Bioterrorism Preparedness, Planning, and Response

Legislation and Presidential Directives
US Department of Homeland Security
Preparedness Activities of Other Federal Agencies
Local and State Planning
Hospital Preparedness
Protection of Building Environments
References

Legislation and Presidential Directives

Since 1995, several federal initiatives have been implemented for responding to terrorist acts, including acts of bioterrorism. Key legislative and executive actions that address the threat of terrorism include the following.

Presidential Decision Directive 39 (PDD-39)

The directive was passed in 1995 and defined the responsibilities of federal agencies in responding to acts of terrorism (including bioterrorism). The directive mandated that:

The lead agency for responding to terrorist acts is the Department of Justice (DoJ).
The lead agency for operational response is the Federal Bureau of Investigation (FBI).
The lead agency for consequence management is the Federal Emergency Management Agency (FEMA).

The Defense Against Weapons of Mass Destruction Act (also referred to as the Nunn-Lugar-Domenici Amendments)

This act was passed in 1996 and directed the Department of Defense (DoD) to enhance preparedness against acts of terrorism (see References: Public Law 104-201: National Defense Authorization Act for Fiscal Year 1997).

The act authorized DoD to provide training and exercises to local jurisdictions so that preparedness at the local level would be improved.
The act also authorized the Department of Health and Human Services (DHHS) through the Office of Emergency Preparedness (now the Office of Emergency Response) to develop Metropolitan Medical Response Systems in local jurisdictions.
The Office of Emergency Response also oversees the National Disaster Medical System and the Disaster Medical Assistance Teams. Some of these teams, known as National Medical Response Teams, are specifically trained to provide medical care to victims of attacks involving weapons of mass destruction, including bioterrorism attacks.

The Antiterrorism and Effective Death Penalty Act

This Act was passed in 1996 and authorizes FEMA and the DoJ through the Office of Justice Programs to provide training to local fire, emergency medical, and public safety personnel on responding to terrorism acts (see References: Antiterrorism and Effective Death Penalty Act of 1996).

The Public Health Security and Bioterrorism Preparedness and Response Act of 2002

The 107th Congress passed the Public Health Security and Bioterrorism Preparedness and Response Act in May 2002 (see References: Public Health Security and Bioterrorism Response Act). The purpose of the Act is to improve national public health preparedness. This legislation includes the following key components:

Authorized more than $1.5 billion in grants to help states, local governments, and healthcare facilities to improve their planning and preparedness, enhance lab capacity, and train personnel and to develop new drugs and vaccines.
Authorized more than $1.15 billion for expansion of the Strategic National Stockpile, including the supply of smallpox vaccine.
Authorized $300 million for the Centers for Disease Control and Prevention (CDC) to upgrade facilities for dealing with public health threats.
Imposed new registration requirements on all possessors of the 36 biological agents and toxins most dangerous to humans and provides for similar regulation of agents that are devastating to crops and livestock.
Authorized $545 million for the Food and Drug Administration (FDA) and US Department of Agriculture (USDA) to hire hundreds of food-import inspectors, develop new methods to detect contaminated foods, and protect crops and livestock.
Empowered the FDA to detain suspicious foods for inspection, require advance notice of food imports, and gain better access to records needed for investigate the source of food contamination.
Authorized more than $100 million to help water utilities analyze the vulnerability of drinking-water systems to deliberate contamination.

The Homeland Security Act of 2002

In November 2002, the 107th Congress passed the Homeland Security Act of 2002; the President signed the Act into law on November 25, 2002 (see References: Homeland Security Act of 2002). The Act authorizes a major restructuring of the federal government in creating the new Department of Homeland Security (DHS) and specifies its primary responsibilities and functions. The Act became effective on January 1, 1003, with a transition period of at least 12 months. Information about the responsibilities and functions of the Homeland Security Department can be found in the Department of Homeland Security section below.

Management of Domestic IncidentsHomeland Security Presidential Directive 5 (HSPD-5)

HSPD-5, issued Feb 28, 2003, calls for the establishment of a consistent, nationwide system to coordinate how federal, state, and local governments prepare for, respond to, and recover from terrorist attacks, major disasters, and other emergencies (see References: Homeland Security Presidential Directive 5). DHS is directed to develop and administer a National Response Plan (NRP) integrating national prevention, preparedness, response, and recovery plans into a single, all-discipline, all-hazards plan. The NRP includes protocols for operating under different threats or threat levels. The National Incident Management System (NIMS), which provides the structure and mechanism for the NRP, includes the following features:

A core set of concepts, principles, terminology, and technologies covering the incident command system
Multi-agency coordination systems
Unified command under DHS
Training
Identification and management of resources (including systems for classifying types of resources)
Qualifications and certification
Collection, tracking, and reporting of incident information and incident resources

All federal departments and agencies are required to participate in and use NIMS in domestic incident management activities and in emergency prevention, preparedness, response, recovery, and mitigation activities.

