Legislative Program Review

& Investigations Committee

Preparedness for Public Health Emergencies

December 2004

PREPAREDNESS FOR PUBLIC HEALTH EMERGENCIES

DIGEST

INTRODUCTION 1

Scope of Review 2

Methods and Limitations 3

Report Format 4

Agency Response 4

I. PUBLIC HEALTH PREPAREDNESS PARTICIPANTS 5

Federal Government Agencies 6

State Level Departments 7

Local, Regional, and Private Entities 9

II. FEDERAL PUBLIC HEALTH PREPAREDNESS GRANTS 11

Grant Descriptions 11

DPH Preparedness Planning and Grant Process 15

III. EVALUATING CAPACITY 19

Needs Assessments 19

IV. PREPAREDNESS AND RESPONSE PLANS 25

Emergency Plans 25

Operational Levels of Planning 25

Command Structure 29

After-Action Reports 30

V. PUBLIC HEALTH PREPAREDNESS EXPENDITURES 31

Department of Public Health 31

Related Federal Grants 36

VI. STATUS OF PREPAREDNESS 39

Overall Conclusion 39

Status of Specific Areas 39

VII. FINDINGS AND RECOMMENDATIONS 45

Planning and Grant Process 46

Assessments 47

Key Public Health Plans 51

Planning Regions 53

Local Health Departments 54

Hospital Surge Capacity 56

Emergency Medical Services 58

Mass Vaccination Clinics 59

Isolation and Confinement 61

Laboratory Capacity 62

Education and Training 64

Communications 66

Contract Process 70

Future Availability of Federal Funding 72

APPENDICES

Introduction

Being ready in advance to handle an emergency can lessen the damage to people and property from the incident. The scope and success of the preparation affects the degree to which the damage is reduced.

On March 25, 2004, the Legislative Program Review and Investigations Committee (LPR&IC) voted to study the status of Connecticut’s preparedness program for public health emergencies. In particular, the committee wanted to evaluate recent assessment, planning, and implementation activities related to improving the public health infrastructure in order to prepare for and respond to acts of bioterrorism, infectious disease outbreaks, and other similar serious public health threats.

Two important elements of a public health emergency are the unpredictability of its onset and the potential it has to affect the well-being of a large number of people. Unexpected incidents involving harm to people or property occur every day (e.g., a robbery or a hail storm), but only some require the involvement of health-related personnel (e.g., an automobile accident or a house fire). Even then, such incidents generally are limited in scope to a few people.

In 2003, the Connecticut General Assembly adopted Public Act 03-236, which defines a “public health emergency” as:

The broadness of that definition points out the variability of the events that can create a public health emergency. A primary focus of preparedness efforts in Connecticut and the rest of the United States since September 11, 2001, has been on incidents resulting from bioterrorism.¹ However, during that same period, outbreaks of SARS raised the possibility of the worldwide spread of a contagious disease for which there is no vaccine, while volatile weather systems disrupted public drinking water and sanitation systems. Thus, the nature of the public health risks of greatest concern for which the state is preparing may change over time.

Ideally then, public health preparedness efforts reflect an “all hazards” approach that enables responders to handle many different kinds of incidents. A successful preparedness effort is based on sufficient resources (e.g., equipment and trained personnel) to allow specific tasks to be performed, the existence of appropriate legal authority, and tested plans that outline who is responsible for what tasks. There also needs to be a recognition that while a comprehensive response may involve all levels of government, initially it is those at the local level who must handle the situation. Therefore, interagency communication and coordination are essential.

Since all the elements of a preparedness program need to be maintained at a certain level of readiness indefinitely, one can never say the job of being prepared is complete. Indeed, the federal Centers for Disease Control and Prevention (CDC) describes public health preparedness for emergencies as a continuous process of improving the health system’s capacity to detect, respond to, recover from, and mitigate the consequences of such events.

Scope of Review

Since 2001, the federal government has distributed $3 billion across the country for health related bioterrorism preparedness activities.² Connecticut has received approximately $56 million, which is described in more detail in Chapter Five. An indirect benefit of this funding has been the opportunity it provides to improve the basic public health infrastructure in the state, which supports routine public health services as well as emergency preparedness efforts.

The program review committee study focused on two aspects of preparedness. One was the current status of preparedness for public health emergencies in Connecticut. In this sense, preparedness refers to the existence of plans, procedures, policies, training, and equipment to maximize the state’s ability to respond to and recover from a public health emergency. A key issue, therefore, was the condition of the major components of public health preparedness (e.g., lab capacity and hospital surge capacity).

The other aspect was the process of building capacity. Specifically, the committee examined the activities undertaken to date by various public health related entities in Connecticut, especially the Department of Public Health (DPH), as they work to prepare for and respond to public health emergencies. (Other important entities examined included local public health departments, acute care hospitals, and emergency medical service (EMS) providers.) A key issue, therefore, was to determine if there is a process in place that adequately identifies the state’s preparedness deficiencies and addresses recognized needs. In particular, the committee looked at the status of efforts to:

Methods and Limitations

The program review study has important limitations. At the outset, it is critical to recognize there are no agreed upon national measures for public health preparedness and no standards for assessment that can be applied.

In addition, without a comprehensive, realistic assessment of threats the state is most likely to face, it is difficult to define how much preparation is enough and hence specify what appropriate preparedness is for the state or any region. The federal government has been a driving force in determining goals for preparedness, and Connecticut has accepted the goals established by the federal government as reasonable and realistic. These goals are in part based on a combination of data and expert judgment. By design, the programs sponsored by the federal government give priority to preparing for biological events before using funding for chemical, radiological, nuclear, or explosive incident planning. Despite the ultimate goal of an all-hazards approach to planning, the availability of these federal dollars has shifted current preparedness efforts toward bioterrorism.

The program review committee did not conduct independent comprehensive reviews of individual local health departments, hospitals, or related health care entities or conduct drills and exercises of emergency plans. In addition, few written evaluations of such drills and exercises were available to provide information about how well the components of the public health emergency preparedness system work together. Assessment methods did include the following.

The committee also sought to examine how Connecticut’s public health preparedness efforts compare with those in other states. However, no up-to-date state-by-state comparisons of performance under the CDC and HRSA grants are available. Multiple attempts were made to contact CDC and HRSA directly to obtain information about the grant review processes as well as data about Connecticut’s efforts to meet critical capacities and benchmarks versus those of other states. Neither agency would discuss its grant program with legislative committee staff.

A December 2003 report by Trust for America’s Health looked at 10 indicators to assess the public health emergency preparedness capabilities of the individual states, but only some of the indicators were from the federal grants, Three states scored the highest, meeting seven of the 10 indicators. Connecticut had achieved four of the indicators, matching the rate of 10 other states and exceeding the rate of 17 states.⁴

Report Format

The first five chapters in this report contain descriptive material about efforts in Connecticut to assess, plan, and respond to public health emergencies. Chapter One describes the participants in the process, while Chapter Two provides an overview of the federal grants. Chapter Three discusses the process used to evaluate capacity, Chapter Four describes the various types of plans being developed, and Chapter Five outlines expenditures. Chapter Six summarizes the overall status of preparedness for public health emergencies in Connecticut. Chapter Seven discusses key areas of preparedness in more detail and presents the committee’s findings and recommendations.

Appendices A and B list the specific critical capacities, benchmarks, and priority areas for the CDC and HRSA grants respectively. Appendix C lists preparedness advisory committee participants, while Appendix D provides information about selected emergency plans. Appendices E and F present the results of the program review surveys of local health departments and acute care hospitals.

Agency Response

It is the policy of the Legislative Program Review and Investigations Committee to provide agencies subject to a study with an opportunity to review and comment on the recommendations prior to publication of the final report. Appendix G contains the response from the Department of Public Health.

Chapter One

Public Health Preparedness Participants

Because the U.S. public health system is composed of a complex network of institutions, preparing for a public health emergency requires the coordinated efforts of local, regional, state, and federal governments, as well as private organizations. Figure I-1 illustrates many of the participants involved in public health preparedness.

Both the Institute of Medicine (IOM) and the Centers for Disease Control and Prevention have documented a general deterioration over the last two decades of the infrastructure that underlies the public health system (i.e., the foundation supporting the planning, delivery, and evaluation of public health activities), within which the entities in Figure I-1 operate.⁵ The deficiencies in this fragmented system are magnified when facing broader threats that require a coordinated response to a multi-jurisdictional emergency.⁶ Below is a description of the principal agencies and organizations involved in public health preparedness in Connecticut.

Federal Government Agencies

In recognition of the gaps identified by IOM and CDC, especially following the terrorist attacks on September 11, 2001, and the subsequent anthrax attacks, the U.S. federal government began a large-scale investment in the public health infrastructure to respond to a variety of concerns, including terrorism (principally bioterrorism) as well as infectious diseases and other similar serious public health threats. These federal grant programs have become the driving force to fund public health preparedness efforts.

Primarily, four federal agencies, in two federal departments, have provided funding and guidance to state and local governments to enhance emergency preparedness planning and infrastructure capacity building activities.

State Level Departments

On the state level, the Governor’s Domestic Preparedness Senior Steering Council created by the governor in 2000 was established to advise the governor on specific plans, policies, and resources necessary to improve the state’s emergency preparedness efforts. It contained several commissioners of state departments as well as local and federal public safety officials. The steering council has apparently been superceded by the newly created Emergency Management Homeland Security Coordinating Council described below.

There are three principal state level agencies that have direct emergency preparedness responsibilities and several other agencies that have important but smaller roles to play in emergency preparedness and response. The primary agencies are the Department of Public Health, the Office of Emergency Management, and the Division of Homeland Security (DHS).

