Public Health Emergencies: Most of Nation Unprepared

Diedtra Henderson

December 19, 2012

More than a decade after the September 11, 2001, domestic terrorism attacks, most of the nation remains woefully unprepared to respond to pressing public health needs during such emergencies, largely because of budget cuts, according to a report released this morning.

The annual report, "Ready or Not?" released by the Trust for America's Health and the Robert Wood Johnson Foundation, ranked states' preparedness to handle public health emergencies resulting from natural disasters, such as Superstorm Sandy; disease outbreaks, such as Escherichia coli; and bioterrorism attacks.

Pointing to the aftermath of the mass shooting last week in Newtown, Connecticut, Jeffrey Levi, PhD, executive director, Trust for America's Health, told reporters it was "a heartbreaking reminder about the importance of ensuring we invest in this as a society."

The report's rankings are based on 10 key indicators, and no state scored a perfect 10. Maryland, Mississippi, North Carolina, Vermont, and Wisconsin rated the highest, each scoring 8 of 10. Kansas and Montana, scoring 3 of 10, ranked the lowest. Colorado, which was recently the nation's epicenter for West Nile Virus infections, ranked 4 of 10. New York, with a tragic history of being targeted by terrorists, was somewhat better prepared for such public health emergencies, ranking 7 of 10. Washington, DC, which is also a terror target, languished in the middle of the pack with a 5 of 10 rating, as did a dozen states.

This year's key indicators are:

  1. Whether the state increased or maintained public health funding from fiscal year (FY) 2010-2011 to FY 2011-2012.

  2. Whether the state could notify and assemble public health staff within 60 minutes to ensure a nimble response to an incident.

  3. Whether the state met the US Department of Health and Human Services' goal of vaccinating 90% of 19- to 35-month-olds against pertussis.

  4. Whether the state requires Medicaid to cover influenza shots with no cost to beneficiaries younger than 65 years.

  5. Whether the state has a complete climate change adaptation plan.

  6. Whether licensed child care facilities must have written evacuation and relocation plans for multiple hazards.

  7. Whether the state has been accredited by the Emergency Management Accreditation Program.

  8. Whether the state participates in a Nurse Licensure Compact.

  9. Whether state public health labs have enough staffing to work five 12-hour days for 6 to 8 weeks in response to an infectious disease outbreak.

  10. Whether the state public health lab increased or maintained their Chemical Laboratory Response Network chemical capacity.

Taken together, the 10 key indicators "offer a composite snapshot of strengths and vulnerabilities," according to the report.

The report finds that states have made "considerable progress" in effectively preparing for public health emergencies "of all types and sizes," an investment that also pays off when contending with day-to-day health emergencies.

For example, among the highest-ranking states for all 10 measures, Vermont increased its public health funding by 10.5% for the 2 fiscal years under examination, