DEPARTMENT OF HEALTH AND HUMAN SERVICES

Interim Public Health and Healthcare Supplement to the National Preparedness Goal (NPG)

The Public Health Security and Bioterrorism Preparedness and Response Act of 2002 addresses the need to enhance public health and healthcare readiness and to protect the nation’s supplies of food and medicine and associated infrastructures in preparation for a potential terrorism or other public health emergency. In particular, as its first line of response to such threats, the nation needs emergency-ready public health and healthcare services in every community. Such entities also need strong connections to state, local and Federal entities responsible for food and drug safety. Also, as envisioned in the Federal Response Plan and Homeland Security Presidential Directive #10, the nation needs to strengthen the capabilities of the federal government to assist and augment local and state emergency response efforts as necessary – especially in responding to mass casualty incidents.

Efforts to enhance public health and healthcare readiness and food defense preparedness at local, state, and federal government levels necessarily emphasize the biological, radiological, and chemical threat agents of highest concern:

• Weaponized biologic pathogens are easy to conceal and release; and, depending on the objectives of the terrorist, only a small quantity of material (e.g., a few kilograms) may be sufficient to cause mass casualties and disrupt society throughout a broad geographic region.
• The effects of a bioweapon may not be evident for days or weeks, depending upon exposure source and other variables across the exposed population. During this latent period, members of the exposed population will have dispersed widely – some to other parts of the nation or to other countries.
• Similarly, because of the diversity of ingredients in today’s processed foods and the rapid movement of food to the consumer, trace back to the source of contamination can be time consuming and difficult. This problem is increased if the threat agent used has a delayed effect that may create a greater separation between cause and symptoms.
• Regardless of whether an event is a known or surreptitious terrorism attack, health care personnel are much more likely to encounter real or potential victims than are the traditional first responders to evident emergencies (e.g. firefighters, hazardous materials specialists, and police).
• Health care personnel who are the first to encounter the consequences of an intentional attack may not recognize anything untoward. Several bioterrorist agents (i.e., the organisms that cause anthrax, plague, and tularemia, respectively) are rarely encountered in ordinary health care situations and, often provoke symptoms similar to those of more common illnesses
• The existing food industry infrastructure which relies on the rapid movement of large quantities of food and food ingredients could unwittingly facilitate the wide distribution of a chemically, radiologically, or biologically contaminated product.
• The longer a terrorist attack goes unrecognized and illness undiagnosed, the longer the delay in initiating treatment, prophylaxis, or other elements of the medical and public health response and, thus, the greater the adverse consequences for those exposed.
• If the pathogen is one that produces a contagious disease such as smallpox or pneumonic plague, then secondary transmission could spread the disease well beyond the initial exposed population – afflicting very large populations of people and animals.
• If the pathogen is a smallpox virus or some other organism against which the vast majority of the U.S. population has little or no protective immunity and for which no effective treatment exists, then the consequences might be as devastating as those produced by a nuclear weapon.
• In addition to producing mass casualties in sufficient numbers to overwhelm patient care resources, bioterrorism (as also could be the case with any mass casualty event) is likely to produce significant psychological, behavioral, and societal consequences with the potential to result in civil disruption and social and economic chaos. Thus, the societal costs can be far more devastating than the economic costs.
• In addition, a foodborne attack, whether biological, radiological, or chemical in nature may also present unique psychological consequences because of delays in identifying the food source for the attack. Casualties may continue to mount for days before authorities can give specific advice to the public.
• A terrorist attack on livestock, crops, or feed for food-producing animals could also trigger a significant public health crisis. Some animal pathogens, such as Rift Valley Fever virus, also cause life-threatening illness in humans. Further, a terrorist attack against the U.S. food supply, one of the largest single segments of the US economy, could wreak economic havoc.

In short, terrorism presents a uniquely severe threat not only to public health but also to social order.