Department of Public Health. The main public health preparedness agency at the state level is the Department of Public Health, which is the grant recipient for a majority of the federal bioterrorism dollars the state receives under the CDC and HRSA grant programs identified above. Both those grants and Public Act 03-236 require DPH to develop a comprehensive public health emergency plan with oversight from an advisory committee. The state statutory planning and federal preparedness requirements are described further in Chapters Two and Four. The department, in addition to regulating various health professions, is also a public health policy advocate and provides a range of health-related technical and consultative services to local and state agencies not available elsewhere in the state.

Office of Emergency Management and Division of Homeland Security. Two other state entities with broad emergency preparedness responsibilities are the Office of Emergency Management, currently within the Military Department, and the Division of Homeland Security, currently within the Department of Public Safety (DPS).

OEM is the modern day “civil preparedness” agency that coordinates a wide range of activities to minimize the effects of various disasters, emergencies, or attacks on the country, often referred to as consequence management. It is responsible for developing a statewide comprehensive (all hazard) emergency response plan (C.G.S. Section 28-5) and for coordinating state resources in response to a wide range of natural and manmade hazards. The office is also responsible for acting as the state’s liaison with the federal emergency management agency and directs the operation of the emergency operations center. In addition, the director of OEM is required to coordinate the preparedness activities of the state’s municipalities and approve local emergency management plans that are required under statute.

Connecticut’s Division of Homeland Security was formed in 2001 in reaction to the events of September 11. The mission of DHS is “to utilize all available resources within state government to develop and implement unified safety and security measures to prevent, mitigate and manage incidents threatening the quality of life of the citizens of the State of Connecticut.”⁷ The division is responsible for overseeing the state’s homeland security and strategy program as well as administering the state homeland security grant program.

In January 2005, OEM and DHS will be combined into a new state agency -- the Department of Emergency Management and Homeland Security (DEMHS), within the Office of Policy and Management (OPM) for administrative purposes only. The consolidation effort and the new department are being guided by a 24-member statewide Emergency Management Homeland Security Coordinating Council that includes representatives of 12 state departments as well as fire chiefs, police chiefs, municipal associations, local civil preparedness agencies, local health directors, EMS providers, hospitals, and 9-1-1 answering point managers. The new agency is to be a focal point for planning and preparedness functions related to emergency management and homeland security, as well as a central place for the distribution of federal funds for those purposes.

Other state agencies. While nearly all state departments are assigned explicit duties during an emergency, a few departments have roles crucial to the state’s response to certain types of public health emergencies.

Local, Regional, and Private Entities

In addition to the state and federal government agencies listed above, local governments, regional entities, and private organizations are essential participants in public health preparedness and response efforts. Because terrorist events and infectious diseases do not recognize political boundaries, recent years have seen increased efforts to build up regionally oriented resources related to planning for various types of emergencies, with specific requirements related to public health issues.

Subsequent chapters describe the roles of many of these entities in more detail as well as the various inter-relationships during a public health emergency.

Chapter Two

Federal Public Health Preparedness Grants

As mentioned previously, public health emergencies can arise from natural or manmade causes. In the past few years increased emphasis and funding have been directed toward preparedness for terrorist incidents and bioterrorism in particular. This has greatly influenced how states perform preparedness functions.

Biological threats are not the only terrorist threats that affect the public heath. Terrorist threats and actions can be delivered through chemical, biological, radiological, nuclear, and explosive (CBRNE) means. While federal funding is largely directed at preparing for and responding to a bioterrorist incident, the improvements can also reinforce certain capabilities that affect the state’s ability to respond to other major public health threats. Indeed, a covert release of a biological agent by a terrorist would probably initially unfold and present itself as a naturally occurring infectious disease. Recently, some attention in federal grants has been drawn to improving each state’s ability to guide the public health management aspects of a chemical terrorism incident. A specific emphasis on other forms of terrorist threats may in fact require different strategies and additional capacity building.

Because of the influence exerted by federal funding on public health preparedness, it is necessary to examine in some detail federally funded bioterroism programs that have guided most of the public health preparedness activities in Connecticut since 2001, keeping in mind the limitations imposed by concentrating on biological threats.

Grant Descriptions

Federal grants. The federal Department of Health and Human Services distributes funding for bioterrorism, chemical, and other public health emergency preparedness through two main programs using cooperative agreements with states.¹⁰ The Centers for Disease Control and Prevention’s Bioterrorism Preparedness and Response Program is intended to “upgrade state and local public health jurisdictions’ preparedness for and response to bioterrorism, other outbreaks of infectious disease, and other public health threats and emergencies.”¹¹ While this program has been in existence since 1999, the funding and requirements associated with it have increased dramatically since September 11, 2001. The other program, administered under HHS’s Health Resources and Services Administration, began in 2002 to upgrade the nation’s health care system to respond to bioterrorism, outbreaks of infectious disease, and other public health threats and emergencies.

The central focus of both these grants is on improving the state’s capacity to detect, respond, and recover from a terrorist threat and other health emergencies. The way in which public health capacity is improved takes a number of different forms and results in many different types of products and outcomes with varying levels of cost and complexity. For example, assessments of various health care entities are mandated, general and disease specific plans involving various levels of government and other health care partners are required, and culturally appropriate public information campaigns on what to do during a public health emergency must be developed. As will be detailed below, the federal government has identified certain capacities and milestones that it deems critical as indicators of progress but also cautions that achievement of any particular milestone “does not guarantee preparedness, {but} failure to achieve any one of them is a near certain indicator that the jurisdiction is inadequately prepared.”¹²

CDC requirements. To enhance public health preparedness, both CDC and HRSA grants require the state to complete specific activities and meet certain benchmarks. The 2002 CDC grant, focusing on state and local public health departments, outlined seven focus areas to improve public health preparedness capacity. Sixteen specific capacities were identified within the focus areas considered critical for states to be prepared for a public health emergency. In order to build these “critical capacities,” CDC developed certain requirements and designated some of the requirements as “critical benchmarks.” In the subsequent grant years, the number of requirements and benchmarks increased. CDC has stated it will move from critical capacities to evidence-based performance goals and measures in the near future. Focus area descriptions are provided in Table II-1. Specific critical capacities and benchmarks related to the CDC grant are presented in Appendix A.

HRSA requirements. The HRSA grant focuses on upgrading hospital and related health care entity preparedness. State and U.S. territorial health departments along with the three largest U.S. cities are eligible to apply for grant funding. Individual hospitals and other health care organizations work with the state health departments for funding through the program.

Beginning in 2002, the HRSA grant required states to develop a needs assessment and an implementation plan for a bioterroism preparedness program for hospitals and related health care entities. The initial applications had to be filed by February 25, 2002. The grant also required the submission of a detailed implementation plan that addressed three critical benchmarks and four top priority areas by April 15, 2002. The current grant (August 31, 2004 – August 30, 2005) contains six priority areas and 16 critical benchmarks, many of which are carried over from the initial grant. The priority areas are outlined in Table II-2; detailed benchmarks are listed in Appendix B.

Cross-cutting requirements. Because public health preparedness and emergency response requires the cooperation of a broad spectrum of health care entities, both HHS grants encourage the integration of the public health and health care communities’ efforts. To that end, the CDC and HRSA grants identify cross-cutting benchmarks and activities that recipients of both grants are expected to attain. Specifically, by now states should have achieved four out of five cross-cutting benchmarks identified in previous grants regarding incident management, a joint advisory committee, laboratory connectivity, and certain jointly funded health department and hospital activities. States are currently working toward completing one remaining benchmark regarding laboratory data and a new benchmark regarding the development of a pandemic influenza plan.

A number of activities are also identified that require the Department of Public Health to explain how its efforts are coordinated between the state and other health care entities in specific areas such as disease surveillance systems, coordination with Indian Tribes, and special needs populations. A more detailed discussion of the status of critical capacities and benchmarks in Connecticut is presented in Chapter Seven.

DPH Preparedness Planning and Grant Process

Figure II-1 illustrates DPH’s structure for preparedness planning. As discussed above, detailed direction about specific capacities and benchmarks that states are expected to achieve come from the CDC and HRSA cooperative agreements with each state health department.

Overall state strategic leadership and direction comes from the commissioner of public health. The department has created the Office of Public Health Preparedness (OPHP) to assist in implementing the activities related to the CDC and HRSA agreements. This office includes a director, an attorney, a hospital preparedness coordinator, a medical director, and a Strategic National Stockpile coordinator.

Advisory committee. As required under the federal grant agreements, DPH’s planning process strives to be collaborative with representatives of both private and public entities that have significant roles in preparedness and response for public health emergencies. To this end, the department created the Public Health Preparedness Advisory Committee (formally called the Advisory Committee on Bioterrorism Preparedness) to review and advise DPH on cooperative agreement activities.

The committee was originally created by DPH in July 2002 and later established in statute. The committee contains over 60 representatives from government (state, local, and tribal), private, and nonprofit organizations related to preparedness. The committee includes representation from local health districts, hospitals and other types of health facilities, EMS providers, and 14 state agencies as well as 18 legislators. (Member agencies are listed in Appendix C). DPH’s chief of staff chairs the committee. The vice-chair is the president of the Connecticut Association of Directors of Health and the secretary is a member of the Connecticut Hospital Association. This committee meets quarterly.

Principal coordinating health care partners within this structure include the Connecticut Association of Directors of Health (CADH) and the two hospital-based Centers of Excellence for Bioterrorism Preparedness, Hartford Hospital and Yale New Haven Health Systems. The health directors’ organization represents local health departments in various planning forums and performs as a contractor for specific tasks, such as designing and implementing assessments of local health departments. Similarly the Centers of Excellence represent the health care community in preparedness efforts and are under contract to DPH to provide coordination of regional planning efforts directly with acute care hospitals and other health care providers, establishment of the emergency credentialing database for hospitals, and assistance to the state laboratory in both chemical and radiological response planning.

