ISSUE REPORT Ready or Not? PROTECTING THE PUBLIC’S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM2008 DECEMBER 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. TRUST FOR AMERICA’S HEALTH The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to IS A NON-PROFIT, NON-PARTISAN improving the health and health care of all Americans, the Foundation works with a diverse ORGANIZATION DEDICATED TO group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 35 years the Foundation has brought SAVING LIVES AND MAKING experience, commitment, and a rigorous, balanced approach to the problems that affect DISEASE PREVENTION A the health and health care of those it serves. Helping Americans lead healthier lives and get the care they need-the Foundation expects to make a difference in our lifetime. For NATIONAL PRIORITY. more information, visit www.rwjf.org. TFAH BOARD OF DIRECTORS REPORT AUTHORS PEER REVIEWERS Lowell Weicker, Jr. Jeffrey Levi, PhD. TFAH thanks the reviewers for their time, President Executive Director expertise, and insights. The opinions ex- Former 3-term U.S. Senator and Trust for America’s Health pressed in this report do not necessarily rep- Governor of Connecticut and resent the views of these individuals or their Associate Professor in the Department organizations. Cynthia M. Harris, PhD, DABT of Health Policy Vice President Scott J. Becker, MS The George Washington University Director and Associate Professor Executive Director School of Public Health and Health Institute of Public Health, Florida Association of Public Health Laboratories Services A&M University James S. Blumenstock Serena Vinter, MHS Margaret A. Hamburg, MD Chief Program Officer Lead Author and Senior Research Associate Secretary Public Health Practice Trust for America’s Health Senior Scientist Association of State and Territorial Nuclear Threat Initiative (NTI) Rebecca St. Laurent, JD Health Officials Health Policy Research Assistant Patricia Baumann, MS, JD Jonathan E. Fielding, MD, MPH Trust for America’s Health Treasurer Director and Health Officer President and CEO Laura M. Segal, MA Los Angeles County Department of Bauman Foundation Director of Public Affairs Public Health Trust for America’s Health Gail Christopher, DN Margaret A. Hamburg, MD Vice President for Health Senior Scientist WK Kellogg Foundation Nuclear Threat Initiative (NTI) John W. Everets Timothy Jones, MD State Epidemiologist David Fleming, MD Tennessee Department of Health Director of Public Health Seattle King County, Washington Senior Staff Center for Biosecurity Arthur Garson, Jr., MD, MPH University of Pittsburgh Medical Center Executive Vice President and Provost and the Robert C. Taylor Professor of Health Irwin Redlener, MD Science and Public Policy Associate Dean for Public Health University of Virginia Advocacy and Disaster Preparedness Columbia University, Mailman School Robert T. Harris, MD of Public Health Former Chief Medical Officer and Senior Vice President for Healthcare BlueCross BlueShield of North Carolina Alonzo Plough, MA, MPH, PhD Vice President of Program, Planning and Evaluation The California Endowment Theodore Spencer Project Manager Natural Resources Defense Council TABLE OF CONTENTS INTRODUCTION . .3 SECTION 1: State-By-State Public Health Preparedness Indicators and Scores . .11 Indicator 1: Mass Distribution -- Strategic National Stockpile (SNS) . .18 Indicator 2: Mass Distribution -- State Antiviral Purchases . .23 Indicator 3: Public Health Laboratories -- Lab Pickup and Delivery Services . .27 Indicator 4: Public Health Laboratories -- Pandemic Influenza Planning . .29 Indicator 5: Biosurveillance -- NEDSS Compatibility . .32 Indicator 6: Health Care Volunteer Emergency Liability Protection . .35 Indicator 7: Entity Emergency Liability Protection . .38 Indicator 8: Medical Reserve Corps Readiness . .41 Indicator 9: Food Safety -- Detection and Diagnosis . .44 Indicator 10: Public Health Funding Commitment -- State Public Health Budgets . .48 Select 2009 State Preparedness Indicators . .50 SECTION 2: Federal Preparedness . .55 1. Funding for Pandemic and All-Hazards Preparedness . .55 2. Pandemic Influenza Preparedness . .58 3. The State of Federal Preparedness . .59 4. The Implementation of the 2006 Pandemic and All-Hazards Preparedness Act . .66 5. Additional Federal Issues . .66 SECTION 3: Hospital Emergency Preparedness . .72 1. Hospital Preparedness Program . .74 2. Mass Casualty Care . .75 3. Financing Hospital Preparedness . .77 4. Preparedness and Health Reform . .77 SECTION 4: Additional Issues and Concerns . .79 1. Transition Terror: Are We Prepared? . .79 2. At-Risk Populations and Community Resilience . .80 3. Children and