In May 2003, the Centers for Disease Control and Prevention (CDC) under the Department of Health and Human Services (HHS) announced $870 million in FY2003 funding for the continuation of cooperative agreements to upgrade state and local public health jurisdictions' preparedness for and response to bioterrorism and other public health threats and emergencies. In February 2004, the National Association of County and City Health Officials (NACCHO) conducted a survey of representative local public health agencies (LPHAs), each from a different state, to identify remaining gaps and to assess progress in local preparedness as a result of the federal funds. Survey sites were selected based on several criteria, including population size of the jurisdiction served and geographic characteristics. NACCHO surveyed 46 LPHAs; 42 responded, yielding a 91% response rate.
Overall, survey results show that federal bioterrorism preparedness funding has facilitated substantial improvements in local preparedness. LPHAs have made the most progress in coordinating with partners, developing response plans, and training staff. However, these are also the very areas where improvements are most needed.
Improvements in Preparedness
The majority of the respondents—40 out of 46—indicated that federal bioterrorism funds have improved local preparedness and response, and that their agency can do much more now than before. Only one respondent strongly disagreed. Several respondents reported that while some progress has been made, they have a long way to go before their agencies will be fully capable of responding to emergencies. Overall, however, the influx of funds enabled improvement in many areas of preparedness, including communication and coordination, emergency response planning and capacity, training and performance evaluation, and epidemiology and surveillance capability (Figure 1).
Respondents cited significant progress in communication and coordination. The federal funds allowed some LPHAs to build better communication systems; others focused on coordinating preparedness efforts with nontraditional community partners such as hospitals, schools, and businesses. The increased knowledge and awareness of these key partners regarding LPHAs' role in bioterrorism preparedness was seen as a positive gain. According to one respondent, a hospital medical director commented, “If I receive a call from [the health director], I will do what ever she asks. Whereas a year or two ago, I might have said “what's a health director?'”
More than two-thirds of respondents had completed, revised, and/or tested their response plans. West Nile virus season and influenza vaccination clinics were utilized as opportunities to test and practice risk communication and mass prophylaxis plans. Many respondents reported an increased response capacity overall, noting that newly acquired resources allow their agency to respond to an emergency 24 hours a day, seven days a week, and to do so more effectively since the funds allowed them to purchase additional equipment like cellular phones and pagers. One respondent stated, “This assures that someone will be reachable at all times.”
Respondents frequently noted training as an area of progress resulting from the HHS funds. More than two-thirds reported the implementation of bioterrorism and emergency preparedness training in areas such as weapons of mass destruction, disease surveillance, infectious disease control, incident command structure, and risk communication. In addition to LPHA staff, community partners such as employees of the fire and police departments, medical personnel and first responders, and volunteers have benefited from these trainings. One agency representative explained that providing disease surveillance and infection control training to the fire and police departments has ensured the likelihood that unusual events will be reported and investigations better coordinated.
Half of the respondents stated that since receiving the bioterrorism funds, their LPHAs have developed stronger disease surveillance and reporting capabilities. This was attributed, to a large extent, to improved coordination and relationships with hospitals, health care providers, and emergency responders, well-developed syndromic surveillance systems, and better trained and equipped staff. This increased capability has helped them respond more effectively to common outbreaks. As one survey respondent stated, “We have much better ability to track disease and respond statewide; our standards and preparation helped greatly in this year's flu outbreak.”
Percentage of Preparedness Costs Defrayed by Bioterrorism Funds
The extent to which federal monies supported LPHAs' preparedness efforts varied (Figure 2). Most respondents reported that their costs were at least 50% covered by federal funding. Almost one-third of respondents (12 out of 41) indicated federal grant money covered 50% to 75% of their preparedness costs, while another one-third (13 out of 41) reported that federal funds were responsible for covering 75% to 99% of their costs. Three respondents noted that 100% of the funding for their preparedness activities came from the HHS grants. (Note: This paragraph evaluates federal funding as a percentage of each local public health agency's spending on preparedness. The figures cited here do not reflect the actual size of each department's budget in real dollar terms, nor do they reflect any information about the amount of funds received by each department from the state.)
Among those LPHAs that reported less than half of their efforts were supported by federal funds, most (9) indicated that federal funds constituted between 0% to 25% of the resources supporting their preparedness efforts.