National PreparednessHomeland Security Presidential Directive 8 (HSPD-8)

As a companion document to HSPD-5, the National Preparedness Directive, issued Dec 17, 2003, establishes policies aimed at strengthening the preparedness of the United States to prevent and respond to threatened and actual domestic terrorist attacks, major disasters, and other emergencies (see References: Homeland Security Presidential Directive 8). It directs federal departments and agencies to:

Develop a national domestic all-hazards preparedness goal, coordinated by DHS and implemented through the provision of federal preparedness assistance to state and local governments, preparation of first-responders, and measurements to assess preparedness
Establish mechanisms for improved delivery of federal preparedness assistance (eg, through planning, grants, cooperative agreements, loans, comprehensive training, homeland security preparednessrelated exercises, technical assistance, and equipment acquisition for major events) to state and local governments
Strengthen preparedness capabilities of federal, state, and local entities by supporting actions that contribute to the national preparedness goal; this includes maintenance of teams, stockpiles, and caches consistent with requirements of the NRP and adoption of quantifiable performance measurements in the areas of training, planning, equipment, and exercises

US Department of Homeland Security

DHS, a new cabinet-level office, was established in response to the events of Sep 11, 2001, to protect the nation against further acts of terrorism and to enhance its ability to prepare for and recover from terrorist attacks. DHS works with other federal departments and agencies, state and local governments, and the private sector to coordinate the analysis of threats and intelligence, guard borders and airports, protect critical infrastructures, and enhance capabilities for emergency preparedness and response. The Homeland Security Act of 2002 defines the department's primary missions and responsibilities and establishes its principal offices. The creation of DHS represents one of the largest reorganizations of the federal government in US history, involving the consolidation of 22 previously disparate federal agencies (see below).

The primary missions of DHS include:

Preventing terrorist attacks within the United States
Reducing the vulnerability of the United States to terrorism at home
Minimizing the damage and assisting in the recovery from any attacks that may occur
Coordinating homeland security responsibilities with other parts of the federal government, with state and local governments, and with the private sector

Effective Mar 1, 2003, the Secret Service (previously in the Department of the Treasury) and the Coast Guard (Department of Transportation [DOT]) were transferred to DHS and report directly to the DHS secretary. The former Immigration and Naturalization Service was transferred to DHS and became the Bureau of Citizenship and Immigration Services. Additional DHS offices include the Office of State and Local Government Coordination, the Office of Private Sector Liaison, and the Office of Inspector General.

Other major responsibilities of DHS are being divided among four directorates. Selected agencies, programs, or resources from elsewhere in the federal government eventually will be transferred (wholly or in part) to one of these directorates. The four directorates are:

Information Analysis and Infrastructure Protection (IAIP)
Science and Technology (S&T)
Border and Transportation Security (BTS)
Emergency Preparedness and Response (EP&R)

Information Analysis and Infrastructure Protection

The IAIP Directorate coordinates capabilities for identifying, analyzing, and disseminating information on current and future threats, partnering with all intelligence-generating agencies. Its specific responsibilities include:

Receiving and analyzing law enforcement information, intelligence, and other information in order to detect and understand the nature and scope of potential terrorist threats to the United States and its allies
Comprehensively assessing the vulnerabilities of key resources and critical infrastructures
Integrating relevant information, intelligence analyses, and vulnerability assessments to identify protective priorities and support protective measures
Developing a comprehensive national plan for securing key resources and critical infrastructures
Taking or seeking to effect necessary measures to protect the nation's key resources and infrastructures (eg, food, water, agriculture, and health and emergency services; energy sources and conduits; transportation; information and telecommunications systems; banking and finance; postal services; and other essential assets and systems)
Administering the Homeland Security Advisory System, exercising primary responsibility for public threat advisories as well as for provision of specific warning information and appropriate protective actions and countermeasures to state and local governments and the private sector
Reviewing, analyzing, and making recommendations for improvements in the policies and procedures governing the sharing of law enforcement, intelligence, and other information relating to homeland security within the federal government and between the federal government and state and local governments

