1. Department of Health and Human Services Centers for Disease Control and Prevention Agency for Toxic Substances and Disease Registry NGA Regional Bioterrorism Workshop CDC Perspectives Glen Koops, M.P.H. Associate Director for Field Services Office of Terrorism Preparedness and Emergency Response May, 13-14, 2004 San Francisco, California

2. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 1 People Protected – Public Health Prepared. Outline 1.Strategic Overview 2.Enhancing State Capacity 3.State Activities 4.Evaluation 5.Workforce Issues 6.Funding

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

4. 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

5. 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

6. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 5 People Protected – Public Health Prepared. Early detection/warning is critical to allow for early intervention. The sooner we know the sooner we can intervene! Strategy: DETECTION

7. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 6 People Protected – Public Health Prepared. 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: DETECTION

8. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 7 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: DETECTION

9. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 8 People Protected – Public Health Prepared.  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: DETECTION

10. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 9 People Protected – Public Health Prepared.  Laboratory Response Network (LRN) Strategy: DETECTION

11. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 10 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 Strategy: CONTAINMENT

12. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 11 People Protected – Public Health Prepared.  Director’s Emergency Operations Center (DEOC)  7,000 square feet; 85 workstations; 24x7 staff; state-of-the-art communication technologies  Emergency Communications System (ECS)  Concept of Operations based on ICS Model  Continuity of Operations Plan (COOP)  Deployable Emergency Response Assets Strategy: CONTAINMENT

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

14. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 13 People Protected – Public Health Prepared. CDC Efforts to Enhance State Capacity

15. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 14 People Protected – Public Health Prepared.  Cooperative Agreement for 62 state, major city and territory health departments expands epidemiology and surveillance capacity to detect, investigate, and mitigate health threats. ($2 billion+ invested to date)  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.  Rapid assessment of surveillance capacities in 8 priority cities.  Forensic Epidemiology training sessions for public health and law enforcement professionals. CDC Efforts to Enhance State Capacity

16. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 15 People Protected – Public Health Prepared. State Activities

17. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 16 People Protected – Public Health Prepared.  Statutes and ordinances, timelines and assessments - updated  24x7 system to receive and evaluate urgent disease reports in place – 49/50 have systems in place  Epidemiologic capacity enhanced  Information technology to assure rapid detection and reporting improving (i.e. BioWatch)  Effective working relationships between clinical and higher-level laboratories  Ongoing education and training of front-line public health and healthcare responders to assure recognition of the early signs and symptoms of unusual health events State Activites – Progress Report

18. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 17 People Protected – Public Health Prepared. 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! State Activities -- Progress Report

19. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 18 People Protected – Public Health Prepared. Site visits by senior CDC management to: Florida Nebraska New Hampshire New York State Texas Washington State

20. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 19 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.

21. 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

22. 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 over 4,000 hospital and public health staff

23. 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

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

25. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 24 People Protected – Public Health Prepared. Project to Define Performance Goals and Indicators... Define “what good looks like” Culmination year of work Input from SMEs, Academics, Public Health Partners, other stakeholders Validated information with extensive literature search

26. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 25 People Protected – Public Health Prepared. Project to Define Performance Goals and Indicators... Performance Goals based on preparedness principles  Systems are connected pieces  Planning should be supported by evidence  Focus is State support of a local response

27. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 26 People Protected – Public Health Prepared. Project to Define Performance Goals and Indicators... Evidence based approach focuses on areas that the literature indicates that there are problems

28. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 27 People Protected – Public Health Prepared. Project to Define Performance Goals and Indicators.. Result: 42 Performance Goals 47 Indicators

29. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 28 People Protected – Public Health Prepared. Example: Performance Goal 2: Internal Agency Staff Awareness of Public Health Role and of Other Community Responder Roles

30. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 29 People Protected – Public Health Prepared. Describe their job functions during a response AND the description matches the employee’s role and responsibilities as written in the Agency’s plan and the jurisdiction’s plan Show documentation of training jointly with response partners whom they are likely to interact with as they carry out disaster role functions Describe the role and responsibilities of response partners whom they are likely to interact with as they carry out disaster role function Identify by name and/or job title whom they report to in a disaster Demonstrate the correct use of equipment used in their emergency job function (e.g., conferencing equipment, blackberries, blast faxing, two- way radios) Example: Measure 2: Percent of a random sample of Public Health Agency staff that have response roles can:

31. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 30 People Protected – Public Health Prepared. Next steps: Field Test to provide input on validity, reliability, and feasibility  Oklahoma  Florida  Washington  Massachussets  Chicago

32. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 31 People Protected – Public Health Prepared. Next steps: Determine appropriate method/resources needed to test progress to goal  Random testing (who, how often)?  Self-reporting?

33. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 32 People Protected – Public Health Prepared. Exercises System to design and proctor exercises Conduct performance-based, interactive exercises Develop system to identify, collect and analyze information about exercises Develop recommendations for change

34. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 33 People Protected – Public Health Prepared. Exercises CDC is working with various agencies to provide opportunities to exercise public health systems  NCEH  ODP  Performance Goals

35. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 34 People Protected – Public Health Prepared. Exercises National Center for Environmental Health Scenario and exercise development, implementation and evaluation 16 grantees annually Including “injects” that will measure performance goals Including activities that test Incident Command principles

36. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 35 People Protected – Public Health Prepared. Exercises Office of Domestic Preparedness Will test every grantee (DHS) yearly Working with NCEH to assure PH components are tested with traditional first responder activities

37. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 36 People Protected – Public Health Prepared. Workforce

38. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 37 People Protected – Public Health Prepared. Preparedness Detection & Reporting Recovery Response & Containment Planning Exercising Partnering Training System Building Testing Surveillance Clinician Training Laboratory Diagnostics Electronic reporting systems Contact tracking Education Quarantine Response Coordination Communicating with Clinicians, Public Health & the General Public Developing Interventions & Therapies Monitoring community mental health Applying Lessons learned to continuously improve Response & Containment Workforce Activities

39. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 38 People Protected – Public Health Prepared. Background n State and Local authorities concern over their ability to recruit, hire, train, and retain qualified personnel to rapidly build public health preparedness systems n Assignment of CDC staff has been a successful model for CDC to assist state and local agencies with program planning and implementation

40. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 39 People Protected – Public Health Prepared. New CDC Initiative (Public Health Readiness Field Program to increase CDC field presence to... 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

41. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 40 People Protected – Public Health Prepared. Ideas we are exploring... nMultidisciplinary and multi-level assignments nStrong training component: Preparedness “Boot Camp” n Assignments within State/Territorial and Local public health agencies nFoster the “dual use” concept nMitigate the silo-effect of categorical programs at federal, state, and local levels Cross-train all CDC assignees so that all have a Readiness Role Pilot Project to out-place Senior Management Officials to improve coordination of Disease Prevention/Health Promotion/Community Protections grants, cooperative agreements and other CDC activities nEmphasize BT while also support an all-hazards approach nMake a dent in long range public health work force needs

42. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 41 People Protected – Public Health Prepared. FUNDING

43. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 42 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

44. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 43 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: $ 934.4 Million Funding

45. Centers for Disease Control and Prevention (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) 44 People Protected – Public Health Prepared. Funding Concerns $80 unobligated reported on FSRs (11/1/03) Draw-down lag Supplanting Allocation formula – change? Funding