At the same time, preparedness cannot be limited to terrorism. Public health threats and emergencies can ensue from myriad other causes – natural epidemics of infectious disease; terrorist acts involving conventional explosives, toxic chemicals, or radiological or nuclear devices; industrial or transportation accidents; and climatological catastrophes. The nationwide public health and health care community as well as food safety officials therefore must prepare for and respond to all manner of emergencies including mass casualty incidents as effectively and efficiently as possible. This necessitates adopting a unitary approach to the extent practicable and enriching it with threat-specific modalities as necessary. As a consequence, terrorism preparedness and response is not an insular activity but rather is job number one within an all-hazards readiness paradigm.

What follows are the Department of Health and Human Services performance objectives for national preparedness in six priority areas for national readiness where the Department has a leading Federal government role. The six priority areas are Emergency Ready Public Health Departments; Emergency Ready Healthcare Entities; Stockpiling of Medical Countermeasures to Support Public Health and Healthcare Emergency Response; Protection of Critical Infrastructure for Public Health and Healthcare Emergency Response; Defense of the U.S. Food Supply; and National Biosurveillance. These priority areas and objectives are a portion of DHHS’ response to Homeland Security Presidential Directive No. 8 and associated HSP directives and are a companion to the Interim National Preparedness Goal.

A: EMERGENCY-READY PUBLIC HEALTH DEPARTMENTS
PERFORMANCE OBJECTIVE A1: EMERGENCY CASE REPORTS

State and local public health departments can receive emergency case reports around the clock and act on them promptly.

Performance Measure: Number and percentage of state and local public health departments demonstrating, through proficiency tests and/or exercises, the following capabilities:

PERFORMANCE OBJECTIVE A2: RISK COMMUNICATION TO PUBLIC

Within 4 hours of receiving an actionable emergency case report, the public health department initiates communication with the public regarding the incident and provides effective reports and guidance to the public thereafter for the life of the incident.

Performance Measure: Number and percentage of state and local public health departments demonstrating the following capabilities:

PERFORMANCE OBJECTIVE A3: ACQUISITION OF SAMPLES

Within 4 hours of receiving an actionable emergency case report, the public health department begins to obtain appropriate samples for laboratory analysis to support the epidemiological investigation and begin sending them to an appropriate laboratory within 1 hour.

Performance Measure: Number and percentage of state and local public health departments demonstrating, through proficiency tests and/or exercises, the following capabilities:

PERFORMANCE OBJECTIVE A4: LABORATORY SUPPORT

The state public health department ensures around-the-clock availability of laboratory support, including surge capacity, for public health emergency response. Performance Measure: Number and percentage of state public health departments demonstrating the following capabilities:

PERFORMANCE OBJECTIVE A5: MASS PROPHYLAXIS

The state and local public health departments organize and direct a mass prophylaxis campaign – should such be needed to prevent mortality and morbidity in the face of a potential or actual mass casualty incident.

Performance Measure: Number and percentage of state and local public health departments demonstrating, through proficiency tests and/or exercises, the following capabilities:

PERFORMANCE OBJECTIVE A6: PROVISIONAL RESOURCES

Currently under development.

B: EMERGENCY-READY HEALTHCARE ENTITIES
PERFORMANCE OBJECTIVE B1: STAFFED SURGE BEDS

Establish systems that, at a minimum, can provide triage treatment and initial stabilization, above the average daily in-patient census, for the following classes of adult and pediatric patients requiring hospitalization within three hours in the wake of a terrorism incident or other public health emergency:

1. 500 cases per million population for patients with symptoms of acute infectious disease – especially smallpox, anthrax, plague, tularemia and influenza;
   
2. 50 cases per million population for patients for whom respiratory failure from entities such as nerve agents or botulinum toxin will lead to a high requirement for ventilator support
   
3. 50 cases per million population for patients suffering burn or trauma; and
   
4. 50 cases per million population for patients manifesting the symptoms of radiation-induced injury – especially bone marrow suppression.

Performance Measure:

Number of staffed beds statewide that awardee is capable of surging beyond the current staffed bed capacity within 3 hours post-event and in a 24-hour period.