Federal resources being brought together under the IAIP Directorate include:

National Infrastructure Protection Center (Department of Justice [in the FBI])
National Communications System (DoD)
Critical Infrastructure Assurance Office (Department of Commerce)
Energy Security and Assurance Program (Department of Energy [DOE])
Federal Computer Incident Response Center (General Services Administration [GSA])

Science and Technology

The S&T Directorate is the primary research and development division for DHS. Its goal is to leverage the nation's scientific and technical resources to prevent or mitigate against threats to the nation's security that could result in large-scale loss of life or major economic losses. The main responsibilities of this directorate are:

Sponsoring research, development, and testing to improve current capabilities or invent new vaccines, antidotes, diagnostics, and therapies against biological and chemical warfare agents
Coordinating the federal government's efforts to develop and implement scientific and technological countermeasures against catastrophic terrorism, including channeling the intellectual energy and extensive capacity of important scientific institutions, such as the national laboratories and academic institutions
Conducting a national scientific research and development program to support the mission of the department, including developing national policy and coordinating the federal government's (nonmilitary) efforts to counter chemical, biological, radiological, or nuclear weapons or other emerging threats (likely to be done via agreements with DHHS)
Establishing priorities and directing and supporting national research on, development of, and procurement of technology and systems for detecting, preventing, protecting against, and responding to terrorist attacks using chemical, biological, radiological, nuclear, or related weapons and materials; preventing the importation of such weapons and materials into the United States
Establishing guidelines for state and local efforts to develop and implement countermeasures in this area
Promoting research and technology to develop sensors to detect chemical and biological weapons from production to deployment

Federal resources being brought together under the S&T Directorate include:

Chemical, Biological, Radiological, and Nuclear (CBRN) Countermeasures Program (DOE)
Environmental Measurements Laboratory (DOE)
National Bio-Weapons Defense Analysis Center (DoD)
Plum Island Animal Disease Center (USDA)

Border and Transportation Security

The BTS Directorate manages border and transportation security and the enforcement of immigration law. Its responsibilities include:

Preventing the entry of terrorists and the instruments of terrorism into the United States
Securing the borders, territorial waters, ports, terminals, waterways, and air, land, and sea transportation systems of the United States
Administering the immigration and naturalization laws of the United States, including the establishment of rules governing the granting of visas and other forms of permission to enter the United States to individuals who are not citizens or lawful permanent residents
Administering the customs laws of the United States
Ensuring the speedy, orderly, and efficient flow of lawful traffic and commerce in carrying out these responsibilities

Federal resources being brought together under BTS include:

The US Customs Service (Treasury)
The enforcement division (eg, border patrol and investigative agents) of the former Immigration and Naturalization Service (DoJ)
Animal and Plant Health Inspection Service (in part) (USDA)
Transportation Security Administration (DOT)
Federal Protective Service (GSA)
Federal Law Enforcement Training Center (Treasury)
Office for Domestic Preparedness (DoJ)

Emergency Preparedness and Response

Preparing for and recovering from the consequences of catastrophesboth natural and manmadeis the primary focus of EP&R. The Directorate's oversight of the federal government's national response and recovery strategy includes the following responsibilities:

Helping to ensure the preparedness of emergency response providers for terrorist attacks, major disasters, and other emergencies
Establishing standards, conducting exercises and training, evaluating performance, and providing funds for the Nuclear Incident Response Team
Providing the federal government's response to terrorist attacks and major disasters
Aiding recovery from terrorist attacks and major disasters
Working with other federal and nonfederal agencies to build a comprehensive national incident management system
Consolidating existing federal government emergency response plans into a single, coordinated national response plan
Developing comprehensive programs for developing interoperative communications technology and ensuring that emergency response providers acquire such technology

Federal resources being brought together under the Emergency Preparedness and Response directorate include:

FEMA
Nuclear Incident Response Team (DOE)
Domestic Emergency Support Teams and the National Domestic Preparedness Office (DoJ)
Metropolitan Medical Response System (DHHS)
National Disaster Medical System (Veterans Affairs, FEMA, DoD, and DHHS partnership) (see References: DHS: NDMS)
Strategic National Stockpile (DHHS)

Preparedness Activities of Other Federal Agencies

Numerous federal departments and agencies have roles in preparing for or responding to bioterrorism events. As indicated above, some of these functions have been or are in the process of being transferred to DHS. Summaries of federal activities related to bioterrorism are as follows.

