Feb 20, 2008 (CIDRAP News) – The distribution of more than $5 billion in federal funds since 2001 has greatly improved states' preparedness to deal with disease outbreaks, natural disasters, and other public health emergencies, the Centers for Disease Control and Prevention (CDC) said today in a first-of-its-kind assessment.
The CDC report, titled "Public Health Preparedness: Mobilizing State by State," is the agency's first major effort to evaluate and describe what state and local public health agencies have accomplished with the increased federal dollars that flowed to states after the terrorist attacks of 2001.
"There has been significant progress toward achieving this goal" of protecting the public from emerging health threats, Dr. Richard Besser, director of the CDC Coordinating Office for Terrorism and Emergency Response, said at a briefing today.
CDC Director Dr. Julie Gerberding called the report the first of an expected series of such evaluations. "It reflects not the totality of preparedness at the state and local level, but aspects addressed by CDC through the cooperative agreement program with states," she said.
Some prime examples of improvement cited in the 164-page report:
- Every state is now equipped to receive and evaluate health emergency reports at all times, whereas only 12 states had "24/7/365" capability in 2001.
- All states have public health laboratories that can communicate quickly with clinical labs today, compared with only 20 states in 2001.
- Every state now has a plan to receive and distribute drugs and other supplies from the Strategic National Stockpile.
- All states are now conducting year-round influenza surveillance, considered critically important given the threat of pandemic flu.
At the same time, much work remains to be done, including increasing the workforce for public health labs, improving the sharing of disease data, and boosting emergency responders' ability to communicate with one another, the report says.
"Overall, I would give an 'A,' for effort and progress. In terms of work to be done, that's absolutely enormous," said Besser.
$5.6 billion provided
The terrorist attacks of 2001 prompted Congress to turn on the funding tap by authorizing the CDC-administered Public Health Emergency Preparedness cooperative agreement in 2002, the report notes.
From fiscal years 2002 through 2007, the CDC provided a total of $5.59 billion to states and other jurisdictions under the program. Annual allocations (rounded off) were as follows: 2002, $918 million; 2003, $970 million; 2004, $850 million; 2005, $963 million; 2006, $991 million; and 2007, $897 million.
The sums for the last 3 years included sizeable chunks designated for pandemic influenza preparedness: $100 million in 2005, $225 million in 2006, and $175 million in 2007.
The report consists of an overall evaluation and a set of state-by-state reports that show how well states meet a number of criteria for disease detection and investigation, public health labs, and response. The report also evaluates four large urban areas: Washington, Chicago, New York City, and Los Angeles County. The various criteria relate to nine public health goals set by the CDC. States are given no overall grade or rating.
Defining the goals and criteria has been "a challenging process," Gerberding said. "There really is no gold standard for preparedness and no list of preordained measures. . . . We've had to invent the airplane while we were flying it."
The report also provides for each state an example of an actual emergency response, a training exercise, or some other event that illustrates an improvement in public health preparedness since 2001.
Besides those already mentioned, significant improvements cited in the report summary or by officials include the following:
- The number of public health epidemiologists working in emergency response has more than doubled, from 115 in 2001 to 232 in 2006.
- Users of the Epidemic Information Exchange, a CDC-based communication system that helps track disease outbreaks, have increased more than 5-fold, from 890 in 2001 to 4,646 in 2006. Most are in state and local public health.
- State and local public health labs that can detect biological agents now number 110, compared with 83 in 2002.
- In 2005, health departments in all 50 states and Washington DC trained personnel on their roles during an emergency, compared with only 14 states in 1999.
In addition, said Besser, "We are now at a point where 90% of the population lives within 100 miles of a Laboratory Response Network (LRN) laboratory." LRN labs use tests equivalent to those of the CDC for detecting bioterrorism agents and other microbial threats, he said, "So we believe their results and can take action sooner."
The report also offers a considerable list of remaining challenges:
- Disease surveillance systems need strengthening. For example, last year 16 states reported no plans to exchange health data electronically with regional networks of healthcare providers.
- For disease surveillance, health departments need to make sure they have a legal framework permitting them to share health information with other jurisdictions.
- The public health lab workforce needs help, with 31 state labs reporting difficulty recruiting qualified scientists.
