals Percent 27 (4) 32 (7) 25 (4) 40 (15) 31 (7) 26 (5) 36 (11) 54 (7) 69 (12) 32 (11) 24 (5) 50 (8)

6 11/02 RAND Prior to 9/11, Only 1/3 of Local Public Health Departments Had SOPs for Biological Attacks Have Response Plans or SOPs for......Biological Incidents...Chemical Incidents Overall Large Metropolitan Counties Other Counties Local public health Hospitals Percent 27 (4) 32 (7) 25 (4) 40 (15) 31 (7) 26 (5) 36 (11) 54 (7) 69 (12) 32 (11) 24 (5) 50 (8) Slightly better for chemical attacks and among large metropolitan counties

7 11/02 RAND Prior to 9/11, Very Few Organizations Had Exercised Their Response Plans for Bioterrorism Response Plans or SOPs Last Exercised for......Biological Incidents...Chemical Incidents Within Past 12 Months Between 1–2 Years Ago 2 or More Years Ago Percent 16 (6) 10 (5) 7 (5) 34 (14) 18 (8) 9 (5) 37 (9) 27 (8) 19 (7) 20 (9) 15 (7) 36 (9) Local public health Hospitals

8 11/02 RAND Prior to 9/11, Very Few Organizations Had Exercised Their Response Plans for Bioterrorism Response Plans or SOPs Last Exercised for......Biological Incidents...Chemical Incidents Within Past 12 Months Between 1–2 Years Ago 2 or More Years Ago Percent 16 (6) 10 (5) 7 (5) 34 (14) 18 (8) 9 (5) 37 (9) 27 (8) 19 (7) 20 (9) 15 (7) 36 (9) Local public health Hospitals Better for chemical attacks

9 11/02 RAND Prior to 9/11, Only Half of Health Organizations Participated in WMD-Focused Task Forces Interagency Disaster Preparedness Task Force Exists in Region Overall Large Metropolitan Counties Other Counties Percent 61 (6) 76 (6) 53 (6) 90 (7) 72 (7) 59 (6) 73 (15) 53 (8) 88 (8) 77 (11) 50 (7) 44 (9) Task Force Addresses Planning for WMD-Related Incidents Local public health Hospitals

10 11/02 RAND Other Findings Showed Local Health/Medical Response to Terrorism Inadequately Addressed  Surge capacity that may be required  Plans for communicating with other health providers, emergency responders, media, or the public  What role other responders, such as law enforcement, may play in the response to, or the investigation of, bioterrorist incidents

11 11/02 RAND OIG/DHHS Survey Showed Improvements in Terrorism Preparedness Capabilities Since 9/11  OIG Study: Purposive sample of 12 states and 36 local health departments  All state health departments and nearly 89 percent of local ones were writing or had written bioterrorism response plan  Local health departments have begun to integrate public health preparedness activities with those of other emergency response organizations  Most local health departments reported belonging to terrorism-related task forces, working groups, or committees

12 11/02 RAND GAO Case Studies at Sites in Seven Cities Show Similar Improvements  Most cities had undertaken steps to improve coordination among local response organizations  Hospitals and other organizations that had not been involved in local response planning increased participation  State/local jurisdictions/response organizations have begun to incorporate bioterrorism in overall plans  However, plans for regional coordination were lagging  Most states were in the process of undertaking assessments of capacity  Applying for DHHS funding helped states identify problems in bioterrorism preparedness and focus planning efforts

13 11/02 RAND GAO Case Studies at Sites in Seven Cities Show Similar Improvements  Most cities had undertaken steps to improve coordination among local response organizations  Hospitals and other organizations that had not been involved in local response planning increased participation  State/local jurisdictions/response organizations have begun to incorporate bioterrorism in overall plans  However, plans for regional coordination were lagging  Most states were in the process of undertaking assessments of capacity  Applying for DHHS funding helped states identify problems in bioterrorism preparedness and focus planning efforts However, despite improvements, fundamental public health readiness issues remain

14 11/02 RAND Written Comments from RAND Follow-up Survey Highlight Local Health Organizations Concerns  “If additional funding is not provided to hospitals, the cost of WMD preparedness will be difficult if not impossible to meet.”  “We are a rural medical facility. Financial survival is difficult in the current climate. Funding is not available for training....”  “Difficult to find balance between efforts for preparedness vs. other public health priorities in a shrinking resource environment.”  “Federal bioterrorism [funding] is just now resulting in ability to recruit and hire dedicated staff for bioterrorism preparedness.”

