Pounds of cure

The anthrax attacks of fall 2001 forced most U.S. citizens to realize how bioterrorism could endanger them right where they live. Since then, federal, state and local public health agencies have worked to prepare for bioterrorism and other large-scale public health threats. On a national level, the Washington, D.C.-based Department of Health and Human Services — the lead federal agency on threats to public health — has established a Bioterrorism Command Center. The center is equipped with population- and weather-mapping systems, as well as with the ability to track public health crises nationwide, so that local governments can be alerted quickly to possible threats.

Locally, governments are generally less prepared. According to the Washington, D.C.-based National Association of County and City Health Officials (NACCHO), many large local health agencies have invested a great deal of time and effort to prepare for bioterrorism. However, most local governments still lack the resources to develop their threat-identification-and-response capacity, hindering their ability to keep residents safe.

Bioterrorism is just one of the many public health emergencies that local governments must anticipate. Other threats include strange and unexpected diseases, such as severe acute respiratory syndrome (SARS). Furthermore, governments always must be ready for outbreaks of more conventional public health threats, such as influenza.

“Even before Sept. 11, and clearly following [the attacks] and the anthrax scare, the importance of public health as an element of community response to acts of terrorism has grown,” says NACCHO President Patrick Libbey. “Part of being prepared is having in place a functional public health response capacity — and not just [in response to] a terrorist event. SARS is another example of how quickly a local government needs to respond.”

NACCHO has identified five areas that local governments should improve to prepare for possible public health emergencies. Those are preparedness planning and readiness assessment; surveillance and epidemiology capacity; health alert networks, communications and information technology; risk communication and health information dissemination; and education and training.

“In this country, [regarding] our public health capacity and infrastructure, we’ve let it go,” Libbey says. “We aren’t going to make up decades of neglect in one year of federal funding.” However, Libbey admits that homeland security funding is making a difference, slowly. “We are better prepared now than we were a year ago,” he says. “But we have a ways to go if you define preparedness as having fully developed plans in place.”

Areas of concern

In 1999, NACCHO developed the Local Centers for Public Health Preparedness project, in which the Atlanta-based Centers for Disease Control and Prevention provided funding for three local health agencies — DeKalb County, Ga.; Denver; and Monroe County, N.Y. — to conduct bioterrorism training and improve their readiness. Recently, a fourth agency, the Kansas City, Mo., Health Department, signed on as well. Already, their efforts have served as models for information-sharing and training on bioterrorism preparedness — as more and more local governments factor public health into their homeland security plans.

DeKalb County, for example, has developed a bioterrorism response plan and related educational exercises. The plan consists of several sections, including an overview of federal agencies and their responsibilities, reference material and local response agencies’ roles. The plan is available on CD-ROM for use by other local public health agencies. Related educational exercises take emergency response personnel and hospital staff through the likely progression of a bioterrorism event, using botulism, plague and smallpox as possible scenarios.

“It can be difficult to get a first response team to understand that a bioterrorism event is very different [from other emergency events],” says William Dyal, director of population-based services for the DeKalb County Board of Health. “There may not be a site to go to or a place to put yellow tape around. The primary response isn’t an immediate, on-the-scene response.” More often, Dyal says, the response unfolds over time, as people get sick and a pattern emerges.

Dyal adds that emergency response workers commonly want to lump biological and chemical threats together, but he points out that the two types of terrorism would play out very differently and require different responses. A chemical attack, for example, would almost always produce an actual scene where people are falling ill very quickly, Dyal says. Biological attacks unfold more slowly and often mysteriously.

Another crucial element of preparedness and prevention is surveillance. “How well is your public health system monitoring health conditions in your community? How ‘real time’ is your data?” Libbey asks. “Much of our surveillance has been passive. What we need is much more active surveillance that identifies, closer to real time, changes in health conditions.”

Basic surveillance capacities would work just as well to identify an outbreak of SARS, smallpox or West Nile virus, Libbey says. After implementing a basic monitoring capacity, communities can start to tailor their surveillance to specific conditions. “You would up your West Nile surveillance as mosquito season approaches,” Libbey cites as an example. “You have to have a more active, more robust way of gathering that information in a systematic way.”

Lines of communication

As in all emergency response plans, communication among pertinent parties is paramount. That is especially true in a public health situation, where emergency responders may not have as thorough an understanding of a viral outbreak, for instance, as they might have dealing with an explosion.

“Most of what [emergency responders] deal with has been event-specific — things that go boom,” Libbey says. “Now we’re looking at conditions that will roll out less specifically, that are less event-based. We’re doing a lot of work engaging [the Federal Emergency Management Agency] FEMA in teaching public health workers incident command for working under these conditions. But if you’re just introducing each other and exchanging information for the first time during an event, it’s not going to go well.”

Understanding the broad spectrum of involved parties helps. Libbey cites the anthrax attacks, for example, which had a criminal element and involved law enforcement. With SARS affecting tourism in certain places, economic and business entities might be stakeholders as well.

Technological interoperability for communication also is an increasingly understood concept that DeKalb County and many others are working to improve. DeKalb, for one, has outfitted key public health personnel with police radios; if a warning comes through, public health workers then tap into a cellular telephone network to reach key parties.

Education and training are as important as planning, surveillance and communication. “One of the things that is last to be funded and first to go is the notion of training and exercise,” Libbey says. “At least in public health, and I suspect in other disciplines, it’s typically underfunded and it’s usually something you do on top of an already full plate. But in emergency preparedness, it’s an ongoing need.”

A regional approach

In addition to improving communication and education in a single locality, bioterrorism preparedness also requires local governments to develop response plans regionally. “There was a time in local governments when regional was not a good word,” Libbey says. But that has changed since Sept. 11, Libbey adds.

Washington, for example, has taken the lead in encouraging its local governments to work together. County public health departments are divided into regions, with one county — usually the most populated — taking the lead. For example, Thurston County is the lead in a western Washington region that also includes the Grays Harbor, Lewis, Mason and Pacific counties.

The county recently has developed a bioterrorism response plan and provided some related training. For instance, the region has trained staff from all the counties’ hospitals on smallpox outbreaks, providing voluntary vaccinations as part of the training. Even if public health workers did not want to get vaccinated, they were trained on what to do if an outbreak occurred.

Of particular importance to the region is the applicability of the bioterrorism response plan in other public health scenarios. “What we’re trying to do is make sure that whatever we do has life well beyond an event,” says Sherri McDonald, director of the Thurston County Public Health and Social Services Department. The smallpox plan, for example, dealt with how to administer vaccinations to many people at one time — a plan that could apply to the distribution of antibiotics in a bioterrorism event, McDonald says.

“We’re trying to get the message out to the general public that the kinds of things they would do to prepare for a bioterrorism attack [such as stockpiling first aid and other supplies] might help them in other ways, such as for a flood or a winter storm,” McDonald says.

Preparing for the future

Looking ahead, NACCHO has piloted a voluntary certification program for local health departments called Public Health Ready. Certification would demonstrate that a local health organization has a response plan in place, that the plan has been exercised with community partners and that the organization has identified subsequent steps.

The certification program encourages local governments to identify the steps they can take to protect residents. “It’s not feasible or appropriate that every local health department be at the same level of readiness,” Libbey says. “But they have to understand their level of readiness and know how to access that level of readiness.”

Perhaps most important, public health agencies need to maintain communication with other emergency personnel. In the absence of an actual attack, local departments can easily become complacent. “The response plan is only as good as your relationship with the first-response community,” Dyal says.

The author is a freelance writer based in Arlington, Va.