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Providing a Framework for Public Health Bioterrorism Preparedness: Public Health Workforce, Collaboration, and Infrastructure Issues
May 17, 2002, Washington, DC

Sponsored by the Center for Infectious Disease Research and Policy (CIDRAP), University of Minnesota, Minneapolis, with support from NTI, Washington, DC

Participants

• Representatives from organizations that serve state and local public health agencies: the Association of Public Health Laboratories, the Association of State and Territorial Health Officials, the Council of State and Territorial Epidemiologists, the National Association of County and City Health Officials, and the National Association of State Public Health Veterinarians
• Representatives from selected professional organizations: the American Society for Microbiology and the Infectious Diseases Society of America
• Representatives from selected foundations: the Robert Wood Johnson Foundation, the Center for Health and Security, and NTI
• A representative from the Johns Hopkins Center for Civilian Biodefense Strategies
• Selected private consultants with expertise in public health practice and infrastructure

See Appendix A for a complete list of meeting participants.

Issues
The group was asked to discuss two key issues that public health officials are now confronting as they implement new programs for responding to the current bioterrorism threat:

• Adequacy of the current public health workforce
• Federal, state, and local public health agency collaboration and infrastructure support

Meeting Format
The format for discussion was relatively informal. Each topic was presented to the group, and members were asked to provide their insights on problems and solutions.

Adequacy of the Current Public Health Workforce

Perceived Problems

1. There is an overall shortage of qualified public health workers available to meet the immediate demands of bioterrorism preparedness. Agencies are being asked to develop new programs and add new staff in the face of a substantial shortage in qualified personnel. An estimated 3,200 to 4,000 new positions were requested in the bioterrorism cooperative agreements recently submitted to the Centers for Disease Control and Prevention (CDC). In addition, an estimated 13,000 to 15,000 persons are needed to provide 24-hour emergency coverage at the local level. According to members of the group, personnel not only require adequate academic training but also require several years of on-the-job training and experience to meet the performance demands of certain key program positions.
2. Different types of expertise are needed for development of an effective overall programmatic response. Examples include program management and administrative support, epidemiology, information technology, risk assessment, public health education, clinical medicine, veterinary medicine, communication and public relations, environmental management and decontamination, microbiology, and chemical detection and analysis.
3. Different levels of expertise are needed within each area of response, ranging from highly trained experts with extensive public health experience to personnel who require minimal training to complete assigned tasks.
4. Because of an inadequate workforce, qualified personnel are: (1) being shifted to different programs within agencies, (2) transferring to different agencies within government, and (3) moving between the public and private sectors. These transitions are creating significant gaps in expertise within certain programs.
5. New financial resources now available to public health agencies for bioterrorism preparedness must be spent quickly, leaving little time to: (1) develop coherent effective plans and (2) meet the immediate needs for workforce training and preparation.

Barriers to Success

1. Public health agencies have a wide range of administrative barriers that must be overcome to ensure the capacity to respond rapidly to new challenges. Examples include noncompetitive pay scales, cumbersome hiring procedures, lack of system flexibility, and inadequate incentives for retaining qualified personnel.
2. Academic schools of public health are focused on degree programs and not on meeting the practical needs of public health workforce training.
3. The current nursing shortage has overshadowed the public health workforce shortage. States are struggling to develop strategies for meeting patient care needs and therefore are not able to focus attention on strategies for enhancing the public health workforce.
4. Many state governments are facing budget shortfalls and have FTE hiring limits and other barriers aimed at limiting the state workforce.
5. The laboratory worker standards established by the Clinical Laboratory Improvement Act (CLIA) in 1998 had an impact on training requirements, so adequate technical expertise may be lacking in some areas.

