1. Workshop: The State of National Governance Relative to the International Health Regulations (2005) Ottawa, Canada, 20-21 September 2006 Overview: United States of America Anthony A. Marfin Centers for Disease Control and Prevention

2. Goal Describe the extent to which United States has a system of governance that will enable effective implementation of the revised International Health Regulations 2005

3. Background: Political Structure Federal system of government States independent sovereign governments States retain powers not expressly delegated to Federal government Full presidential system

4. Who does public health? Concurrent jurisdiction U.S. Constitution division of jurisdiction: “[P]owers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States, respectively, or to the people.” Federal government given power “to regulate commerce with foreign nations, among the several States (interstate)” Movement of disease affects commerce

5. Responsibility for public health is shared but most functions are decentralized Within a single state: All aspects of surveillance, reporting, & public health clearly belong to state/local HDs International and interstate events: Jurisdiction of federal government Federal public health entities DO NOT have direct authority over state/local public health entities Who does public health?

6. National Core Capacities Where public health activities are performed ActivityNationalStateLocal Case detection/notificationNo Yes Yes Collection of case dataNo Yes Yes Analysis & interpretationYesYesYes Investigation of cases & confirmation of diagnosis: Epidemiologist*YesYes Clinician No*Yes Laboratory **Yes DisseminationYesYesYes Response/Intervention*YesYes * Upon request

7. Notifiable Diseases “Notifiable diseases” vary between counties & states Federal government, only 9 quarantinable diseases Harmonization through consensus with professional organizations of state/local public health officers Example (CSTE): “…by supporting the use of effective public health surveillance and good epidemiologic practice through training, capacity development, and peer consultation, developing standards for practice …”

8. IHR negotiation & approval USG will implement IHRs in a manner consistent with our fundamental principles of federalism IHRs will be implemented by the Federal Government to the extent that the implementation of the Regulations comes under the legal jurisdiction of the Federal Government To the extent that IHR obligations come under the legal jurisdiction of the state/local governments, the USG will bring these obligations with a favorable recommendation to the notice of the appropriate state authorities

9. Development of surveillance systems Work with professional groups representing state and local health officers and epidemiologists to adopt the IHR 2005 requirements as a standard As necessary, provide financial and technical support to states to adopt a new standard

10. Surveillance: Detection, notification, verification & reporting Performed by state/local government; technical / lab assistance from federal government (upon request) Federal government has constitutional authority to ensure that these processes meet IHR 2005 requirements in interstate or international settings No authority over events that occur within a state (without an interstate or commerce connection) Mechanisms to ensure that these processes meet IHR 2005 requirements are being discussed Currently, USG works with professional groups representing state/local government to adopt requirements as their standard

11. Surveillance: Detection, notification, verification & reporting Communication: CDC’s Epi-X – Rapid, firewall-protected privileged information sharing system between federal, state, and local health officials Health Alert Networks CDC forward-deployed field stations (Quarantine Stations)

12. Jurisdictional authority for PHEICs Federal government will express authority over PHEICs within specific jurisdictions (i.e., international and interstate events) Otherwise, U.S. state/local governments will have such authority (intrastate events involving non- Federal assets or resources) Regarding PHEICs in intrastate settings, USG will take appropriate measures to facilitate the implementation of IHRs at the local level

13. Potential Obstacles Potential obstacles to communication/collaboration Dual reporting system Variation in technologic capacity amongst states/counties Need for rapid movement of information Establishing and using a National IHR Focal Point for all international communications

14. Overcoming these obstacles How to overcome these obstacles Standardize data collection based on scientific principles Simplify data transfer (“NECESSARY not desirable”) Web-based data systems (“workspaces”) that are jointly accessible and maintained by 3 levels of government XML file transfers between data systems Dedicated communication system for public health practitioners Communication protocols between 3 levels of government Communication protocols within federal government for sending/receiving international communications Methods to overcome obstacles will require: Agreements regarding data sharing Development and access to secured electronic communication systems

15. Summary & conclusions Obstacles to implementation include: Decentralized public health delivery system Implementing in a manner consistent with fundamental U.S. principles of federalism. Full implementation relies cooperation from state and local governments Rapid communication between 3 levels of government Technical support for state/local HDs No expectations of outside agencies for any assistance with implementation