Staff group and working group. Advisory committee members are invited to send representatives to the “Public Health Preparedness Working Group” and the “Smallpox/Infectious Disease Preparedness Workgroup,” both of which meet at least monthly to discuss existing and emerging planning issues. There is also a DPH senior staff group, which is an internal department coordinating group that monitors the grants and prepares the actual grant applications annually; it usually meets twice a month.

Subcommittees. The large advisory committee is broken down into seven subcommittees. Six oversee the focus areas outlined in the CDC grant, and one subcommittee is dedicated to the HRSA grant. Each subcommittee is co-chaired by a DPH staff member and a local health director, except the HRSA subcommittee, which is co-chaired by a member of the hospital association. These subcommittees typically meet monthly.

Grant process. Figure II-2 illustrates the federal grant process. While grant activity is on-going, each grant process officially begins with the receipt of a guidance document from CDC or HRSA that sets out explicit direction on what is to be accomplished during the next grant period. There is a federal mandate for grant guidance to be released no less than 30 days before the beginning of a grant period. This year DPH received the guidance document on June 14 for the CDC grant, which was due on August 1 for a grant year that begins on August 31, 2004. In previous years, the department has been given as little as four weeks to respond. Similarly, the HRSA guidance document was received at the end of May, and the application was due on July 1, 2004.

Sometimes the grant will specify what proportion of the funding must go to a particular area or entity; other times DPH makes those decisions. For example, HRSA restricts state administrative funds to 10 percent and up to another 10 percent may be allocated to statewide planning efforts conducted by the awardee or contractor. On the other hand, CDC does not restrict the proportional allocation of state administrative funding versus local funding.

The focus area subcommittees usually meet monthly during the year but may meet biweekly during the grant application time frame. Using the grant guidance as a framework, DPH will invite proposals from the subcommittees. Drafts of a work plan and a budget are developed by DPH staff and circulated among the subcommittees. Discussions also occur among the working group and the larger advisory committee, though usually no vote is taken on priorities.

Then, a negotiating dynamic ensues. While DPH is the primary entity responsible for driving the grant process, the CDC grant does require that the applications demonstrate consensus, approval, or concurrence between the state and local health departments. Specifically, a significant number of local public health officials must concur with the proposed use of funds. Practically, this is demonstrated by the overall planning structure and a letter of support from the Connecticut Association of Directors of Health. For both HRSA and CDC Cooperative Agreements, there is concurrence with public health and health care partners on the proposed use of funds.

A final document is assembled and submitted to the governor’s office for notification purposes; then the application goes to CDC or HRSA. The application is submitted electronically over a secure web site operated by the federal government. The federal grant agencies that review the documents may ask DPH for clarifications, and they generally approve the grants before the start of the grant period. DPH provides the granting agency status updates throughout the year.

Chapter Three

Evaluating Capacity

An important element of a successful public health preparedness program is the ability to respond to a variety of events. Depending on the nature of an incident, there might be a need to provide immediate medical treatment to victims, identify the biological or chemical composition of a substance, provide vaccinations to thousands of people, or quarantine individuals. Such activities will be performed by a variety of public and private health care related workers.

In order to ensure that a timely and comprehensive response appropriate to a particular emergency will be available, a certain level of response capacity is required. Accordingly, an important part of the emergency preparedness process is an assessment of the resources currently in place versus an estimate of what is likely to be needed to respond to various types of emergencies. At a minimum, this evaluation of capacity would include a review of:

Needs Assessments

Under the federal CDC and HRSA grants Connecticut has received, the state was supposed to assess the capacity of specific health care entities to respond to public health emergencies involving bioterrorism. The state also had to examine communication systems, information technology infrastructures, and legal authorities.

Although the Department of Public Health was the primary grant recipient, it was allowed to subcontract out tasks. DPH staff performed the analysis of the state’s legal authority to respond to public health emergencies and surveyed local health departments regarding their information technology capacity. The department also took responsibility for the assessment of emergency medical services. A local communications assessment was prepared by an outside consultant, while the University of Connecticut (UConn) College of Continuing Studies was hired to assess the Public Health Emergency Preparedness Communications Infrastructure.

The Connecticut Association of Directors of Health carried out the assessment of the local health departments. The two hospital-based Centers of Excellence compiled the assessments for the hospitals in their regions as well as the other entities in their areas that make up what is referred to as the Healthcare Provider Continuum (e.g., urgent care centers, nursing homes, and home health care agencies). All of the assessments were carried out under the direction of DPH. Figure III-1 summarizes the number and type of entities evaluated as well as the organization coordinating the assessment.

CDC provided sample assessment tools, but they were based on county government systems and had to be modified in Connecticut to reflect the public health structure here. Representatives of DPH and the two COEs revised the various survey instruments for the entities being assessed by the COEs to clarify and categorize questions. Others, such as the Connecticut Hospital Association, statisticians, and epidemiologists, provided input during the process of developing a weighting system to determine preparedness levels within individual topic areas as well as overall preparedness ratings for the entities.

The Connecticut Association of Directors of Health convened a working group of local health directors and DPH staff to review and revise the form for local health departments. The data entry company also provided feedback regarding the design layout of the instrument.

The assessments for the hospitals and other providers reviewed by the COEs were divided into 16 sections. Table III-1 indicates which providers were rated on each category.

The questions on the assessment survey sent to local health departments were organized around the focus areas defined in the CDC grant. The questions were categorized according to seven cross-cutting issues. Those issues were:

Figure III-2 summarizes the major steps in the assessment process. All of the survey instruments were self-assessment tools. Most were distributed at the end of 2002 or the beginning of 2003, seeking information for calendar year 2002.

In an effort to increase response rates, after the initial mailing, COE staff made follow-up visits to individual hospitals and relevant trade associations as well as telephone calls to facilities that received a survey. After CADH e-mailed the assessment tool to all local health directors, it held three regional workshops where local health department staff could get answers to any questions they had about the survey instrument. Table III-2 lists the response rates for the various assessments.

Returned surveys were entered into computerized databases, and the responses tallied. The coordinating entities analyzed the results in the aggregate as well as by individual facility or subset (e.g., part-time health district, full-time health district, and full-time health department), depending on the type of resource being evaluated. Then, they prepared written reports describing their findings (including the level of preparedness of respondents) and recommendations. Although the northern and southern COEs used the same data collection instruments, the formats of their final reports differed with respect to how results are reported. Most of the final assessment reports were submitted to DPH in August 2003; a few were not completed until spring of 2004.

The overall goal of the surveys was to identify existing resources related to bioterrorism preparedness. In the case of hospitals, the effort also sought to assess the ability of each to respond to and manage a biological, chemical, incendiary, or explosive mass casualty event and to identify areas for future training and planning on the regional and statewide level. The local health department assessments were aimed at measuring progress toward meeting critical capacities and benchmarks specified in the CDC bioterrorism grant.

After the health provider assessments were completed in 2003, DPH contracted with the UConn College of Continuing Studies to conduct a meta-analysis of the various assessment instruments and responses, looking for commonalities. UConn delivered its report in October 2003, including a cross-comparison of assessment results, identification of gaps in the instruments and results, and suggestions for future assessment efforts.

The final product in this initial assessment process will be a comprehensive assessment of Connecticut’s capacity to respond to a bioterrorism incident. That document, known as “The Connecticut Assessment of Response Capacity,” will identify areas of need and recommend capacity enhancements to strengthen the response infrastructure in the state. DPH is responsible for producing the final report, which will include an assessment of its own capacities. The projected completion date for the document is December 2004.

More detailed information about the contents of the capacity assessments are presented in Chapter Seven. One ongoing concern about the lengthy process leading to the comprehensive assessment is the fact most of the data that will be in it reflect the status of public health preparedness in 2002. Many of the entities that returned surveys have subsequently experienced turnover of personnel and/or replaced equipment, while others took steps to improve their emergency response capabilities. None of that information will be reflected in the final assessment report prepared by DPH.¹³

Chapter Four

Preparedness and Response Plans

A written plan is one of the main elements of a public health preparedness program. Without a plan, the parties responding to a public health emergency will not have a shared understanding of their individual roles and responsibilities and how those intersect with the duties of others also providing assistance. In order for a response plan to be successful, it must be tested and evaluated periodically, and the command structure must be clear. This chapter examines the major emergency preparedness plans in Connecticut, command structures, and plan evaluation.

Emergency Plans

A wide variety of public health response plans have been developed at all levels of government by a number of different entities. Some address specific situations (e.g., smallpox) or aspects of an incident (e.g., mitigation), while others serve as addendums to the general emergency plan of the particular entity. An Emergency Operations Plan (EOP) is the key document for most organizations that respond to emergencies. That plan, which is designed to cover all types of hazards, identifies the functions common to all emergencies and indicates which agencies are responsible for each function. An EOP:

An EOP also includes appendices that provide detailed information specific to particular hazards (e.g., terrorism, tornado, hurricane, etc.). The focus of a specific EOP will be on the actions of the governmental entity creating that plan, but the response plans of other entities will be incorporated by reference.

Organizational Levels of Planning

Figure IV-1 displays the many entities currently involved with the preparation of emergency plans in Connecticut. The top row lists the key federal agencies that support the planning process in Connecticut through grants and mandates.

The federal agencies provide guidance and technical assistance to the states and to local governments regarding development of preparedness capabilities and response plans as well as

capacity building. As noted in Chapter One, two important divisions in the federal Department of Homeland Security are the Office of Domestic Preparedness and FEMA. Both provide funding for broad emergency preparedness efforts. The principal source of public health specific funding is the Department of Health and Human Services through various CDC and HRSA grant programs.