Remaining Gaps in Preparedness
NACCHO asked respondents what gaps remain to be filled in order to achieve a high level of preparedness. Forty LPHAs responded, revealing several overarching themes. The need for additional training, staffing, plan development and testing, relationship building with agency and community partners, and regional preparedness and coordination was most frequently cited (Figure 3).
Respondents reported that ongoing education for designated response teams, staff not actively involved in emergency preparedness, and community partners is needed. Some reported a need for training in epidemiology and contact tracing for staff, while others stated a need for community awareness education.
While a better-trained staff would mitigate the gaps that remain, additional public health staff is needed. Respondents reported a particular need for epidemiologists, public health nurses, and staff for planning, response and mitigation. Several responders indicated a need to bolster surge capacity so that during an emergency, response could be ensured and maintained 24 hours a day, seven days a week.
Respondents frequently cited the need to develop stronger plans for overall bioterrorism response, Strategic National Stockpile distribution, and mass prophylaxis.
Relationship building, coordination, and support, whether from political leadership; the health care sector; emergency services, such as fire and EMS; or the general public is seen as an area requiring progress. Likewise, LPHAs would like to strengthen preparedness through stronger partnerships at the regional and state level. As one survey respondent reported, “Far more work is required to forge relations and consistency in the regional medical, health, and emergency management communities.”
Less frequently mentioned factors limiting preparedness include unmet needs for equipment to enhance communication capability, syndromic and sentinel surveillance mechanisms, laboratory capability, improved risk communication, and standardized guidelines for quarantine and isolation.
When asked what they need to fill the gaps in preparedness, 39 LPHAs responded. Overall, the number one response was increased funding (17) to subsidize preparedness efforts, which would help resolve other needs reported by survey respondents, such as hiring more staff (10), developing and participating in additional training and educational opportunities (9), and mitigating the perceived need for more time (5).
In addition to increased funding, some felt there should be flexibility in the administration of the federal dollars and that leaders should understand how to use the funds to strengthen and sustain all areas of public health. Competition for funding is a concern for some respondents, who reported that more collaboration between state and local agencies is needed to bridge the financial gaps in preparedness.
The Usefulness of In-Kind State Resources
NACCHO asked what in-kind resources respondents received from their states, whether those resources were useful, and what resources, if any, would have been more useful to their agency. Twenty-one out of 42 respondents reported receiving in-kind resources from their state, while 13 did not and 8 were uncertain. The most commonly reported in-kind resources were training (21), staff time (6), computers or other electronics (6), supplies (6), and lab support (2).
Of the 21 respondents who reported having received in-kind resources, not one disagreed that they were useful to their agency. However, 19 of those agencies noted that other resources would have been even more useful. These included plan development and technical assistance as well as more and better training. “Better” was defined as audience-specific, readily available, and adaptable. One respondent suggested that “sharing training experiences…even [as] an observer” would be valuable.
Conclusions and Implications
The results of this survey confirm other recent findings about the general state of national bioterrorism preparedness.1,2 Local public health agencies are better prepared now than they were before Congress appropriated funds for improving state and local capacities, but much remains to be done.
Progress has been made in all areas covered by the CDC cooperative agreements. The greatest steps forward have occurred in communications and coordination, development of bioterrorism response plans, and training of public health staff. Disease surveillance and reporting capabilities have improved due to new mechanisms for cooperation between LPHAs and other first responders. However, the areas of greatest progress are also the areas of greatest concern. Survey respondents reported that they need more and better planning and exercising of plans, training, and coordination with other partners and other jurisdictions in order to achieve optimal preparedness.
LPHAs have used federal funding to make improvements. Federal funds covered at least half of increased local costs in most jurisdictions surveyed and more than 75% in one-third of the respondents. All respondents found that in-kind resources contributed by the states were helpful, but most believed that the state could have helped them in other, more useful ways.
Lack of funding—and the additional staff and training capacities that funding buys—remains the single most prevalent barrier to greater advances in bioterrorism preparedness. These survey findings lead to two conclusions about the federal role in improving local bioterrorism preparedness. First, continued national progress will require sustained and increased federal support. Second, federal and state governments must make a concerted effort to optimize the use of current funding so that it meets local needs.