A report issued on Oct 9, 2001, from the General Accounting Office identified the federal departments and agencies that have responsibilities related to the medical and public health consequences of a bioterrorism attack (see References: GAO: Bioterrorism: Public health and medical preparedness).
Preparedness activities within DHHS also were outlined in testimony by D. A. Henderson (then director of the Office of Public Health Preparedness) before the Committee on Science of the US House of Representatives on Dec 5, 2001 (see References: Henderson 2001).

Key preparedness and planning responsibilities of selected federal agencies other than DHS are outlined in the table below.

Bioterrorism Medical and Public Health Preparedness: Key Responsibilities Among Selected Federal Agencies Other Than the Department of Homeland Security (DHS)*
*Agency*	*Key responsibilities*	*Links*
US Department of Agriculture (USDA)	—Personnel conduct cargo and product inspections of travelers and baggage at borders to prevent the entry of animal or plant pests and diseases. —Food Safety Inspection Service inspects farms and other production and processing sites to assure food safety. —Participates in several foodborne disease surveillance systems that involve collaboration between the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and US Department of Agriculture (USDA).	USDA Homeland Security Web page Food Safety Inspection Service: Food Defense & Emergency Response
Department of Defense (DoD)	—Several areas of DoD are involved in biosecurity, including the Defense Threat Reduction Agency, the Defense Advance Research Projects Agency, and the Joint Task Force of Civil Support. —The National Guard and US Army also have responsibilities for responding to crises. —The US Army Medical Research Institute of Infectious Diseases conducts research on potential bioterrorist agents and provides guidance on medical management issues.	US Department of Defense Defense Threat Reduction Agency US Army Medical Research Institute of Infectious Diseases
Department of Health and Human Services (DHHS)
Agency for Healthcare Research and Quality (AHRQ)	Funds various projects to improve preparedness. Examples: ~Training modules to teach health professionals how to address varied biological agents ~Best methods of training clinicians ~Tools for assessing hospital preparedness	AHRQ: Responding to Bioterrorism Public Health Emergency Preparedness Bioterrorism and Emerging Infections
CDC	—The goal of CDC's bioterrorism program is to enhance public health preparedness against bioterrorism attacks. Areas of focus include: ~Surveillance ~Epidemiology ~Rapid laboratory diagnosis ~Emergency response ~Information systems CDC works toward its goal by: ~Providing funding to state and selected local health departments ~Coordinating the Health Alert Network ~Coordinating the Laboratory Response Network —CDC also participates in several foodborne disease surveillance systems that involve collaboration between CDC, FDA, and USDA. —Recently, CDC coordinated the smallpox vaccination program through state and local health departments.	CDC: Public Health Emergency Preparedness & Response CDC's Bioterrorism and Public Health Preparedness
CDC: National Institute for Occupational Safety and Health (NIOSH)	Issues guidance documents on worker safety and safety in the workplace.	NIOSH: Emergency Response Resources
FDA	—Conducts various programs on food safety. —Recently published a guidance document for industry on food security prevention measures. —Monitors the occurrence of foodborne illnesses through several surveillance systems that involve collaboration between CDC, FDA, and USDA.	FDA information on counterterrorism
Health Resources and Services Administration (HRSA)	Has primary responsibility for promoting hospital preparedness for mass casualty events, including those caused by bioterrorism.	HRSA information on bioterrorism preparedness activities
National Institutes of Health (NIH)	Has funded research in the areas of diagnostics, clinical therapies, vaccines, and basic science through the National Institute of Allergy and Infectious Diseases (NIAID).	NIAID biodefense activities
Office of the Assistant Secretary for Public Health Emergency Preparedness	—Ccoordinates public health preparedness for terrorism acts, including bioterrorism. —Includes the Office of Emergency Response, which houses the Secretary's Command Center, a state-of-the-art command facility.	Office of the Assistant Secretary for Public Health Emergency Preparedness
Department of Justice (DoJ): Federal Bureau of Investigation (FBI)	Responsible for coordinating federal domestic preparedness against weapons of mass destruction. Counterterrorism Division includes National Domestic Preparedness Office	Federal Bureau of Investigation (FBI)
Department of Veterans Affairs (VA)	—Provides medical backup to DoD and DHHS as needed for medical disasters. —Provides support to DHHS/DHS for maintaining the Strategic National Stockpile.	Statement before the House Committee on Veterans Affairs regarding the VA's ability to respond to DoD contingencies and to national emergencies
Environmental Protection Agency (EPA)	—Has the authority and responsibility to prepare for and respond to emergencies involving oil, hazardous substances, and certain radiologic materials. —Has required communities to develop emergency plans for release of hazardous substances through Local Emergency Planning Committees. —Has assisted in training first-responders to handle terrorist events. —In the event of a terrorist act involving environmental contamination, EPA is responsible for assisting with environmental monitoring, decontamination efforts, and long-term site cleanup.	EPA Emergency Management Programs
*Other federal departments and agencies also are involved in bioterrorism preparedness. Examples include the Department of Commerce (National Institute of Standards and Technology Office), the Department of Energy. Information about preparedness activities of other federal agencies can be found at First Gov: America Responds to Terrorism: Government Agencies Perform after September 11, 2001.

