Providing a Framework for Public Health Action and Bioterrorism Preparedness: Recommendations for Federal Funding of Public Health Activities
Prepared by The Center for Infectious Disease Research and Policy University of Minnesota And The Workgroup on Bioterorrism Preparedness
The Center for Infectious Disease Research and Policy, University of Minnesota, brought together a Workgroup on Bioterrorism Preparedness on October 3, 2001. The Workgroup included members from the following organizations: the American Society for Microbiology, the Alfred P. Sloan Foundation, the Association of Public Health Laboratories, the Association of State and Territorial Health Officials, the Center for Infectious Disease Research and Policy at the University of Minnesota, the Council of State and Territorial Epidemiologists, Emory University School of Public Health, the Infectious Diseases Society of America, the Johns Hopkins Center for Civilian Biodefense Studies, the National Association of County and City Health Officials, the National Association of State Public Health Veterinarians, and NTI. The members did not seek endorsement from their respective organizations for the recommendations contained in this report and the recommendations may not reflect the position of the respective organizations.
The meeting of the Workgroup was supported by NTI.
Recommended Federal Funding for a Public Health Response to Bioterrorism
The following amounts are needed for hospitals and federal, state, and local public health agencies to effectively respond to bioterrorism. The funds identified below represent an initial investment in upgrading the public health system for biodefense. Additional funds will be needed to effectively maintain such systems over time. The numbers provided below represent a first effort to achieve broad consensus in the public health community regarding funding for bioterrorism; the numbers will likely be refined with further discussion.
|1. Improve State and Local Preparedness
|$835 million (broken out in items a-d)|
a. Bioterrorism Preparedness Planning
b. Staffing, Training, Epidemiology, and Surveillance
c. Information and Communication Systems
d. Laboratory Enhancement
|2. Upgrade CDC Capacity for Bioterrorism||$153 million|
|3. Develop Federal Expert Response Teams||$45 million|
|4. Improve Hospital Response Capabilities||$295 million|
|5. Improve Disaster Response Medical Systems||$62 million|
|6. Improve International Surveillance||$20 million|
|7. Improve Food Safety||$100 million|
|8. Develop and Implement Applied Research Initiatives||$50 million|
|9. Improve the National Pharmaceutical Stockpile (NPS)||$250 million|
|10. Accelerate Development of Smallpox Vaccine||$60 million|
|11. Develop Other Vaccines for Civilian Use||$100 million|
1a. Improve State and Local Preparedness: Bioterrorism Preparedness Planning (Amount: $35 million)
Justification for Funding Recommendations
Every state and all local communities with moderately large populations should have a bioterrorism preparedness plan in place and the plan should be validated through simulation exercises. Planning at the state or local level should involve the public health agency (or agencies) and all other agencies that would be involved in responding to a bioterrorism event. An estimated $500,000 is needed, on average, for each state and territory and for the largest metropolitan areas to support the costs of immediately developing and testing a comprehensive plan (assuming up to 70 jurisdictions).
- In 1999,many states applied for CDC funding for bioterrorism preparedness planning, but only 11 were funded. For those states whose applications were approved but not funded, the existing CDC cooperative agreement provides a mechanism to fully fund those activities and to rapidly move funds out to those states for implementation.
State and local health departments must improve their ability to recognize and respond to bioterrorism events by integrating bioterrorism preparedness activities into existing communicable disease prevention and control programs.
- The CDC's Emerging Infections Programs, which are now operational in nine states, have been highly successful in enhancing the kind of long-term capacity needed at the state level and should be redesigned to include bioterrorism activities and expanded to other states and selected large metropolitan areas.
- Additional funds are needed to train public health practitioners (epidemiologists, physicians, nurses, veterinarians, educators, and other program staff) to respond to bioterrorism events and to rapidly and effectively coordinate their actions across local, state, and federal agencies. Resources also are needed to recruit and train more public health practitioners (including medical and veterinary epidemiologists) through schools of public health and other colleges.
Bioterrorism events may originate from or involve animal populations; therefore, every state health department should have a State Public Health Veterinarian who can provide expertise in zoonotic diseases. Currently, about half of the states have a designated State Public Health Veterinarian.
An effective response will require close coordination between federal, state, and local agencies. Expertise must be available at each level to meet the demands of a bioterrorism crisis. Although federal leadership will be critical, too much reliance on federal resources may limit the overall effectiveness of a response. An estimated 1.33 million dollars is needed per 1 million population per year to implement and maintain bioterrorism preparedness activities.
1c. Improve State and Local Preparedness: Information and Communication Systems (Amount: $200 million)
Several essential information systems have been developed (or are in development) to effectively disseminate outbreak and disease information within or across jurisdictions. Funds are needed to expand or fully implement these systems to assure an effective response to bioterrorism.
- A system for emergency alerts (i.e., the Health Alert Network or HAN) must be in place in each jurisdiction so that public health agencies can rapidly communicate critical health information with each other in the event of a bioterrorism attack. Additional funding is needed to assure that all jurisdictions have fully operational alert systems in place.