State plans. The second row from the top in Figure IV-1 shows the major state agencies in Connecticut involved in the development of a variety of emergency plans with a public health component. The plans cover a range of potential problems from natural disasters to specific diseases. Other plans are linked to specific events, such as the arrival of the millennium. Still others detail how the resources needed to respond to an emergency will be obtained rather than the logistics of how the response will be carried out.

Table IV-1 lists examples of state operational plans with public health related components that have been developed during the past decade or are nearing completion. (See Appendix D for a more detailed description of some of the major ones.)

Several of the plans were prepared under the direction of the Office of Emergency Management as part of its civil preparedness responsibilities. Two key OEM documents are the Emergency Management Plan and the related Natural Disasters Response Plan. They provide the framework for Connecticut to put forward a coordinated and effective response to a wide range of natural and manmade hazards, with a key goal of maximizing the preservation of life and property. Other plans contain public health components that represent an adjunct to the broad goal of minimizing the effects of major disasters on the citizens of the state.

Several of the plans listed in Table IV-1 were prepared by DPH in anticipation of or in response to federal mandates (e.g., pandemic influenza). In addition, the department is currently working on its own Emergency Response Plan, which will outline the department’s operational responsibilities during a natural or manmade emergency.

The Division of Homeland Security developed the Connecticut Homeland Security Strategy, based on a statewide assessment of emergency response capabilities that it coordinated. The strategy document is the basis for the state’s Initial Strategy Implementation Plan, which details how Connecticut will spend the money it is receiving under the State Homeland Security Grant Program.

The process of creating these state plans involved many people over an extended period of time. It also required coordination with regional and local governmental entities as well as private health care providers, all of whom are responsible for developing emergency response plans of their own.

Regional plans. Because a disaster will not affect just one community, there is a recognition that local efforts must be integrated on a regional basis. The third row in Figure IV-1 highlights several public health related planning efforts currently underway at the regional level.

Currently, regional public health emergency plans are not mandatory in Connecticut. Regions are encouraged to develop general Emergency Disaster Plans, but to date only two regional workgroups -- Capitol Region and Southeastern Connecticut -- have done so. However, under the CDC and HRSA grants, DPH has made a commitment to develop a comprehensive plan that includes regional response strategies. DPH has contractual agreements with CADH, local health departments, the two Centers of Excellence, and the acute care hospitals to support creation of regional Public Health Preparedness Plans. To further help the effort, DPH compiled a directory of preparedness planning partners grouped into 10 previously defined preparedness regions. To date, only one plan has been completed.

The Office of Emergency Management contracted with the Regional Planning Organizations in the state to help develop emergency response plans. These plans cover a variety of incidents including those involving chemical, biological, radiological, and conventional weapons.

Local Smallpox Mass Vaccination Plans are also being prepared under contractual agreements with DPH. For that purpose, Connecticut is divided into 42 regions, and the plans have to be coordinated with the other local emergency plans in the geographic area. The smallpox plans also could be used as the framework for dealing with other situations that require a mass vaccination effort. DPH is reviewing the documents to verify they are complete.

Also operating at the regional level are the two hospital-based Centers of Excellence. Each provides assistance to multiple hospitals, based on a division of the state into northern and southern regions. Individual hospitals are responsible for their own facility emergency management and smallpox plans, but the COEs provide guidance documents and templates to help the individual hospitals with those tasks.

Local plans. Long before the current emphasis on bioterrorism, local governments were developing emergency operations plans to help them deal with a broad range of situations. Plans dating back to the 1940s, for example, discuss what to do in the event of an invasion by a foreign enemy as well as how to deal with a natural disaster. The need to address an increasing range of public health related issues and mesh those efforts with existing local plans results in the volume of activity displayed in the bottom row of Figure IV-1.

This component of the system is crucial because it brings so many people into the process. It is the foundation on which all other efforts should build, and it is the organizational level most directly concerned with ensuring recovery efforts are completed. In many parts of the U.S., much of this activity would occur at the county level. In Connecticut, a state with strongly independent towns and no county government, the preparedness planning process has been adjusted to reflect that situation while encouraging multi-town activities as much as possible.

For local public health purposes, Connecticut’s 169 towns currently are grouped into 96 departments/districts, ranging in size from one town to 18 towns. All local health departments and districts have been asked to produce a Local Bioterrorism Response Plan. In addition, using the contractual process, DPH required each department or district with a full-time health director (currently numbering 50 and covering 123 towns) to develop a Local Public Health Emergency Operations Plan that includes a description of the working relationships between the towns, first responders, and hospitals in the geographic area.¹⁵ Each of these plans is then supposed to become a supplement to the Local Emergency Operations Plan that every town is statutorily mandated to prepare.

In conjunction with all of these local government based plans, every hospital and health care facility in the state has to prepare a Health Care Facility Emergency Operations Plan in order to meet national accreditation standards. Like the plans prepared by local towns, these documents address a variety of events including incidents that affect routine operations (e.g., a power outage), result in an unusually large number of severely injured patients (e.g., a bus crash), or require treatment of highly infectious patients (e.g., a SARs outbreak). Depending on the service area of the facility, these plans may cover a wide geographic area that crosses multiple town lines.

Command Structure

An important factor in the successful implementation of an emergency response plan is clarity among responders concerning who is in charge. When an emergency occurs, the first people on the scene will be representatives of the local response team. Depending on the nature of the incident, this may include fire, police, EMS, and other specialized personnel. They are responsible for determining what resources the situation requires.

In Connecticut, under C.G.S. Sec. 7-313e, the highest ranking local fire official at the scene of an emergency is authorized to take charge. Except for special situations such as a hazardous materials spill, state resources are called to the scene only if local resources are overwhelmed by the scale or nature of an incident. Even then, if a local fire official is on the scene, that person remains in charge. On-site involvement of federal personnel occurs even less frequently. Generally, intervention must be at the invitation of state officials, and usually this is done only if state resources are overwhelmed.¹⁶

Given the potential for multiple government agencies to be involved in a situation, answering the question “Who’s in charge?” before an emergency exists reduces confusion and expedites the response process. In an effort to provide a consistent nationwide approach to incident management for federal, state, and local governments working together, Homeland Security Presidential Directive-5 instructs the secretary of homeland security to develop and administer the National Incident Management System (NIMS). All federal agencies must adopt NIMS, and beginning in federal fiscal year 2005, states and local organizations that want to receive federal preparedness assistance also must adopt NIMS.

One short-term way state and local governments can demonstrate their commitment to NIMS is by adopting the Incident Command System (ICS), a process management system already in use throughout the country. ICS allows a flexible response to an incident based on common terminology and structure. It incorporates five functions -- logistics, finance, administration, planning, and operations -- although not all are activated during every incident.¹⁷

When more than one agency has jurisdiction over some aspect of an incident, ICS relies on a Unified Command (UC) structure. In such a case, the agencies work together through a designated member from each agency, with a single commander overseeing the operation. Collectively, those representatives form the unified command. Depending of the specifics of the situation, at various stages in the response different participants may play a larger role.

In Connecticut, the Department of Public Health indicated it has incorporated the principles of NIMS and ICS into its emergency response plan, and it has provided basic ICS training for its staff. Likewise, the Office of Emergency Management has the goal of ensuring its plans are consistent with federal NIMS requirements by January 2005.

After-Action Reports

Another important component of the public health preparedness program that complements the planning process is the wide range of exercises and drills conducted by the various entities with public health responsibilities. Drills and exercises provide an opportunity to test previously developed plans that specify how participants will respond to an emergency. These training activities can involve theoretical discussions off-site (e.g., “table-top exercises”) or live practices carried out on-site, partially or completely in real time, depending on the skills and equipment to be tested. The goal is to learn what does and does not work when a misunderstanding will not result in physical harm to anyone. These training sessions also give participants an opportunity to meet people they will be working with if there is an emergency and familiarize themselves with the command structure.

A common product of such training is an “after-action report.” Shortly after the conclusion of the exercise or drill, representatives of the major participants prepare written summaries of the event from their perspective, including elements that worked and those that need improvement. The reports frequently address issues such as who was authorized to make decisions and whether activities occurred with or without proper authorization, the workability of radio and other communication systems, the conditions under which medical care was provided, and the adequacy of staffing at the command center and other satellite locations.

The purpose of after-action reports is to identify resource deficiencies and help participants understand what actions they need to take to improve their response when a real event that is similar in nature arises. The reports also can be a valuable reference tool for non-participants.

Chapter Five

Public Health Preparedness Expenditures

Primarily, it is the Department of Public Health, the Office of Emergency Management, and recently the DPS Division of Homeland Security that manage programs that directly or indirectly support public health preparedness. This chapter identifies the major funding sources and expenditures for public health preparedness and related programs.

Department of Public Health

The program review committee asked DPH to indicate the amount it spends annually on public health preparedness and to identify the sources of revenue for such expenditures. The department, however, does not maintain its financial records in a way to easily retrieve that information. The department instead provided funding amounts based on federal grants received whose purpose is or is reasonably related to public health preparedness. Similarly, the amount of state funding directed toward preparedness is estimated based on approximations of state employee time associated with federal grant initiatives.

Overall funding. Over the last five years, DPH has received funding from the federal government through seven grant programs related to public health preparedness, though funding for some programs was for a shorter specified period of time. These grants include: Epidemiology and Lab Capacity for Infectious Diseases; Public Health Laboratory Biomonitoring; Emerging Infections; Water Protection Coordination; Training for Improved Response to Bioterrorism; Public Health Preparedness and Response to Bioterrorism; and Hospital Preparedness for Bioterroism. (The latter two grants were described in detail in Chapter Two.) Figure V-1 shows the trend in preparedness funding since 2000.

CDC and HRSA funding. The CDC public health preparedness and HRSA hospital preparedness grants are the largest federal grants DPH receives for emergency preparedness and represent about 83 percent ($19 million) of total federal funding awarded the agency for preparedness in 2004. Figure V-2 shows the trend in awards for these grants.