Local and State Planning

Bioterrorism Funding to State and Local Health Departments

Passage of the Bioterrorism Act of 2002 provided funding to all states for bioterrorism preparedness through a cooperative agreement program operated by CDC. The agreement provides support to state and selected local health departments in the following areas (see References: CDC: Public Health Emergency Preparedness and Response: Preparation and Planning: Cooperative Agreement Award Notice and Grant Guidance):

Preparedness planning and readiness assessment (Focus Area A): Establish strategic leadership, direction, assessment, and coordination of activities within the jurisdiction.
Surveillance and epidemiology capacity (Focus Area B): Enable state and local health departments to enhance, design, and develop systems for rapid detection of unusual outbreaks that may be the result of bioterrorism.
Laboratory capacitybiological agents (Focus Area C): Ensure that core diagnostic capabilities for bioterrorism agents are available at all state and major city/county public health laboratories.
Laboratory capacitychemical agents (Focus Area D): Ensure that core diagnostic capabilities for chemical agents are available at all state and major city/county public health laboratories.
Health Alert Networ)/Communications and Information Technology (Focus Area E): Enable state and local public health agencies to establish and maintain a network that will:

Support exchange of key information and training by linking public health and private partners
Provide rapid dissemination of public health advisories to news media and the public
Ensure secure electronic data exchanges
Ensure protection of data, information, and systems, with adequate backup, organizational capacity, and surge capacity

Risk Communication and Health Information Dissemination (Focus Area F): Ensure that state and local public health organizations develop an effective risk-communication capacity that provides for timely information dissemination to the public during a bioterrorist attack.
Education and Training (Focus Area G): Ensure that state and local health departments have the capacity to:

Assess the training needs for key public health and clinical care providers in their jurisdictions
Ensure that education and training are provided to key target audiences

Top 10 Suggestions from State Health Officials Who've Been There

In January 2002, the Association of State and Terrotorial Health Officials (ASTHO) convened several sessions with state health officials affected by the terrorist and bioterrorist attacks that began on Sep 11, 2001. These officials developed a list of the top 10 suggestions for other state public health officials to consider as they develop their bioterrorism preparedness plans (see References: ASTHO). Several preparedness assessment tools for state and local public health agencies also are available on the ASTHO Web site (see References: ASTHO: Preparedness assessment tools).

Actions to take before an emergency

Establish strong relationships with top state officials in law enforcement.

Establish these relationships among the highest levels to avoid complex chains of communication.
Disaster sites that are also crime scenes have special chain-of-evidence issues that should be discussed with law enforcement.

Prepare for the possibility that various levels of law enforcement may have poor communications among themselves (FBI, DoJ, state and local authorities).

Recognize that public health may sometimes serve as a communications bridge between different law enforcement agencies.
Establish strong relationships with top state officials in law enforcement.
Prepare procedures for addressing classified information issues.
Build protocols with law enforcement for determining what information is classified and what can be made public.
Create a team of law enforcement and public health personnel that can assess each new piece of information. Give this team the authority to make on-the-spot decisions about what can be made public.

Address, in advance of an emergency, who will need FBI security clearance.

Ensure that one or more senior public health staff have sufficient security clearance to be involved in law enforcement activities and briefings.
Determine which local authorities require clearance in order to attend meetings and participate in decision making.

Plan in advance for multi-jurisdictional issues with regional input.

Deal now with issues such as interstate needs, public/private capacity sharing, and out-of-state volunteer credentialing.
Whenever possible, have written agreements and contact protocols for these regional issues.

