Department of Health and Human Services Centers for Disease Control and Prevention Agency for Toxic Substances and Disease Registry Federal-State Working Relationships to Achieve National Preparedness The CDC Perspective National Governors Association Center for Best Practices Regional Policy Workshop on Bioterrorism New Orleans, March 15, 2004

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 1 People Protected – Public Health Prepared. Outline CDC’s Strategy Best Practices Workforce Funding

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 2 People Protected – Public Health Prepared. CDC’s Strategy

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 3 People Protected – Public Health Prepared. All-Hazards Approach Science Service Systems Biological Chemical Nuclear Radiological Trauma/Nat’l. Disasters OUR VISION People Protected – Public Health Prepared. OUR GOAL To combine our strengths in times of crisis to reduce suffering and death. Strategy

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 4 People Protected – Public Health Prepared. Dimensions of Public Health Readiness Number of Cases 1 1,000s – 100,000s Level of Effort Assess – Diagnose – Isolate – Treat – Manage Report – Mobilize Response – Investigate – Prophylaxis Communicate to stakeholders and public – enhance surveillance & reporting Deliver mass intervention – call up reserve workforce Manage high volume of data and information Activate community-wide mass care system – manage the dead Command and control – vital to assure containment Time Resources Local Global PREPARE DETECT REPORT RESPOND CONTAIN RECOVER Strategy

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 5 People Protected – Public Health Prepared. Strategy Preparedness Detection & Reporting Recovery Response & Containment Planning Exercising Partnering Training System Building Testing Surveillance Clinician Training Laboratory Diagnostics Electronic reporting systems Communicating Clinicians Public Health General Public Responders Intervention Therapies Education Quarantine Contact tracking Coordination Monitoring community mental health Apply Lessons learned – continuous response improvement Workforce Activities

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 6 People Protected – Public Health Prepared. Early detection/warning is critical to allow for early intervention. The sooner we know the sooner we can intervene! Key Services & Efforts – Detection Strategy

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 7 People Protected – Public Health Prepared. Key Services & Efforts – Detection Hospitals DoD & VA Vital Records Environmental (BioWatch) Pharmacy Data Veterinary Laboratory Cargo/ Imports Immigration International Schools Employers Law Enforcement ACTION POINT Intersection of Information & Analysis Media Clinicians Public First Responders Quarantine Stations Border States Current State Strategy

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 8 People Protected – Public Health Prepared. Hospitals DoD & VA Vital Records Environmental (BioWatch) Pharmacy Data Veterinary Laboratory Cargo/ Imports Immigration International Schools Employers Law Enforcement Media Clinicians Public First Responders Quarantine Stations Border States ACTION POINT Intersection of Information & Analysis Key Services & Efforts – Detection Desired State Strategy

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 9 People Protected – Public Health Prepared. 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  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  Quarantine Stations – New York– Chicago– Miami– Atlanta – Los Angeles– San Francisco– Seattle– Honolulu Strategy

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 10 People Protected – Public Health Prepared.  Laboratory Response Network (LRN) Key Services & Efforts – Detection Strategy

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 11 People Protected – Public Health Prepared.  Strategic National Stockpile (SNS), etc.  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 Key Services & Efforts – Containment Strategy

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 12 People Protected – Public Health Prepared. 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 Strategy  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)

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 13 People Protected – Public Health Prepared. 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. Strategy

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 14 People Protected – Public Health Prepared. 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! Strategy

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 15 People Protected – Public Health Prepared. Strategy Strategic Imperatives and Preparedness Workforce 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

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 16 People Protected – Public Health Prepared. Best Practices

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 17 People Protected – Public Health Prepared. Site visits by senior CDC management to: Florida New Hampshire New York State Texas Washington State Best Practices

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 18 People Protected – Public Health Prepared. 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. Best Practices

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 19 People Protected – Public Health Prepared. 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) Best Practices

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 20 People Protected – Public Health Prepared. 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 Best Practices

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 21 People Protected – Public Health Prepared. 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 Best Practices

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 22 People Protected – Public Health Prepared. 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 Best Practices

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 23 People Protected – Public Health Prepared. Workforce

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 24 People Protected – Public Health Prepared. 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 Workforce

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 25 People Protected – Public Health Prepared. Workforce Background n State and Local authorities concern over their ability to recruit, hire, train, and retain qualified personnel n Assignment of CDC staff has been a successful model for CDC to assist state and local agencies with program planning and implementation n 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.” n OTPER Field Services Office formed November 1, 2003

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 26 People Protected – Public Health Prepared. 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)

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 27 People Protected – Public Health Prepared. Workforce PHRFP Overview nMultidisciplinary and multi-level nStrong training component nLeverage and coordinate readiness activities of other CDC field programs n Assignments within State/Territorial and Local public health agencies nField Services support by OTPER as necessary

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 28 People Protected – Public Health Prepared. Workforce PHRFP Basic Principles: n Emphasis on Staff Development More than a staffing service for state and local agencies -- a long term professional development program n Expand and enhance Do not supplant the current federal, state and local public health workforce n 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 n 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

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 29 People Protected – Public Health Prepared. 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

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 30 People Protected – Public Health Prepared. Workforce We hope the PHRFP will: n Meet state and local public health preparedness needs n Foster the “dual use” concept n Mitigate the silo-effect of categorical programs at federal, state, and local levels n Provide Support and enhance the good work the categorical programs do n Emphasize BT while also support an all-hazards approach n Make a dent in long range public health work force needs

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 31 People Protected – Public Health Prepared. FUNDING

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 32 People Protected – Public Health Prepared. * The appropriation amount of $1.16 billion does not include the rescission and indirect costs. FY04 Appropriation by Budget Line ($1.16 Billion) (compared with $1.54 Billion in FY03 ) Funding

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 33 People Protected – Public Health Prepared. 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: $ Million Funding

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 34 People Protected – Public Health Prepared. CDC Goals for 2004 n 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 n Public health workforce (improve the quality and quantity) Implement the Public Health Readiness Field Program Partnering with the Centers for Public Health Preparedness n Stronger ties with HRSA and DHS (HSPD 8) Funding

Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 35 People Protected – Public Health Prepared. Funding Concerns $80 unobligated reported on FSRs (11/1/03) Draw-down lag Supplanting Allocation formula – change? Funding