- Health departments are having trouble finding and keeping qualified epidemiologists, according to a 2006 survey.
- Health departments need to maintain a system of all-hazards planning, training, exercising, and improving, which should equip them to help at-risk groups such as the elderly.
- Though many cities now have systems that allow different response agencies to communicate, more progress is needed in that area.
While all states now have plans for distributing materials from the Strategic National Stockpile, much more work is needed in that area, said Besser. "Countermeasure distribution is a critical function and one we need to devote our best and brightest to tackling," he said. "Each locality reported in this document faces unique challenges."
Among the success stories in the report is Wisconsin's investigation of the spinach-related Escherichia coli O157:H7 outbreak in the fall of 2006. Wisconsin was the first state to identify the E coli strain in that outbreak, leading to detection of the national outbreak, said Besser. The federal funding provided the lab capacity that made the identification possible, the report says.
The report also tells how Utah responded quickly to a suspected smallpox case in a truck driver in 2006. Physicians had been trained to communicate quickly with public health agencies, and the state lab was able to test quickly for smallpox and determine that the case was actually chickenpox. Before federal aid was increased, the state would have had to send samples to the CDC for testing.
Many of the criteria on which states are judged are questions answered yes or no, and the answers vary considerably among the states.
"A highly variable starting point has led to some highly variable progress reports at this point in time," commented Gerberding. She said the emphasis in the evaluation so far has been on response capacity, adding, "In the future you will see much greater emphasis not on capacity but on results."
In response to a question, Besser said he sees the CDC report as complementing the work of Trust for America's Health (TFAH), a nonprofit organization based in Washington, DC, which has published an evaluation of state preparedness each year since 2003. In its 2007 report, TFAH said that although states have made progress preparing for public health emergencies, federal funding cuts threaten to erode the gains.
"TFAH has done a tremendous service," Besser said of the group's work in monitoring state preparedness.
Gerberding added that the TFAH reports take a broad view of state preparedness, whereas the CDC report specifically assesses the impact of the agency's cooperative agreement program investments.
Public health experts praise report
Several public health experts outside the CDC gave the CDC report generally high marks today.
In a press release, Jeff Levi, PhD, TFAH executive director, called the report "an important first step forward for transparency and accountability.
"By providing information about progress as well as shortcomings, this report allows policymakers and the public to better understand the need for a committed, sustained investment to maintain and improve preparedness," he said. "We look forward to future reports that contain more timely information that closely tracks the performance standards required in the recently passed Pandemic and All Hazards Preparedness Act."
Michael T. Osterholm, PhD, director of the University of Minnesota Center for Infectious Disease Research and Policy, publisher of CIDRAP News, said he gives the CDC and state agencies a lot of credit for gains in preparedness since the 2001 terrorist attacks. "That's a very positive situation," he said.
However, Osterholm said he has two major concerns about the state of preparedness. One is inadequate funding.
"Too many policymakers view preparedness funding like constructing a building: once it's built, it's done," he said. Instead, maintaining a public health system is more like building a fire department, which requires ongoing and substantial investment that allows it to adapt and respond, Osterholm said.
His other concern is that though preparedness systems in the United States are equipped to respond to local or regional events such as a natural disasters, the systems are not prepared for a pandemic that would affect the whole nation, disrupting supply chains of vital products such as food, power, and medications.
Karen Smith, MD, MPH, a spokeswoman for the National Association of County and City Health Officials (NACCHO), called the CDC report a "terrific first step." Smith is also a public health officer in Napa County, Calif.
"This [report] represents an amazing amount of work. Every state is dramatically different, and it's very hard to evaluate disparate areas," she told CIDRAP News. "Though the report does not provide an in-depth look, the data support what we've known: we are better prepared."
Smith also credited the CDC for developing methods to systematically gauge state preparedness and said that such measurement is among the most important preparedness work in public health. "For me at a local level, I hunger for objective ways to see how I'm doing," she said.
Benchmarks will help show federal officials where to focus their resources, Smith said, which is particularly important when public health budgets are stretched or declining.
Full CDC report on state preparedness
Feb 20 CDC press release
Dec 18, 2007, TFAH press release on state preparedness