Review personal information restrictions and emergency powers.

Examine the ability of hospitals to share patient status information in times of emergency and the authority of the health department to lift privacy restrictions.
Plan for concerns of vital records, including death certificates and identity theft.

Actions when an emergency occurs

Arrange for the availability of an immediate 1-800 phone number.

More than one number may be needed so that providers, law enforcement, and others can reach the department 24 hours a day. Announce availability of the numbers immediately to avoid confusion and frustrations.
A separate number should be made available for general inquiries and public information.

Capitalize on strong relationships between the public health and provider communities.

Work with local public health authorities to reach out to providers.
Distribute fact sheets, diagnostic guides, procedural protocols, and contact information to the provider community.

Recognize the emotional and mental health needs of first-responders, health department personnel, and the public.

To mitigate post-traumatic stress concerns, have on-site teams available for first-responders, including mental health counselors and other therapeutic services.
In longer-term stress situations, provide opportunities for health department staff not directly involved to make contributions to the effort. Address their safety concerns and attempt rumor control through information sharing.

Address long-term outcomes of the current events.

Recognize and prepare for long-term mental health and substance abuse needs of the general public following such events.
Strengthen occupational health monitoring systems and build up syndromic surveillance systems for future events.
Establish support services for survivors.
Revisit your emergency response plan. Update, discuss, and revise it as needed, and ensure that all personnel are prepared to implement it.

Guidance from the National Association of City and County Health Officials

In January 2001, the National Association of City and County Health Officials (NACCHO) published a guidance document titled Elements of Effective Bioterrorism Preparedness: A Planning Primer for Local Public Health Agencies (see References: NACCHO).

The document relates preparedness planning to the following essential public health services and suggests that questions be considered under each to assess preparedness:

Monitor health status to identify community health problems

Do the agency and its partners monitor indicators that may signal a public health emergency?
Is reporting and analysis of surveillance data sufficiently timely for emergency situations?

Diagnose and investigate health problems and health hazards in the community

Does the agency's information system have sufficient capacity for rapid, secure communication and dissemination of important health information?
Does the agency have adequate access to epidemiologic expertise?
Do the agency and its partners have adequate access to laboratory diagnostic capability to investigate and identify the causes of a public health emergency?

Inform, educate, and empower people about health issues

Has the agency developed protocols for releasing information to the local media in the event of a bioterrorist attack?
Does the agency have a protocol for contacting other community partners responsible for emergency response?
Does the local public health system have the capacity to rapidly inform and educate the local agency about a public health emergency?

Mobilize community partnerships to identify and solve health problems

Has the local agency identified and contacted all necessary local, state, and federal partners that address emergency preparedness and response issues?
Is the local agency's response plan informed by and integrated with other community emergency response plans?
Does the local agency collaborate with all necessary community partners that address emergency preparedness and response issues?

Develop policies and plans that support individual and community health efforts

Does the response plan formally identify what will be expected of the agency and its partners in an emergency situation?
Does the agency's response plan link with partners' plans and broader emergency plans for the jurisdiction?
Does the response plan include rosters and inventories for identifying local personnel and resources?
Does the agency have a response plan that includes all appropriate protocols and guidance needed during an emergency?
Does the response plan include how the Strategic National Stockpile resources will be accessed and used?
Has the plan been tested through tabletop simulations or filed exercises?

Enforce laws and regulations that protect health and ensure safety

Have the agency and its partners reviewed and evaluated laws and regulations regarding emergency preparedness and response?
Has the agency updated regulations or recommended legislative changes to existing statutes to assure appropriate authority in an emergency?

Link people to needed personal health services and assure the provision of healthcare when otherwise unavailable

Can the agency assure community access to critical health services during an emergency?
Do the agency and its partners have plans for expanding the emergency medical system to include other resources when the demand surpasses existing capacity?
Can the agency and its partners assure effective medical management of patients and the "worried well" during an emergency?

Assure a competent public health and personal healthcare workforce

Has the agency conducted an assessment of the competencies and training needs of its workforce as they relate to bioterrorism and other public health emergencies?
Does the agency have access to training and continuing education opportunities?

Evaluate effectiveness, accessibility, and quality of personal and population-based health services

Has the agency recently organized or participated in a tabletop scenario to assess response readiness?
Does the agency have a plan to continually improve its response plan?