Both grants increased from 2002 through 2004. In 2005, the CDC grant will decline to about $10.8 million from $13.2 million in 2004, while the HRSA grant will remain level for 2005 at $6.2 million.

The calculation to determine the grant amount each awardee receives involves a base amount plus an amount equal to its proportional share of the national population. Sixty-two jurisdictions were awarded funding from both grants, including major cities, U.S. possessions, and territories. In the most recent grant year, Connecticut ranked 32^nd and 34^th respectively for HRSA and CDC funding. The overall amount available under the CDC grant has declined nationwide from $870 million in FY 04 to $844 million in FY 05. HRSA funding has remained the same in the last two grant years at about $498 million.

Connecticut has been one of the slower states in terms of spending the money it has received from the CDC and HRSA grants. A November 2004 report prepared by the Association of State and Territorial Health Officials found that one-third of the states had spent or obligated 98 percent of their CDC funds, and half the states had spent or obligated a similar proportion of their HRSA funds as of August 31, 2004. Only 10 states ranked below Connecticut’s overall rate of 87 percent “spent or obligated” for the two grants as of that date, but the worst state -- Pennsylvania -- had only “spent or obligated” 66 percent of the two grants. (Connecticut had spent 79 percent of the CDC grant and obligated an additional 9 percent. It had spent 61 percent of the HRSA grant and obligated an additional 25 percent.)¹⁸

DPH and contractor funding. Table V-1 shows the amount of funding from the CDC and HRSA grants that went to the Department of Public Health and to contractors for FY 04 and FY 05. Primarily but not exclusively, the contractors are other health care system partners such as hospitals, community health centers, school-based health centers, the Connecticut Poison Control Center, local health departments, regional planning entities, the UConn Health Center, and the EMS council. In part, the extent that funding is being directed to contractors demonstrates that capacity building is focused to some degree on local public health and hospital development, but improvements to DPH’s capabilities can benefit all health partners.

Table V-1 shows the portion of the grants retained by DPH increased between FY 04 and FY 05 -- from about a 50 percent split in CDC money in 2004 to 55 percent in FY 05. For HRSA, there was a 90 percent split to contractors and 10 percent to DPH in FY 04 with an 85/15 percent split in FY 05.

Preparedness partner funding. The amounts received under the CDC and HRSA grants by the principal preparedness partners -- hospitals, Centers of Excellence, health departments, and health districts -- for FY 03 and FY 04 are shown in Table V-2.

Department of Public Health employees and preparedness funding. While not all state-funded staff time dedicated to preparedness has been fully accounted for, it is clear the federal government funds a large number of DPH employees devoted to this effort. Figure V-3 shows the trend in the number of DPH full-time equivalent (FTE) employees dedicated to preparedness by funding source. The number of FTEs overall has increased from 8.5 in 2000 to 74 in 2004. The estimate for the number of FTEs supported by state funding is about four, but as noted above because of the accounting system this estimate probably does not capture all the time state employees devote to preparedness.

CDC focus area expenditures. Table V-3 shows the percentage of preparedness money spent by focus area. Focus areas A, B, and E have consumed two-thirds of the funding over the last two years. These areas support a number of diverse preparedness activities.

For example, focus area A supports the work of 14 DPH employees dedicated to public health preparedness leadership and planning activities, including a project manager, a smallpox coordinator, an attorney, a Strategic National Stockpile coordinator, and various support personnel. Major contractors under this area include local health departments required to develop, exercise, and evaluate local and regional emergency response plans, and CADH, which provides support, technical assistance, and coordination for all local health departments in the development of public health emergency management plans.

Focus area B supports the work of 15 DPH employees dedicated to public health emergency surveillance and epidemiologic activities, including nine epidemiologists, a toxicologist, sanitarians, and various support personnel. Major contactors with responsibilities in this area include the full-time local health departments. Each is required to ensure epidemiologic scenario-specific response planning for biological agents and coordinate this effort with overall emergency planning. Funding is also provided for the development and maintenance of mass vaccination clinics in 42 areas of the state.

Focus area E supports the work of seven DPH employees dedicated to public health preparedness communications activities, including a planning analyst, an epidemiologist, and several technical positions. Major contractors under this area include various companies that provide support for communications equipment and software, including telephones, cell phones, satellite phones, and fax machines. In addition, this focus area supports the development and testing of local health alert networks that will allow local health department directors to provide emergency public health notifications and alerts to key stakeholders (e.g., physicians, pharmacies, police, and fire departments).

Related Federal Grants

Under the broader designation of emergency management, Connecticut receives additional federal funding that directly or indirectly benefits public health preparedness. The Emergency Management Performance Grant (EMPG) program, operated by the Federal Emergency Management Agency, is based on an “all hazards” approach to preparedness. The program is designed to help state and local governments put an emergency management system in place. The grant money, which must be matched on an equal basis, can be used for planning, training, and public education purposes as well as emergency operations personnel, based on the needs of the grant recipients in the areas of disaster mitigation, preparedness, response, and recovery.

In Connecticut, the Office of Emergency Management, which is responsible for developing the governor’s emergency response program, oversees allocation of the grant. Typically one-quarter of the money is disbursed at the local level; the rest is retained at the state level. Figure V-4 shows the amount of the Connecticut grant annually since FY 00.

OEM uses about half to two-thirds of its share to pay for staff who provide planning and training assistance to help municipalities and the two tribal nations prepare for and respond to natural and manmade disasters. Local allocations, which are based on population and program participation, are used to develop plans and prepare staff for emergencies. In federal fiscal year 2003, individual local grants ranged from $1,000 to $58,000. Preliminary allocations for federal FY04 range from $600 to $44,000.

OEM also receives approximately $1 million annually for Nuclear Safety Emergency Preparedness. This money, which utility companies are required to provide, pays for preparedness planning and training activities as well as communications and equipment upgrades related to emergencies at nuclear power plants. Additional money is allocated to towns in the vicinity of a nuclear power plant, based on the role they would be expected to play in the event of an incident.

Another federal program that supports public health preparedness is the Domestic Preparedness/State Homeland Security Grant Program, established to provide money for enhanced detection equipment, mobile decontamination trailers, and personal protective equipment for first responders. Funding is provided to the states through the federal Office of Domestic Preparedness, which initially was with the Department of Justice (DOJ), but has since moved to the Department of Homeland Security.

In Connecticut, OEM manages the FY 99 through FY 02 equipment grants provided through the Department of Justice. Beginning with the FY 03 grant, the program was transferred to the Division of Homeland Security. Figure V-5 shows the amount of money Connecticut has received from this program since FY 99.

In the early years of the program, all of the money went for equipment. Priority recipients were state and regional entities that provide field emergency response services, followed by municipalities with large populations, and then smaller towns. Hospitals in highly populated areas also were eligible to receive funding.

In federal FY 03, program funding grew dramatically as the allowable uses expanded to cover equipment for more municipalities, increased security measures at critical infrastructure sites, updated state and local needs assessments, and additional training. In Connecticut, approximately two-thirds of the FY 03 grant was allocated to equipment.

Chapter Six

Status of Preparedness

Preparing for a public health emergency is an ongoing process. Even if all required plans, personnel, and equipment are put in place, things change. New health threats arise, equipment goes out-of-date, and people leave their jobs. A successful public health preparedness program must incorporate procedures that routinely re-examine the system to ensure resources are adequate and plans remain valid. Public safety and health personnel will always find a way to respond to an unexpected incident, but, without a continuous process, the response may not be as thorough or prompt as it could be, possibly resulting in the unnecessary loss of life.

This chapter looks at the overall status of preparedness for public health emergencies in Connecticut. Chapter Seven discusses key areas of preparedness in more detail as well as presenting the program review committee’s findings and recommendations.

Overall Conclusion

The Department of Public Health and its related health partners have made significant progress over the last three years in improving the state’s ability to prepare for, respond to, and recover from various types of public health emergencies. However, a number of components that would enhance these efforts need to be further developed, especially as preparedness efforts shift from planning to system performance.

Status of Specific Areas

To determine the status of specific areas of preparedness, multiple sources of information were analyzed including:

Immediately below, is a summary of the Department of Public Health’s progress against the critical benchmarks established by the federal government for its two main preparedness grant programs. Also presented are selected results of surveys administered by the program review committee to local health department directors and hospital emergency plan coordinators.

CDC requirements. To enhance public health preparedness, both the CDC and HRSA grants require states to complete specific activities and meet certain benchmarks. The 2002 CDC grant, focusing on state and local public health departments, outlined seven broad focus areas to improve public health preparedness capacity. Sixteen specific capacities considered critical for states to be prepared for a public health emergency were identified within the focus areas. In order to build these “critical capacities,” CDC developed certain requirements and designated 14 of the requirements as “critical benchmarks.”

These 14 benchmarks should have been met by June 2004. Analysis of these benchmarks as of November 2004, is presented by focus area in Table VI-1. The committee found that nine of the 14 have been completed in Connecticut, while five are partially or nearly complete.

The nine benchmarks achieved by the Department of Public Health involved the establishment of a broad-based advisory committee and an organizational structure to support its preparedness efforts, as well as a system to receive and evaluate urgent disease reports and other communication enhancements. A number of plans were also developed, such as an interim plan to distribute pharmaceuticals.

The department has acknowledged that two benchmarks within Focus Areas A and C are only partially complete. These relate to the development of a statewide plan for responding to bioterrorism and other public health threats and emergencies (which is in draft form), and the development of a plan to improve the working relationship between and among laboratories in the state. Program review believes the following Focus Area A benchmarks are also only partially complete:

Current benchmarks. Subsequently, new requirements were added to the federal agreements for the next two years and the number of benchmarks has increased to 25. These requirements incorporate or expand some of the previous benchmarks as well as add new mandates. These benchmarks and related activities must be completed by August 2005.