15 11/02 RAND Funding of Bioterrorism Preparedness Activities Remains a Fundamental Readiness Concern  Post 9/11, federal funding for bioterrorism preparedness has increased, esp. for public health  However, wide variation across states in how funding is being allocated  Much of the focus is on capacity building and improving public health infrastructure  Some states are taking a comprehensive approach to include coordination, response planning, etc.  Degree to which funding will reach local level is a concern  Hospitals only now receiving bioterrorism funding in any substantial amounts (complex incentives for investing in preparedness)  Question of whether “supplantation” may occur in current fiscal crisis

16 11/02 RAND Workforce Issues Are Another Fundamental Readiness Concern  Health officials have cited workforce shortages as impediments that funding alone will not solve  Shortages of trained epidemiologists, lab personnel, and hospital personnel  Manpower shortages limiting ability to implement active surveillance systems  Health departments reluctant to hire new staff without guarantees of sustained federal (or state) funding

17 11/02 RAND Concern Over Effects of Increasing Focus on Bioterrorism Is Also a Fundamental Issue  Some public health officials fear overemphasis on bioterrorism to exclusion of other types of public health threats/emergencies  State and local health officials concerned that focus on bioterrorism may divert attention and resources from other public health functions and programs  Recent implementation of smallpox vaccination program  Forcing cutbacks in other basic health services, such as childhood immunizations and tuberculosis prevention

18 11/02 RAND DHHS Review of States’ Bioterrorism Plans Also Identified Shortcomings  Some States’ workplans inadequately addressed coordination  With the Metropolitan Medical Response System (MMRS) cities  Between health departments and hospitals  With bordering states or countries  DHHS also requested priority be given to development of plans for  Receiving materials from the National Pharmaceutical Stockpile  Ensuring adequate surge capacity within hospital regions  Provisions be made for isolation rooms in hospital ERs

19 11/02 RAND At Most Fundamental Level Is Question of “How to Know How Much Readiness Is Enough”  Current metrics for assessing how prepared a community really is for bioterrorism are inadequate  CDC’s list of critical benchmarks  DHS Advisory Council’s statewide template initiative  Need to go beyond these efforts to develop quantifiable performance measures and model of preparedness that:  DHS can use to assess how prepared U.S. is  Communities can use to assess local preparedness and inform resource allocation decisions  Individual health organizations can use to assess where they stand relative to their peers

20 11/02 RAND Questions and Answers  How prepared are local health responders for biological and chemical terrorism?  What role should the media play in informing the public health response to terrorism? Questions  Preparedness efforts are improving since 9/11, but fundamental readiness concerns persist  Media can help with public education and provide input to communications plans being developed Answers

21 11/02 RAND Communications with the Media and Public During 9/11 and Anthrax Attacks Was Poor  There was a problem of health officials not speaking with one voice  Spokespersons who contradicted guidance from public health officials  Public health officials appeared unresponsive to what citizens wanted to know  Individuals’ risk for contracting anthrax, need for antibiotics, etc.  Lack of coordination between local, state, and federal levels

22 11/02 RAND Evidence Suggests Such Problems Still Exist After 9/11  DHHS review of state risk communications plans  Lacked sufficient details on communications with the public or media  Several did not identify public information officers  OIG survey found most health departments did not have complete risk communication plan for communicating with public and media  Only 25% of state health departments; 33% of local ones

23 11/02 RAND Evidence Suggests Such Problems Still Exist After 9/11  DHHS review of states’ risk communications plans  Lacked sufficient details on communications with the public or media  Several did not identify public information officers  OIG survey found most health departments did not have complete risk communication plan for communicating with public and media  Only 25% of state health departments; 33% of local ones Health departments are working to rectify problems and develop communications plans

24 11/02 RAND Improving Communications About Preparedness and Response to Bioterrorist Incidents  Public health officials should undertake public education component in advance  Provide frank assessment of where jurisdictions stand on response planning, quarantine plans, evacuation plans, etc.  Media can play a role in educating the public  Media can help inform communications plans  Make public health officials aware of what media needs to know and is going to be asking during an event  Make them aware that there must be a “go-to” person among health officials to get information when an incident occurs... or will go elsewhere