- The National Electronic Disease Surveillance System (NEDSS) is a system designed by CDC to integrate a myriad of separate databases for public health surveillance so that reporting can be simplified and outbreaks (including bioterrorism attacks) can be rapidly detected and characterized across the different systems. Additional funds are needed to fully implement NEDSS.
Epi-X is a rapid secure communication system for public health agencies that is sponsored by CDC for sharing information about outbreaks and critical health events as they unfold. This system would allow rapid communication of critical public health information in the event of a bioterrorism attack. Ongoing funds are needed to maintain the operation of Epi-X.
Rapid communication systems (such as two-way radios or other systems) also are needed to allow state and local agencies to effectively communicate during times of crisis when conventional modes of communication may not be accessible.
1d. Improve State and Local Preparedness: Laboratory Enhancement (Amount: $200 million)
The Laboratory Response Network (LRN) is critical to a successful response to bioterrorism. The LRN is a multi-level laboratory network composed of county, city, state, and federal public health laboratories and is designed to receive and analyze laboratory specimens from a range of sources. The system is designed to assure definitive identification of suspected bioterrorism agents as quickly as possible. Additional funding is needed to assure that LRN laboratories are prepared to accurately identify potential for full implementation.
- The National Laboratory System (NLS) is a communication system designed to rapidly share laboratory information between public health, hospital, and commercial laboratories. Such communication will contribute to early detection and effective monitoring of bioterrorism events. Additional funding is needed for full implementation.
Chemical terrorism preparedness also is needed and should be integrated into the laboratory improvements.
Resources for improved diagnostic testing and identification of potential bioterrorism agents by animal and wildlife laboratories also are needed, as is improved communication between human, animal, and wildlife laboratories.
2. Upgrade CDC Capacity for Bioterrorism (Amount: $153 million)
(Amount: $153 million)
- CDC is the lead public health agency for federal bioterrorism preparedness and must be able to provide effective leadership to the public health and medical communities. Additional funding is needed for CDC to conduct deterrence, preparedness, detection, confirmation, response, and mitigation activities.
3. Develop Expert Response Teams (Amount: $45 million)
(Amount: $45 million)
Public health management of a bioterrorism attack will be extremely challenging. Teams of national experts who can deal effectively with the demands of such a crisis should be recruited and trained. These experts should have extensive experience in management of outbreaks or have clinical experience with diseases caused by potential bioterrorism agents. The teams should be maintained on alert status and federalized as needed for deployment.
4. Improve Hospital Response Capabilities
- Hospitals must be able to effectively triage and treat victims of a bioterrorism attack. This requires improvements in infection control (i.e., adequate isolation capabilities), expanded ability to provide intensive care, and adequate protections for healthcare workers (antibiotic prophylaxis, personal protective equipment, and vaccines [if available]).
5. Improve Disaster Response Medical Systems (Amount: $62 million)
Adequate disaster response systems are needed to coordinate disaster management during a bioterrorism event.
6. Improve International Surveillance (Amount: $20 million)
- International surveillance is needed to monitor the occurrence of illnesses caused by potential bioterrorism events in other areas of the world. Currently, surveillance activities are conducted by CDC and by the Department of Defense.
7. Improve Food Safety (Amount: $100 million)
- Foodborne agents could be involved in a bioterrorism attack. Funds are needed: 1) to improve surveillance for foodborne diseases at the state and local level, 2) to improve outbreak response capabilities, 3) to enhance rapid communication of information about foodborne disease outbreaks, and 4) to provide federal oversight for food safety activities.
8. Develop and Implement Applied Research Initiatives (Amount: $50 million)
- Applied research is needed (particularly at the state and local level) to assess effectiveness of various public health strategies, such as evaluation of surveillance methods, evaluation of laboratory preparedness, and evaluation of rapid communication networks.
9. Improve the National Pharmaceutical Stockpile (NPS) (Amount: $250 million)
Additional stockpiles of anti-infective agents are needed to effectively provide treatment and prophylaxis to large populations in the event of a wide scale bioterrorism attack. Ideally, enough medication to treat or provide prophylaxis to 40 million persons should be stockpiled. These supplies will need to be rotated on an ongoing basis.
10. Accelerate the Development of Smallpox Vaccine (Amount: $60 million)
(Amount: $60 million)
- Release of smallpox virus has serious global public health ramifications. Containment measures, including the ability to conduct mass vaccination campaigns, will be critical to a successful response effort. Enhanced production of smallpox vaccine is urgently needed to contain the spread of smallpox if this agent is released through a bioterrorism attack. Also, lack of vaccine availability will cause widespread panic in the face of an epidemic, which will be extremely difficult to control. Ideally, enough vaccine should be available to vaccinate the entire US population.
11. Develop Other Vaccines for Civilian Use (Amount: $100 million)
(Amount: $100 million)
- Development and production of vaccines for civilians (other than smallpox as indicated above) is important to the long-term protection of the U.S. population against bioterrorism attacks.