Analysis of these benchmarks as of November 2004 is presented by focus area in Table VI-2. Five of the 25 appear to be substantially complete, while 12 are partially complete. Seven of the benchmarks relate to the development and conduct of specific drills or exercises to test aspects of the state’s preparedness efforts and should all be completed by the end of the program year.¹⁹

The department appears to have substantially completed benchmarks that include the development of a financial tracking system and a 24/7 emergency notification system, as well as enhancements to existing benchmarks involving the system used to receive and evaluate urgent disease reports and the program to distribute pharmaceuticals.

HRSA requirements. The HRSA grant focuses on upgrading hospital and related health care entity preparedness. Beginning in 2002, the HRSA grant required states to develop a needs assessment and an implementation plan for a bioterrorism preparedness program for hospitals and related health care entities.

In Year One (FY 2002), five critical benchmarks were established that should have been completed by the end of August 2003. DPH completed four of the five benchmarks, including the designation of a coordinator for hospital preparedness, establishment of a hospital preparedness planning committee, completion of a statewide needs assessment, and ensuring funds are properly distributed to hospitals. The fifth benchmark, the creation of a statewide plan for hospitals to respond to an epidemic, was not completed. This benchmark was not completed by many states, and a similar requirement was incorporated into subsequent grants.

Current benchmarks. The current grant (Year Three, September 1, 2004 - August 31, 2005) and the previous year’s grant (Year Two) contain six priority areas and 16 critical benchmarks. The department has about two and one-half years remaining to complete these benchmarks.

As shown in Table VI-3 (above), the department appears to have substantially completed five benchmarks in the areas of financial tracking, isolation, decontamination, communications capacity, and health surveillance systems. It continues to develop several areas related to the ability of hospitals to accommodate a large sudden influx of patients (regional surge capacity), the development of a mutual aid plan for the emergency medical services system, hospital lab capacity, and training of health care workers.

Survey of local health departments and hospitals. Another source of information about the status of public health preparedness efforts on the state and local level from the perspective of those working in the field were program review surveys of local health department directors and hospital emergency response plan coordinators.²⁰ The results of each survey are presented in full in Appendices A and B, while relevant questions are summarized below and discussed further elsewhere in the report.

The consensus among those two groups is that Connecticut is better prepared today than it was three years ago. They also believe they are somewhat prepared to well prepared in the major public health preparedness areas.

Chapter Seven

Findings and Recommendations

The process of preparing for public health emergencies involves completion of a variety of activities. The major tasks can be grouped within the four stages shown in Figure VII-1.

During the first phase of the process, participants identify the types of emergencies they may be called upon to deal with and initiate contact with others who might be involved in the response. This stage is followed by compiling assessments that catalog existing resources and identify gaps. During the third phase, the roles of the various individuals, agencies, and institutions expected to respond during a public health emergency are defined, and written plans are prepared detailing their responsibilities in the event of general and certain specific incidents. Successful resolution of an emergency is heavily dependent on a carefully thought out plan that has been tested, with specific tasks practiced regularly. By the final stage, participants are ready to act in a coordinated manner when an emergency occurs.

Since preparedness is a fluid condition, going through the four stages of the process just once is not enough. After all of the stages are completed the first time, the process should repeat itself routinely. Subsequent cycles would adjust the scale of activities in each segment as appropriate, acknowledging the base work completed in the initial effort, accommodating new threats and information, and recognizing that some aspects of the process are harder and will take more time. For example, building relationships and crafting new plans is more complex than renewing agreements and updating existing plans. However, all aspects of the preparedness system should be reviewed periodically and updated if necessary.

Because of national events and the subsequent focusing of federal grant programs on bioterrorism, Connecticut’s recent efforts to prepare for public health emergencies involved jumping into all of the areas described above simultaneously rather than sequentially. Consequently, progress has occurred within all stages of the process, but none are totally complete.

The remainder of this chapter looks at how much progress Connecticut has made in completing the elements of the preparedness process described above. It represents a status report on the ongoing public health emergency preparedness process underway in Connecticut. Some issues that are discussed do not include recommendations because the specific activities that need to occur have already been identified and are underway. The specific issues areas addressed are:

Planning and Grant Process

The Department of Public Health’s overall public health preparedness planning and grant development processes demonstrate an inclusive and collaborative goal setting and monitoring effort across governmental levels and among public and private partners. However, resource allocation decisions are closely controlled by DPH, and overall direction to hospitals and local health departments does not always appear to be clear.

The Department of Public Health has established a collaborative planning and grant process with representatives of private and public entities that have significant roles in preparedness and response to public health emergencies. The department created the Public Health Preparedness Advisory Committee, including over 60 representatives of various organizations, which meets regularly to advise the department on its preparedness activities. The committee structure involves a number of working groups and subcommittees devoted to particular preparedness issues, such as preparedness planning, lab capacity, and infectious disease preparedness. It also includes representatives of the key coordinating partners, the hospital-based Centers of Excellence and the Connecticut Association of Directors of Health. Many participants in the process have noted that public health and health care partners are finally being recognized as an important part of the emergency response community, and this is reflected on both the state and sub-state levels of government.

The results of two program review surveys of local health directors and hospital emergency response plan coordinators found two-thirds of respondents believe the perspectives of local health departments and hospitals are sufficiently represented in the state’s planning process. However, both groups were split on the overall direction and leadership provided by the department regarding public health emergencies, with about half of each group rating DPH as somewhat effective to not effective.²¹

In addition, written comments attached to the surveys and interviews with local health directors by committee staff indicated dissatisfaction with certain aspects of the planning process that require stronger direction and leadership from DPH, such as better coordination of regional planning efforts, lack of mutual aid agreements, better integration of local and state response efforts, and contracting. For example, 59 percent of respondents to the program review survey of local health departments/districts, said DPH was somewhat effective to not effective in providing useful feedback on local public health emergency response plans. Some local health directors, in written comments, indicated a preference for a stronger top-down approach to the planning process, while many others emphasized that the planning process should be more flexible in accommodating unique local and regional needs.

Respondents to the hospital survey also emphasized the need for a better integrated process for regional planning. In addition, they cited the need to better define the role of administrative agencies, who guide planning efforts, and operational entities, who have implementation responsibilities, in the planning process.

A number of local health directors and other active participants in DPH’s grant process have noted the department’s practice of developing grant priorities and presenting them to the planning group as a near “done deal” that effectively precludes them from meaningful participation in the budget allocation process for the two federal preparedness grants. Required letters of support from local health directors, however, accompany federal grant applications indicating concurrence with the proposed use of funds, and funding to local health departments has not decreased as it has in other areas. Unfortunately, the complexity and cost of public health preparedness efforts compared to the funding available may make priority differences among planning partners inevitable, but ideally participants should feel like true “partners” when budget decisions are made.

Assessments

As of November 2004, the Department of Public Health still had not completed all of the capacity assessments of specific health care entities required by the federal CDC and HRSA grants. The ones that have been done vary in comprehensiveness, and the department has no specific schedule for updating them, making it difficult to determine public health emergency preparedness levels statewide.

In the event of a public health emergency, the state needs to know what response capabilities will be available in areas such as personnel, communications, and legal authority. A key mechanism for compiling that information is a formal evaluation of the parties, facilities, and systems already in place. Such an assessment is usually summarized in a written report. There are two types of assessments: capacity, which focuses on quantifying existing physical assets such as personnel and equipment; and performance, which examines the timing and manner in which people and organizations respond to an emergency, based on real or test situations. Both types should identify changes needed to enhance future capacity and performance.

Capacity assessments. Staff from DPH conducted some of the required assessments, while others were performed by contractors under the direction of the department. Table VII-1 lists the assessments, who conducted each, and where applicable the proportion of each group being evaluated that supplied data.

Some differences within the capacity assessment process are appropriate. For example, the assessments for the health care providers listed in Table VII-1 examined a total of 16 issues. The same 11 issues were covered for every group, while the remaining issues (e.g., laboratory capacity and pharmaceutical stockpile) were only examined for relevant entities. Other differences are of concern, however, including the following:

Recommendation: The Department of Public Health should establish a timetable for periodically updating capacity assessments of key public health emergency response partners such as the department itself, acute care hospitals, local health departments, and emergency medical services. DPH also should identify other statewide issues that have not been examined so far (e.g., hazards vulnerability to determine the probability of particular events occurring in Connecticut) and develop a schedule for completing assessments of those topics.

Since the completion of the formal assessments listed in Table II-1, other tools have been put in place to gather some of the desired data on a more regular basis. This includes web-based daily bed capacity counts for all acute care hospitals in the state, which are accessible to the hospitals and DPH.

Performance assessments. Conducting periodic drills to test written response plans enables participants to judge the overall workability of the plans and the feasibility of performing the specific duties assigned to them when actually needed. After-action reports, formal evaluations used to examine the results of such events, provide information about readiness for public health emergencies. Prepared subsequent to exercises and drills as well as many real incidents, ideally an after-action report briefly describes the purpose or objective of the event, the nature of the incident that took place, who was involved, elements of the operation that worked well, and areas that need improvement.

The format and level of detail contained in the after-action reports prepared by Department of Public Health staff vary considerably. In addition, the department does not appear to have a formal process in place to ensure steps are taken to correct problems identified in the reports.

Program review examined 11 after-action reports prepared by DPH staff between January 2003 and September 2004.²² Several issues recurred during the 21-month period covered by these reports, including:

Examples of differences in the formats of the individual reports examined by program review include:

After-action reports can be an important management tool helping to identify problems and solutions, as more drills are required in the current program year. Although the reports are prepared for various types of events (e.g., program site visits, tabletop exercises, drills, and medical support at events with large crowds), a certain degree of consistency regarding the types of information provided and the manner of presentation would be useful. Indeed, DPH is developing a standardized AAR form for outside partners such as hospitals to complete after they participate in drills and exercises.

