View from a State North Carolina Public Health Population 9.5M 54,000 square miles 5 th in growth rate in US 100 counties Decentralized Public Health system 85 local health departments (county or district) Jeffrey Engel, M.D. Former State Health Director Senior Advisor for Health Policy NC DHHS

Major Investments in Preparedness NCPH State Capacity –Epidemiology –Laboratory –Informatics Regional Capacity –Epidemiology, Planning, Response –Laboratory Local Capacity –Preparedness Coordinators

New Capacity in Public Health Strategic Building of an Integrated System State (Division of Public Health) –Office of Public Health Preparedness and Response –State Laboratory: Bioterrorism and Emerging Pathogens Program –Biosurveillance and Informatics Syndromic surveillance system with NC Hospital Association National Electronic Diseases Surveillance System Regional –Regional epidemiology offices –Hospital-based epidemiologists –Regional labs (Charlotte, Asheville, Greenville)

E. coli Outbreak* at State Fair Response October 2011 North Carolina Departments of Health and Human Service and Agriculture and Consumer Services *25 ill, 6 hospitalized, 3 needing dialysis

Public Health Operations Organization Operations Aaron Fleischauer Surveillance David Sweat Epidemiology Jennifer MacFarquhar Case-Control Stephanie Griese Liaison Carl Williams

Public Health Operations Organization Operations Aaron Fleischauer Surveillance David Sweat Epidemiology Jennifer MacFarquhar Case-Control Stephanie Griese Liaison Carl Williams

Information Fusion for Outbreak Investigation Joint Investigation Epidemiology Agriculture Food Safety/Environment

Joint Operations Karen Beck Carl Williams

Epidemiology with context

Successful Outcome Eight days following initial reported cases

State Reductions 2011 Budget Elimination of Public Health Pest Management Program –NC no longer has any entomologists, so…. –Hurricane Irene August 2011 Post-hurricane marsh mosquito nuisance No state capacity to respond Every county “on their own” Aerial spraying costly ($100,000 per application) FEMA reimburses 75% Dare County sprays, Pamlico County does not

Irene: August 27, 2011 cbsnews.com, accessed Feb. 1, 2012

Recent Reductions PHEP Grant State Position Eliminations –Two lab positions –Two epidemiologist positions –One vet position (Dept. of Agriculture) Regional –7 teams of 4 people down to 4 teams of 5 people (8 positions) –13 hospital epidemiologists down to 8 (5 positions) Local –70% down to 25% of local health departments who can support a full-time preparedness coordinator (38 positions)

North Carolina Summary Public Health Preparedness and Response –PH major critical infrastructure is a trained and adequate workforce –Technical resources: lab, informatics –Communication: common language (National Incident Management System), protocols and plans Since 2008, Federal and State Reductions Resulted in Loss of 60 Positions