Research for new insights and innovative solutions to health problems

Do the agency and its partners in the system conduct or participate in research related to bioterrorism or other public health emergencies?
Do the agency and its partners access and share innovative research on public health emergencies?

Hospital Preparedness

Issues around hospital preparedness and training have been addressed by several federal agencies and professional organizations, including:

DHHS

Health and Resources Services Administration (HRSA)
CDC

American Hospital Association (AHA)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Association for Professionals in Infection Control and Epidemiology (APIC)

DHHS Activities

HRSA hospital bioterrorism preparedness activities include (see References: HRSA):

The Hospital Bioterrorism Preparedness Program, which facilitates development of coordinated hospital preparedness plans at the state and local levels through a cooperative agreement funding process
Training in hospital preparedness activities

CDC has facilitated hospital preparedness through:

Development of infection control guidelines for managing bioterrorism events (see References: APIC/CDC: Bioterrorism readiness plan: a template for healthcare facilities); this document was prepared by the APIC Bioterrorism Task Force in conjunction with CDC
Development of the Laboratory Response Network, which provides guidance and protocols to hospital clinical laboratories on handling and processing specimens for identification of the Category A bioterrorism agents (see References: CDC: Public health emergency preparedness and response: laboratory information)
Providing support to state health departments for hospital bioterrorism coordinators through a cooperative agreement process (see References: CDC: Public health emergency preparedness and response: preparation and planning: cooperative agreement award notice and grant guidance)

AHA Resources on Hospital Preparedness for Mass Casualties

In March 2000, AHA convened a forum of experts to develop recommendations and strategies for hospitals and hospital associations around issues related to hospital preparedness for mass casualty events (see References: AHA: Hospital preparedness for mass casualties). The group addressed the following issues:

Community-wide preparedness
Staffing
Communication
Public policy

Key recommendations from the forum included the following:

Hospitals will have a key role in responding to any major disaster; therefore, hospitals need to be involved in community planning efforts.
Hospitals may be the "victims" of a disaster; therefore, hospitals need to have plans for evacuation, quarantine, and diversion of incoming patients.
A list of candidates for a "reserve staff" should be developed, and these persons should receive regular training so they can immediately step into roles in the hospital on an as-needed basis.
The Federation of State Medical Boards should develop procedures allowing physicians licensed in one jurisdiction to practice in another under defined emergency conditions.
Medical staff credentials committees should develop a policy on the recognition of temporary privileges in emergency situations.
Backup and redundant communications systems (both internal and external) need to be developed, tested, and drilled.
A single community spokesperson for the mass casualty incident needs to be identified in advance.
Community-wide systems for locating patients need to be planned with a single point of contact.
A means of paying for hospital planning, education, standby supplies, and training for mass casualty events needs to be determined.
The Emergency Medical Treatment and Labor Act (EMTALA) needs to be refined to establish "safe harbor" provisions so that a hospital assigned a role of caring for unexposed patients does not have to violate either its status as a "clean" facility or its EMTALA obligation.
Federal provisions are needed to assure financial relief to assist hospitals in caring for disaster victims and in disaster recovery.
Standardized resources for staff training, building design, and facilities operations should be developed and disseminated.

AHA has developed a chemical and bioterrorism checklist for hospitals to assess their state of preparedness for chemical and biological incidents (see References: AHA: Chemical and bioterrorism preparedness checklist).

Additional resources are available from AHA through their Disaster Readiness Web site (see References: AHA: Disaster Readiness).

Bioterrorism Readiness Plans

Several organizations have published bioterrorism or disaster readiness plans on the Internet. Examples include the following:

California Department of Health Services: California Hospital Bioterrorism Response Planning Guide
Stanford Hospital: Stanford Hospital Bioterrorism Response Preparedness Plan
Wisconsin Department of Health & Family Services: Hospital Disaster Plan
APIC/CDC: Bioterrorism Readiness Plan: A Template for Healthcare Facilities

JCAHO Standards That Address Mass Casualty Preparedness

Several JCAHO standards require hospitals to prepare for mass casualty events, including those caused by bioterrorism (see References: JCAHO: Emergency management in the new millennium).