Recommendation: The Department of Public Health should develop a standardized template for after-action reports prepared by agency staff. The document should indicate the format and minimum content of such reports. In addition, the department should disseminate the results of after-action reports more widely within the agency, implement corrective actions to reduce the reappearance of the same issues in the reports, and document the results of those efforts in a written report prepared annually for the Public Health Preparedness Advisory Committee.

Key Public Health Plans

Key core public health preparedness and response plans have been completed, though some incomplete plans that are required have been under development for years. Most operational plans are only beginning to be developed.

Table VII-2 contains a description and status of key plans the Department of Public Health is responsible for developing or overseeing.

Planning participants, outside of DPH, have expressed frustration over the fact that several plans that have been under development for years are still incomplete or in a draft form, especially the statewide EMS mutual aid plan, the crisis and risk communication plan, and the DPH emergency response plan. It should be noted that DPH’s emergency response plan has only recently been completed and is currently being circulated after being under development for three years. It will in all likelihood remain in draft form, because it is part of the state’s overall response plan maintained by the Office of Emergency Management. That plan is in draft form because OEM believes this protects the plan from public disclosure.

Most of the plans described above identify basic roles and responsibilities of participants and overarching goals. True operational plans, which specify procedures and protocols, especially those for biological agents with the greatest potential for adverse public health impact from mass casualties (i.e., Category A agents), have yet to be developed. With the notable exception of the statewide and regional smallpox plans, which are fairly mature in their development, the Department of Public Health is just beginning to work on such plans.

Not only are plans important because they are required under federal grant applications and in some cases state statute, they also improve decision-making, clarify roles, and enhance organizational responsiveness during a crisis. Absence of a plan does not mean an agency would not rise to the demands of an emergency but it does raise serious doubts. An organization that has neither developed plans nor practiced a plan calls into question whether it can respond effectively to an incident to mitigate losses.

Planning Regions

The various local, regional, and state entities working to develop broad and incident-specific public health emergency response plans in Connecticut do not all use the same geographic configurations, which complicates the process of integrating those plans.

In the event of a public health emergency, entities at the local level will be called upon to deal with the situation first. However, given the small geographic size of Connecticut, it is likely that any significant public health emergency will ultimately require at least a regional response. To ensure that those additional resources are smoothly integrated into the response effort, pre-event regional planning is important.

Complicating coordination is the large number of different regional configurations used in Connecticut. At least 14 different maps currently define governmental planning and service regions within the state. The configurations that divide the state range from two to 42 regions. For example, fire service responders use three regions, EMS uses five regions, and state police use 11 districts within three regions. Table VII-3 lists some of the key plans related to preparing for public health emergencies in Connecticut and the geographical configuration each is based on. Many of these plans are intended to be incorporated into broader emergency plans prepared by other entities.

Eighty-nine percent of the local health department directors who responded to the program review survey agreed somewhat or strongly that the use of different regional planning configurations hinders the process of developing public health emergency response plans. Seventy-nine percent of respondents to the survey of hospitals expressed the same view.

Given that participation in the plan development process for some public health preparedness partners is voluntary, these participants may need to be motivated to become involved in the process. Requiring them to do so within a system that uses multiple planning regions is just one more complication to overcome.

It is important to note that the use of multiple planning regions is an ongoing issue that is not unique to emergency preparedness. To address the problem in the areas of transportation, the environment, and economic development, the state has been using 15 regional planning organizations to promote regional cooperation and planning.

Recommendation: A long-term goal of the state of Connecticut should be the development of a single set of geographic boundaries for all emergency preparedness purposes. The Department of Public Health should work with the new Department of Emergency Management and Homeland Security on a proposal to implement this goal.

A variation of this recommendation was adopted by the coordinating council for the new Department of Emergency Management and Homeland Security with respect to overall preparedness planning. The council recommended creation of defined regions for emergency planning and preparedness purposes that at least initially would not impact service delivery.²³

Local Health Departments

Recent efforts to prepare for public health emergencies in Connecticut have magnified the degree to which part-time local health departments lag behind full-time departments/districts in terms of capacity to respond.

The role of a local public health department today includes identifying health problems and hazards in the community, educating people about health issues, enforcing laws and regulations that protect health and ensure safety, and assuring a competent public and personal health care workforce.²⁴ Preparation for public health emergencies cannot be separated from this broader role since the ability of a local health department to sustain emergency preparedness efforts depends on a strong overall public health infrastructure being in place for the area it serves. As discussed in Chapter One, a general deterioration in the infrastructure that underlies the public health system (i.e., the foundation supporting the planning, delivery, and evaluation of public health activities) has been documented over the last two decades. Concerns in Connecticut include the following:

Recommendation: The Department of Public Health and the Office of Policy and Management shall develop a strategy to improve the emergency response capacity of areas served by part-time health departments through the direct provision of additional resources or the creation of additional full-time local health districts. DPH shall submit the strategy to the committee of cognizance for public health matters by January 1, 2006.

The Department of Public Health should also identify mechanisms to increase staff resources for any local health department that is involved in a public health emergency. The department should consider whether the state’s public health emergency powers need to be amended to facilitate such surge capacity.

Hospital Surge Capacity

The state’s hospitals have made progress on many of the basic elements of preparedness; however, some aspects of surge capacity are lacking.

Acute care hospitals would play an essential role in any large-scale chemical, biological, radiological, nuclear, or explosive event, as well as an infectious disease outbreak. Many victims would no doubt first seek treatment at emergency departments. Hospital preparedness efforts must take into account the need to accept and treat a sudden, large increase in the number of patients that may occur. The ability to do this is referred to as surge capacity.

The federal government has provided some direction in this area, and while the federal guidance does not fully define all aspects of hospital preparedness, it is an attempt to identify what can be realistically achieved in a relatively short time period. In Connecticut, a number of federally defined readiness indicators aimed at insuring aspects of surge preparedness such as decontamination capabilities, availability of personal protective equipment, redundant communication systems, and isolation capacity have been met or are very close to being met. However, there are a few areas in particular where surge capacity is lacking.

In response to the program review survey, 92 percent of hospital emergency plan coordinators believed preparedness for a public health emergency in Connecticut has improved, but some specific elements need more attention. Regarding surge capacity, only 33 percent of respondents said their hospitals are “well prepared” in having procedures in place for the discharge of patients to make room for victims of a public health emergency, and only 21 percent are “well prepared” in having the capacity to address a mass casualty incident. Half of the respondents rated DPH as somewhat effective to not effective in planning for a sufficient statewide surge capacity for hospitals in the event of a public health emergency.

Emergency Medical Services

A number of initiatives relating to the preparedness of emergency medical service providers are incomplete or have not been timely.

Emergency medical services are a crucial element in a comprehensive response to many public health emergency scenarios, such as a mass trauma event, as well as providing transportation services to and from hospitals that are trying to increase surge capacity by freeing up beds for victims of a public health emergency. According to hospital preparedness coordinators who responded to the program review survey, emergency planning efforts between their hospitals and EMS providers in their regions are well coordinated. Half strongly agreed, while one-third agreed somewhat. Seventeen percent disagreed somewhat.

Unfortunately, a number of initiatives relating to EMS preparedness are incomplete or have not been timely, as indicated by these examples.

Recommendation: The Department of Public Health should establish a timeline for the accomplishment of key tasks related to facilitating EMS preparedness for a public health emergency. The state should determine which EMS providers have personal protective equipment and have received the required training. In addition, the state should work jointly with municipalities to identify funding sources to pay for personal protective equipment training for those providers not trained. The state should include in its funding agreements with municipalities an assurance that the appropriate training and distribution of equipment has occurred.

Mass Vaccination Clinics

Progress has been made in developing the state’s capacity to respond to a biological event (especially smallpox) where protective treatment (i.e., prophylaxis) is possible through the development of mass vaccination clinics and certain preparations in the state’s hospitals, but preparedness efforts in this area still fall short of what is required.

In November 2002, the federal government mandated that recipients of bioterrorism preparedness money redirect certain funding to plan and implement the National Smallpox Vaccination Program. This program targets key public health, health care, and emergency response personnel to form the backbone of smallpox response teams who would investigate outbreaks, care for patients, and vaccinate members of the public. Elements of the program such as the development of mass vaccination capabilities and underlying infrastructure may also be useful in response to other biological agents where prophylaxis is possible, such as a pandemic flu outbreak.

In Connecticut, the key strategies for implementing the smallpox program and protecting the public in response to similar events involve the creation of 42 regional mass vaccination clinics for the public and various activities related to preparation of the state’s 32 acute care hospitals, including the West Haven Veterans’ Administration Medical Center. This includes pre-vaccination of response personnel.

Important elements of a successful mass vaccination clinic include comprehensive plans, recruitment and training of teams, pre-vaccination, development of public communication plans and messages, and evaluation of plans and staff through drills and exercises.

Isolation and Confinement

The governor and the Department of Public Health have statutory authority (P.A. 03-236) to restrict the movement of people within the state in the event of a public health emergency. Local health departments can restrict movement within a narrower area. However, protocols regarding the manner in which such orders would be implemented have not been established. In addition, Connecticut is relying heavily on voluntary compliance with local confinement orders because the law carries no specific penalties for violation of those orders to isolate or quarantine people.

A public health emergency that involves a communicable disease or contamination by certain substances (e.g., biological toxin or chemical or radioactive substance) may necessitate placing individuals under quarantine or in isolation. A person who is or is reasonably believed to be infected or contaminated may be isolated from other people in an effort to reduce the spread of the disease. Likewise, someone who has been exposed to a communicable disease or contamination may be asked to remain physically separate from other people in a confined place (i.e., quarantined).