Preparedness . .81 4. Behavioral Health Considerations . .83 5. Public Health Workforce . .84 SECTION 5: Recommendations . .85 1. Funding . .86 2. Restructuring of Federal Health Agencies . .88 3. Transparency, Accountability, and Oversight . .90 4. Surge Capacity . .91 5. Preparedness and Health Reform . .92 6. Public Health Workforce . .92 7. Research and Development . .93 8. Legal Preparedness . .94 9. Health and Sick Leave Benefits . .95 10. Food Safety Reforms . .95 11. Community Resiliency . .96 Appendix A: CDC and ASPR Preparedness Grants by State . .98 Appendix B: Influenza Antiviral Drug Purchases by States, Territories, and Select Cities . .99 Appendix C: Data and Methodology for State Indicators . .100 Appendix D: Federal Preparedness Advisory Groups, Panels and Committees . .104 Appendix E: Key Deliverables and Due Dates under PAHPA . .107 Endnotes . .112 1 Introduction ore than seven years after the terrorist attacks of September 11, 2001 Mand the subsequent anthrax-laced mailings in October of that year, and three years after Hurricanes Katrina and Rita devastated the Gulf Coast region, America has grown complacent about public health emergency preparedness. In January 2009, President-elect Barack Obama will be inaugurated as president. Periods of governmental transition, here and abroad, are often seen as a time when new leaders are tested in international affairs, especially during war-time. Many national security experts are concerned that the United States could face another terrorist attack, which requires higher levels of vigilance, including increased attention to possible bioterror threats.1 President- elect Obama has noted the importance of assuring a smooth transition. Asked about his transition team’s priorities he told CBS’s 60 Minutes, “Number one, I think it’s important to get a national security team in place because transition periods are potentially times of vulnerability to a terrorist attack.”2 While significant progress has been made to of economic deterioration, and based on the better protect the country from health emer- course of past recessions, the Center predicts gencies, funding for essential programs has that 2010 state budget gaps will be about $100 been cut, putting these improvements in billion.3 Trust for America’s Health (TFAH) jeopardy. Additionally, a number of critical is deeply concerned about the potential im- areas of preparedness still have significant pact of these budget cuts on states’ ability to gaps, including surge capacity and biosur- be prepared for emergencies. veillance systems, and these problems are less Pandemic flu, emerging infectious diseases, likely to be addressed as funding decreases. terrorism, and catastrophic natural disasters Federal funding for state and local prepared- remain serious threats to our national security. ness is down more than 25 percent from FY Instead of cutting these programs, President- 2005 levels. In addition, there is no longer elect Obama, his administration, and the any supplemental funding for states and lo- 111th Congress must prioritize public health calities for pandemic influenza preparedness, emergency preparedness and dedicate sus- even though state and local public health de- tained and increased funding to ensure Amer- partments are expected to play a key role in icans are well protected. the nation’s strategy for combating pandemic Americans expect and rely on the govern- influenza. State and local governments will ment to protect them from terrorism and not be able to make up for the shortfalls in the natural disasters, since people have little current economic climate. According to the power to protect themselves from these Center on Budget and Policy Priorities, 33 crises. In a recent survey conducted by states are facing shortfalls to their 2009 state Greenberg Quinlan Rosner Research and budgets, and 16 states already project short- Public Opinion Strategies for TFAH, 61 per- falls to their 2010 budgets. At the current rate 3 cent of Americans say that preparing for areas, however, where continued, concerted major disasters is a very important issue for action is needed. From assuring an adequate government to focus on. stockpile of pandemic influenza counter- measures to having adequate laboratory ca- It is also clear that Americans will blame the pacity to respond to a chemical or government if preparedness is lacking dur- radiological event, federal and state policies ing future emergencies. When Americans still fall short of their stated goals. In many learn more about the details of gaps in pre- other areas, a lack of transparency makes it paredness, they are very concerned and be- hard for the American people