Two Environment of Care (EC) standards that address emergency preparedness were revised in January 2002 (see References: JCAHO: Emergency management standards EC.1.4 and EC.2.9.1):

The organization has an emergency management plan (Standard EC 1.4)
Drills are conducted regularly to test emergency management (Standard EC 2.9.1)

According to the revised JCAHO standard EC 1.4, "The emergency management plan must comprehensively describe the organization's approach to responding to emergencies within the organization or in its community that would suddenly and significantly affect the need for the organization's services, or its ability to provide those services." The plan must addresses the four phases of emergency management:

Mitigation
Preparedness
Response
Recovery

Protection of Building Environments

In May 2002, the National Institute of Occupational Safety and Health (NIOSH) released a guidance document, Protecting Building Environments from Airborne Chemical, Biological, or Radiological Attacks (see References: NIOSH 2002). The major recommendations from the document includeg:

Physical security

Prevent access to outdoor air intakes (relocate outdoor air intake vents, extend outdoor air intakes, establish a security zone around outdoor air intakes).
Prevent public access to mechanical areas.
Implement security measures (guards, alarms, cameras) to protect vulnerable areas.
Isolate lobbies, mailrooms, loading docks, storage areas.
Secure return air grilles.
Restrict access to building operation systems.
Consider general building physical security upgrades (such as fencing, access points).

Ventilation and filtration

Evaluate heating, ventilation, and air conditioning (HVAC) control options and consider adding new options if deemed necessary.
Assess filtration and increase filter efficiency if deemed necessary.
Assess ducted and nonducted return air systems to minimize mixing between air-handling systems.
Consider installing low-leakage dampers to minimize flow of outdoor air into the building when the HVAC system is shut down.
Maximize building air tightness.

Maintenance, administration, and training

Emergency plans, policies, and procedures should be in place.
Conduct ongoing training for HVAC maintenance staff.
Conduct ongoing preventive maintenance of the HVAC system.

Things not to do

Don't permanently seal outdoor air intakes.
Don't modify the HVAC system without first understanding the effects on the building systems and occupants.
Don't interfere with fire-protection and life-safety systems.

Additional information, including specific and detailed instructions for filtration and air cleaning, can be found in a companion NIOSH document, Guidance for Filtration and Air-Cleaning Systems to Protect Building Environments from Airborne Chemical, Biological, or Radiological Attacks (see References: NIOSH 2003.)

References

AHA. Chemical and bioterrorism preparedness checklist [Full text]

AHA. Disaster readiness [Web page]

AHA. Hospital preparedness for mass casualties. Aug 2000 [Full text]

Antiterrorism and Effective Death Penalty Act of 1996. Public Law 104-132 [Full text —may load slowly]

APIC/CDC. Bioterrorism readiness plan: a template for healthcare facilities. Apr 13, 1999 [Full text]

ASTHO. Top 10 suggestions from state health officials who've been there [Full text]

ASTHO. Preparedness assessment tools [Web page]

CDC. Public health emergency preparedness and response: laboratory information [Web page]

CDC. Public health preparedness and response: preparation and planning: cooperative agreement award notice and grant guidance [Web page]

DHS: NDMS (National Disaster Medical System) [Home page]

GAO. Bioterrorism: public health and medical preparedness GAO-02-141T. Oct 9, 2001 [Full text]

Henderson DA. The science of bioterrorism: HHS preparedness. Testimony before House Committee on Science. Dec 5, 2001 [Full text]

Homeland Security Act of 2002. Public Law107-296 [Full text]

Homeland Security Presidential Directive 5 (HSPD-5). Management of domestic incidents. Feb 28, 2003 [Full text]

Homeland Security Presidential Directive 8 (HSPD-8). National preparedness. Dec 17, 2003 [Full text]

HRSA. Information on bioterrorism preparedness activities [Web page]

JCAHO. Emergency management in the new millennium. Joint Commission Perspectives 2001 Dec;21(12):1-27 [Full Text]

JCAHO. Emergency Management Standards EC.1.4 and EC.2.9.1 [Full text]

NACCHO. Elements of effective bioterrorism preparedness: a planning primer for local public health agencies. Jan 2001 [Ordering information]

National Defense Authorization Act for Fiscal Year 1997. Public Law 104-201. Weapons of mass destruction are addressed in title XIV [Full text—may load slowly]

NIOSH. Protecting building environments from airborne chemical, biological, or radiological attacks. May 2002 [Full text]

NIOSH. Guidance for filtration and air-cleaning systems to protect building environments from airborne chemical, biological, or radiological attacks. Apr 2003 [Full text]

Office of Emergency Response [Web site]

Public Health Security and Bioterrorism Response Act. Public Law 107-188 [Full text—may load slowly]


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