Potential Solutions

Strategies to Enhance Workforce Training and Education

1. Develop a menu of training approaches that agencies could use to enhance workforce preparedness. These approaches should be time-sensitive and should be focused on defined skill sets. Examples include distance learning, task-oriented training modules, mentoring programs, and other experiential approaches. Examples of creative training programs cited during the discussion include the California mini-EIS program and "Team Diarrhea" in Minnesota that provides graduate students with on-the-job training in investigating foodborne disease outbreaks.
2. Establish a mechanism for state and local agencies to share innovative training ideas and avoid duplication of limited resources.
3. Encourage schools of public health to develop focused training programs that are not specifically oriented toward academic degree candidates. In addition, programs offered should emphasize practical skills, internships, and field experience.
4. Implement "debt forgiveness" programs for professionals who enter public health as a career path (particularly those with senior management potential, such as physicians and others with appropriate advanced degrees).
5. Encourage schools of public health to develop faculty tenure tracts that focus on public health practice rather than just on academic research. This would allow greater collaboration between academic faculty and local and state public health practitioners. Such an approach also would allow students to be better prepared to enter the workforce (ie, to have the necessary practical skills) and would enhance the relevancy of academic centers to the day-to-day practice of public health.
6. Enhance interest in public health careers by educating the public on the critical role that public health plays in bioterrorism preparedness through such tasks as outbreak detection and response and large-scale interventions (eg, mass vaccinations or antibiotic prophylaxis).
7. Develop, disseminate, and market training programs for paraprofessional (ie, "shoe leather") epidemiologists to support and augment the work of fully trained epidemiologists.

Strategies to Complement the Existing Workforce

1. Use the federal intergovernmental personnel agreement (IPA) model as a way to temporarily move key personnel from one agency to another.
2. Consider developing a national public health reserve workforce that could be mobilized to go anywhere in the country during a public health crisis.
3. Establish networks among local health departments so that isolated practitioners in small agencies can access information and training opportunities, as well as be part of a professional community that can rapidly respond to regional crises.

Federal, State, and Local Public Health Agency Collaboration and Infrastructure Support

Perceived Problems

1. Lines of authority for managing a bioterrorist event among federal, state, and local public health agencies have not been clearly defined.
2. In some jurisdictions, competition for bioterrorism preparedness funding exists between state and local public health agencies.
3. Insufficient mechanisms exist in many jurisdictions for effective collaboration between public health agencies and law enforcement agencies (including local and federal Federal Bureau of Investigation [FBI] agencies). Key issues that need to be addressed include security concerns, joint planning, coordination of responsibilities, and methods for information sharing.
4. Adequate community planning for a bioterrorism event (ie, planning involving the many different agencies and organizations that would be critical to the successful management) has not been undertaken in many states. Essential community functions are fragmented between public health agencies, hospitals, and law enforcement agencies. Planning and communication activities across these agencies often are lacking or, at best, are inadequate.
5. Goals for bioterrorism preparedness at the local level have not been clarified in many jurisdictions.
6. In some state public health agencies, bioterrorism activities being carried out by different parts of the agency are not always being adequately communicated within the agency and consequently a clear overall approach to public health preparedness is not being established.
7. Many elected public officials (ie, legislators, mayors, governors) do not have a clear understanding of public health activities and therefore do not advocate for public health infrastructure support. This is particularly true at the current time, since many new governors have recently taken office and have appointed new health commissioners.
8. Elected officials are expecting to see rapid improvement in competencies with the new bioterrorism preparedness funding. Expectations for success may be higher than what health departments can deliver in the short time frames provided.

Barriers to Success

1. Functions within public health agencies often are organized vertically without adequate cross-communication. For example, in the laboratory setting, microbiology, chemical, and radiological programs often are organized as separate laboratory sections. This structure creates a significant problem when a laboratory is asked to identify an unknown material. This "stovepipe" approach is particularly common at the federal level and then filters down into state and local agencies.
2. In some instances, local public health departments have focused on the building of agency bioterrorism preparedness rather than looking more broadly at the most effective approach to assuring protection of the population served. For example, in jurisdictions where individual local agencies are small, building capacity in each one may not be the best use of available resources.
3. Traditionally, public health agencies have not necessarily performed well in communicating their successes to elected officials. This is particularly important now with the need to demonstrate improvement in competencies as a result of the bioterrorism preparedness funding and to demonstrate significant progress nationally to Congress and the Administration.