Number of staffed beds within for each major metropolitan area and other regions of the state for which a predictable high-risk scenarios have been identified through the HVA that the awardee is capable of surging beyond the current staffed bed capacity within 3 hours post-event and in a 24-hour period, by type of illness or injury (i.e., acute infectious disease, botulinum intoxication or other acute chemical poisoning, burn and trauma, and radiation-induced injury).

Number of staffed beds (by hospital and other healthcare facility) within each major metropolitan area and other regions of the state for which a predictable high-risk scenarios have been identified through the HVA that the awardee is capable of surging beyond the current staffed bed capacity within 3 hours post-event and in a 24-hour period by type of illness or injury (i.e., acute infectious disease, botulinum intoxication or other acute chemical poisoning, burn and trauma, and radiation-induced injury).

PERFORMANCE OBJECTIVE B2: ISOLATION CAPACITY

Ensure that all participating hospitals have the capacity to maintain, in negative pressure isolation, at least one suspected case of a highly infectious disease (e.g., small pox, pneumonic plague, SARS, Influenza and hemorrhagic fevers) or febrile patient with a suspect rash or other symptoms of concern who might be developing a highly communicable disease.

Identify at least one regional healthcare facility, in each awardee hospital preparedness region, that is able to support the initial evaluation and treatment of at least 10 adult and pediatric patients at a time in negative pressure isolation within 3 hours post-event.

Performance Measure:

PERFORMANCE OBJECTIVE B3: VOLUNTEER HEALTHCARE PROFESSIONALS

Develop a system that allows for the advance registration and credentialing of clinicians needed to augment a hospital or other medical facility to meet patient/victim care and increased surge capacity needs.

Performance Measure:

Number of volunteer healthcare professionals registered in the advance registration system

Number of Doctors (including physician extenders) – by Physician Type

Number of Registered Nurses – by Registered Nurse Type

Number of Behavioral Healthcare Professionals – by Type of behavioral healthcare professions

PERFORMANCE OBJECTIVE B4: HIGH-RISK SCENARIOS

For each metropolitan area or other designated region of the state, describe high-risk scenarios (e.g., accidental or terrorist-induced explosion at a petrochemical facility) that are pertinent to the community and assess the nature and extent of the patient surge that the incident would engender.

Performance Measure: Number and percentage of metropolitan areas or other state-designated regions completing the scenarios and assessments.

PERFORMANCE OBJECTIVE B5: VULNERABILITY ANALYSES AND PROTECTION OF CRITICAL INFRASTRUCTURE

For each participating hospital and other healthcare facility, identify and assess the likely events (including cyber threats and the high-risk scenarios addressed in CB X) that could affect adversely the quality, capacity, and continuity of healthcare operations and develop plans to mitigate the consequences of such events.

Performance Measure: Number and percentage of healthcare entities that have conducted vulnerability analyses and prepared mitigation plans

PERFORMANCE OBJECTIVE B6: PATIENT TRANSPORT

For each metropolitan area or other designated region of the state, establish a system for transporting patients from an incident scene or from local hospitals to healthcare facilities in adjacent jurisdictions, to temporary healthcare facilities within or near the affected jurisdiction, and to nearby airports for transport to more distant healthcare facilities.

Performance Measure: Number and percentage of metropolitan areas or other state-designated regions that have developed a patient transportation system involving regular local healthcare facilities, temporary healthcare facilities, and access to air transport evacuation.

C: STOCKPILING OF MEDICAL COUNTERMEASURES TO SUPPORT PUBLIC HEALTH AND HEALTHCARE EMERGNECY RESPONSE

Currently under development

D: PROTECTION OF CRITICAL INFRASTRUCTURE FOR PUBLIC HEALTH AND HEALTHCARE EMERGENCY RESPONSE

Currently under development

E: DEFENSE OF THE U.S. FOOD SUPPLY
PERFORMANCE OBJECTIVE E1: FOOD DEFENSE PREPAREDNESS

Federal, State and local food safety officials as well as industry stakeholders have the most up-to-date information appropriate for determining vulnerabilities, preventive measures, laboratory capability/capacity, emergency response procedures, and recovery procedures for food emergencies.