How a quarantine or isolation order would actually be implemented is still unclear. Many details about how an individual would be quarantined, including their ability to access food, health care, and social services as well as the specific roles of public safety personnel need to be developed.

For larger outbreaks, the availability of sites in Connecticut where a significant number of individuals can be isolated or quarantined for an extended period of time is limited. The state is in the process of acquiring a 100-bed mobile hospital that could be set up anywhere in the state, but it would not be able to handle a situation involving hundreds or thousands of people. In such a case, other options for the state might include reopening a mothballed state building, transferring residents out of a currently operating institution, or temporarily taking over a private facility.

Only 39 percent of the respondents to the program review survey of local health departments rated DPH effective to very effective in planning for isolation and confinement of people, 51 percent said the department was somewhat effective to not effective, and 11 percent did not know. With respect to whether local health departments have a plan to quarantine and/or isolate people from the general population in a public health emergency, only 3 percent said their department was well prepared, 59 percent were somewhat prepared, and 38 percent were not prepared.

Recommendation: The Department of Public Health, in conjunction with the Department of Public Safety and the new Department of Emergency Management and Homeland Security, should establish protocols regarding the circumstances under which the movements of people within Connecticut will be restricted during a public health emergency. In addition, the departments should identify the mechanisms that will be used to enforce compliance with those protocols. If statutory changes are needed, DPH should submit language to the legislature regarding the changes.

Laboratory Capacity

The state’s laboratory system and capabilities have improved, especially in the ability to handle and analyze biological agents. Chemical and radiological capabilities are still under development. The state’s lab facilities and information technology system have far outlived their useful lives.

The goal of the state lab is to be able to handle and identify a comprehensive range of materials, including biological, chemical, and radiological agents. The federal government has established a nationwide network of local, state, and federal testing laboratories, called the Laboratory Response Network, which provides the infrastructure and capacity to respond to various biological and chemical threats and other public health emergencies.

Laboratories are designated as either a sentinel laboratory or a reference laboratory based on their ability to handle various dangerous substances. Sentinel laboratories are the basic diagnostic facilities, such as hospital clinical laboratories, that initially identify likely bioterrorism agents and submit specimens to reference laboratories for confirmatory testing. Reference laboratories, of which the DPH lab is one, are more advanced public health laboratories that can provide confirmatory testing for certain substances. The proximity that laboratories in the national network have to one another ideally allows for the transfer of samples to another lab if the state cannot perform required tests or becomes overwhelmed in an emergency situation. Characteristics of lab capacity in Connecticut include the following:

Education and Training

Education and training opportunities for public health preparedness have been expanded and enhanced, though some improved management practices should be implemented.

The goal of DPH’s training and education program, based on federal requirements, is to ensure that appropriate training in public health preparedness is provided to the state and local public health workforce and health care professionals. Over the last three years, in support of that goal, DPH has engaged in a number of activities. For example, DPH has:

In addition, the Southern Tier Center of Excellence recently implemented a learning management system for that region.

The program review committee makes the following observations with regard to the training and education activities conducted or overseen by DPH:

Recommendation: The Department of Public Health should work to make all state-sponsored public health preparedness training and education opportunities accessible through a single management system that allows users to register on-line and tracks courses, users, test scores, and other information that would assist in identifying training gaps and managing the training program. DPH should evaluate overall satisfaction of potential and actual participants with the training programs offered, not just individual courses.

Communications

Extensive improvements have been made to public health emergency communications systems at the state and local level in Connecticut. However, additional enhancements are needed to achieve wider and more complete participation in the systems.

In partnership with local health departments and other public and private entities, DPH has worked to build up the emergency preparedness communications system in Connecticut. The primary goal of this effort is ensuring that individuals and institutions who would be involved in the response to a public health emergency can be notified within a reasonable amount of time from the onset of the event. The system also provides ongoing contact as needed during an emergency and incorporates redundant mechanisms to remain operational if there is a power or equipment failure. On a routine basis, the system offers participants access to a wide range of information about public health issues. Key developments in the communications area include the following.

Recommendation: The Department of Public Health should develop a more frequent schedule for routinely testing the WANS, Nextel, and radio components of the statewide Health Alert Network. Based on the results of those tests, DPH should modify elements of the current system as needed to correct any weaknesses identified.

The Department of Public Health has not been timely in its implementation of a comprehensive risk communication program for public health emergencies, including outreach efforts aimed at the general public.

In the context of public health preparedness, the word “communication” also refers to the dissemination of information about health and risk issues, including the provision of general, preventive, and diagnostic facts. Ideally, the state would ensure basic materials are prepared in advance of an emergency, copies are made available to emergency response partners in paper or electronic form, and methods have been identified to reach the general public and special populations during a public health threat or emergency. All of these activities should be based on a risk communications plan that is developed following an assessment.

A critical benchmark in the CDC Year Three grant, to be completed by June 2004, was preparation of an interim risk communications and information dissemination plan. Under the current year’s grant, a final plan is due by August 2005. The required plan is to include a process for developing an effective risk communication capacity that enables state and local public health organizations to disseminate timely information during a public health emergency. Elements of that effort include key individuals trained in communication skills, identification of spokespersons, printed materials, timely reporting of critical information, and effective interaction with the media. Key developments in Connecticut are set out below:

Recommendation: The Department of Public Health should accelerate efforts to select and implement a strategy for informing the general public about what to do in the event of a public health emergency, prior to such an event occurring. In addition, the department should complete any unfinished incident/disease specific information sheets for public health emergencies likely to occur in Connecticut.

Contract Process

Payments to contractors under the CDC and HRSA grants have been delayed considerably, slowing implementation of preparedness activities for hospitals and local health departments.

Connecticut has received approximately $20 million in federal funding each of the past two years. More than half of this money was disbursed to local and regional partners. Indeed, DPH relies on contracts with a number of private and governmental entities such as local health departments and acute care hospitals to complete many of the activities required by the two federal public health preparedness grants. These tasks include assessing capacity, developing plans, and training workers. In some cases, funds are coordinated through organizations like the Connecticut Association of Directors of Health and the two hospital-based Centers of Excellence. In other instances, payments go directly to the individual entities.

Unfortunately, contract payments to many of those entities were months behind schedule. This delayed the hiring of staff on the local and regional level and slowed the performance of contract deliverables such as plans and assessments. In written testimony submitted to the program review committee for its September 22, 2004, public hearing, one town described its experience with an award of $85,065. The town noted that it:

Three-quarters of the respondents to the hospital survey agreed somewhat (29 percent) or strongly (46 percent) that delays in disbursements from the grants impeded emergency preparedness planning for their facility. Eighty-two percent of the local health directors responding to the committee’s survey agreed somewhat (27 percent) or strongly (55 percent) that the delays had a similar effect.

It appears disbursement of CDC and HRSA funds to contractors was hampered by actions inside and outside the Department of Public Health. As the level of funding and the scope of required activities grew, DPH lost staff to layoffs and an early retirement initiative. The state was also introducing a new accounting system, CORE-CT, when DPH needed to enter a large volume of contracts in a short period of time. Communication delays between DPH program and fiscal staff regarding successful performance of contract deliverables also slowed down the processing of payments.

Another complication affecting some of last year’s contracts occurred in January 2004 when the attorney general instituted new oversight procedures for state contracts. Parties receiving contracts for more than $100,000 had to sign affidavits indicating they had not given gifts to relevant state workers during the preceding 10 years. If employees of the contractor had given a gift, information had to be provided about the date of the gift and its value. This issue is less of a problem for the current grant because contractors are more familiar with its provisions, and the applicable contract value has been increased to $500,000.

Another cause of delays was at the local level. It can take local health departments as long as six weeks to obtain approval from their governing municipalities to sign the contract with the state. Only after DPH receives the signed document from the contractor is it submitted for required state approvals.

Contractor frustration with the various delays was compounded by perceptions of DPH’s performance related to resolving contract issues. Sixty percent of respondents to the local health department survey said DPH was somewhat effective to not effective in providing technical assistance to facilitate the administration of contracts.

For the current federal funding period, DPH fiscal staff indicated they were trying to provide contracting entities with advance information about the amount of their awards and send out required paperwork earlier than in previous years. It appears, however, that contract documents for municipal signature only went out in late November.

Future Availability of Federal Funding

Federal funding for public health preparedness has declined and will probably continue to diminish in the future. The Department of Public Health does not have a formal mechanism in place to guide the reallocation of resources if federal funding is reduced.

The program review committee makes the following observations regarding federal funding for public health emergency preparedness:

While these recent investments in public health preparedness by the federal government have begun to address the long neglected local public health and health care infrastructure, continued funding is by no means secure. Even related preparedness efforts funded through three formula-based Homeland Security grants are anticipated to decline between 20 and 57 percent next year. While some of the focus of preparedness efforts may move to a maintenance role, the need for a robust public health preparedness program will not diminish.

Guidance and funding from the federal government have been concentrated on building capacity in targeted focus areas. As the public health emergency preparedness program matures, the next step is to test those capabilities and actually determine how well the various systems work together. While some additional capacity building is still needed, establishing minimum targets for acceptable performance of the system and evaluating that performance should now be of paramount concern. Performance measures and benchmarks would also assist in identifying and prioritizing spending needs.

Recommendation: The Department of Public Health should develop a strategy to manage a potential reduction in federal funding that anticipates a decrease in overall expenditures and the need for additional state spending. As part of the strategy, the department should identify preparedness gaps and overlaps, define relevant performance measures for the public health emergency preparedness system, and develop spending priorities that target specific resources based on those measures.

While results of assessments of system performance will help guide future spending priorities, some examples of spending reallocations that the department, along with the Office of Policy and Management, may want to consider include:

Note: Two respondents did not indicate the size or geographic location of the facility they work for.