Potential Solutions

Joint Planning Activities

1. Provide agencies with a set of tools to help them rapidly move new preparedness programs forward. Examples include boilerplates for position descriptions, contract language, and other administrative items.
2. Support regional approaches to bioterrorism preparedness in areas where small local health departments do not have adequate core capacity to each build their own preparedness capabilities.
3. Establish a mechanism for states to share preparedness plans. A clearinghouse or Web site for sharing information could serve this purpose.
4. Develop best-practices models for state and local bioterrorism preparedness programs to give agencies direction on how best to structure programs, particularly across agencies and services. Information gained through a structured assessment of the state plans (particularly assessing progress over time) could be used to guide this process.
5. Establish a set of core competencies for bioterrorism preparedness. This would give states and local agencies a way to measure their preparedness activities and would help to define a set of expectations for future program development and maintenance.
6. Develop advocacy campaigns and effectively use a spokesperson or spokespersons to enhance support for state and local public health preparedness by elected officials. For example, a highly visible spokesperson could publicize short-term gains and progress toward long-term outcomes resulting from the new infusion of resources into public health.

Clarification of Authorities and Roles

1. Define bioterrorism preparedness at the local level. The National Association of County and City Health Officials is in a position to guide this process.
2. Develop a set of principles for effective bioterrorism preparedness collaboration between local and state health departments. As part of this activity, the National Association of County and City Health Officials and the Association of State and Territorial Health Officials could expand their existing Principles for Collaboration.
3. Conduct an assessment of the state plans and identify a core set of practices that should be included at the state level as preparedness activities move forward. Over time, this type of process could be used to determine the most successful approaches to improving state preparedness.
4. Manage expectations of elected officials with regard to using the new bioterrorism preparedness funding at the state and local levels. State health departments need to demonstrate competency improvement and enhancement of preparedness. Blueprints for how best to communicate successes in this area would be useful. As part of this process, state public health agencies should be strongly encouraged to meet with new governors and/or their staff members and to establish effective relationships with them.

Appendix A: Meeting Participants

Mike Auslander, DVM, MSPH State Public Health Veterinarian and Assistant Director of Epidemiology Kentucky Department for Public Health Frankfort, Kentucky Scott Becker Executive Director, Association of Public Health Laboratories Washington, DC Georges Benjamin, MD President, Association of State and Territorial Health Officials Secretary, Maryland Department of Health and Mental Hygiene Baltimore Donna Brown, JD, MPH Government Affairs Counsel National Association of County and City Health Officials Washington, DC Matt Cartter, MD, MPH President, Council of State and Territorial Epidemiologists and Epidemiology Program Coordinator Connecticut Department of Public Health Hartford Asha George, DrPH, MSPH Senior Program Officer, NTI Washington, DC Mary Gilchrist, PhD President, Association of Public Health Laboratories Director, University Hygienic Laboratory University of Iowa Iowa City Robert Guidos, JD Director of Public Policy, Infectious Diseases Society of America Alexandria, Virginia Elin Gursky, ScD Senior Fellow, Johns Hopkins Center for Civilian Biodefense Strategies Baltimore Margaret Hamburg, MD Vice President of Biological Programs, NTI Washington, DC

Joseph Henderson Vice President and Chief Public Health Officer Scientific Technologies Corporation Decatur, Georgia Richard Hoffman, MD, MPH Public Health Consultant Denver Nancy Kaufmann, RN, MS Vice President, Robert Wood Johnson Foundation Princeton, New Jersey Barbara Levine Association of State and Territorial Health Officials Bethesda, Maryland Marcia Mabee, PhD, MPH Washington Liaison, Council of State and Territorial Epidemiologists Reston, Virginia Thomas Milne Executive Director, National Association of County and City Health Officials Washington, DC Kristine Moore, MD, MPH Medical Director, Center for Infectious Disease Research and Policy University of Minnesota Minneapolis Michael Osterholm, PhD, MPH (Chair) Director, Center for Infectious Disease Research and Policy University of Minnesota Minneapolis Janet Shoemaker Director, Office of Public Affairs American Society for Microbiology Washington, DC Karl Wittnebel, MD, MPH Senior Program Officer, Biological Programs, NTI Washington, DC Jayne Young Director, Center for Health and Security New York