Performance Measure: The extent to which State, local, and Federal food safety entities demonstrate the following capabilities: (e.g., this could be the percentage of states or the number of food sectors of higher concern for which guidance has been produced.)

Awareness

• Federal, State, and local food safety officials heighten industry food defense awareness during routine food safety duties.

• Based on priorities established by the appropriate Federal agency(s), Federal food safety officials develop guidance and make it available for food industry sectors of higher concern. To the extent possible, Federal food safety officials share information on vulnerabilities with State and local officials.

• Federal and State food safety officials and industry are trained to conduct vulnerability assessments on their higher risk food industry segments and such assessments are conducted with all partners.

Laboratory Capacity and Capability

• State and local food safety officials and laboratories are routinely included in regional and national food sampling programs to augment Federal resources and to build and maintain the necessary framework for cooperative efforts during a food emergency.

• State and local Food safety officials should have a working relationship with LRN and FERN laboratories which have met the network’s requirements for all the Food Defense related major biological and chemical threat agents.

FDA, USDA, and CDC coordinate the FERN and LRN to conduct food testing during a public health emergency involving the food supply, including capacity for analyzing a high volume of food samples during an emergency event.

Exercises

• Exercises including Federal, State and local food safety officials and the industry are conducted to facilitate emergency operations and to identify gaps or weaknesses in operational plans.

PERFORMANCE OBJECTIVE E2: FOOD DEFENSE RESEARCH

Based on Federally-established priorities, the following research is conducted and applied to existing challenges in food defense:

Performance Measure: Application of applied research outcomes that are relevant to food defense challenges faced by Federal, State and local food safety officials and the industry.

• Develop a comprehensive picture of the characteristics of major threat agents when added to food.

• Develop, harmonize, and evaluate methods for the detection, enumeration, and identification of major threat agents when applicable. Such methods continue to be evaluated and made available through laboratory networks and other venues as appropriate.

• Determine what processing parameters will inactivate major biological threat agents in foods. Such parameters are incorporated into food safety/defense plans as appropriate.

PERFORMANCE OBJECTIVE E3: FOOD EMERGENCY PREVENTION

Federal, State and local food safety officials incorporate food defense activities seamlessly into day-to-day food safety activities.

Performance Measure: The extent to which Federal, State, and local food safety entities demonstrate the following capabilities:

• Federal, State and local food safety entities adopt procedures and develop necessary infrastructure to maximize the sharing and use of available information in guiding food surveillance strategies based on risk.

• Federal and State food safety entities develop and implement critical infrastructure protection plans with specific provisions for the food sector infrastructure.

PERFORMANCE OBJECTIVE E4: FOOD EMERGENCY RESPONSE AND RECOVERY

Federal, State, and local food safety and public health entities as well as industry stakeholders have resources and training and have access to information and resources to successfully coordinate the response to and recovery from a foodborne terrorist attack.

Performance Measure: The extent to which Federal, State, and local food safety and public health entities demonstrate the following capabilities:

• Federal, State and local food safety and public health entities are able to communicate electronically so that they can access current incident management, surveillance, and alert information streams as well as shared information on laboratory methods and procedures and epidemiological information presented in a coherent fashion.

• Federal and State food safety and public health entities work cooperatively to include food defense considerations into response plans at all levels of government.

• Federal and State food safety and public health entities work cooperatively to develop and adopt plans for disposal of contaminated food products and decontamination of food facilities.

PERFORMANCE OBJECTIVE E5: RISK COMMUNICATION

In the event of a food emergency, public health departments and Federal, State and local food safety officials work together to provide effective reports and guidance to stakeholders.

Performance Measure: Number and percentage of state and local public health departments and food safety entities demonstrating the following capabilities:

• Employ readily available, culturally appropriate public information materials and well-exercised public communication protocols regarding Food Defense related biological and chemical threat agents.

• Pre-identify a spokesperson and employ a plan to help food safety and public health officials provide coordinated up-to-date information to the public and stakeholders regarding the incident.

• Establish an information hotline that can be activated or expanded as required to provide critical information.

F: NATIONAL BIOSURVEILLANCE

Currently under development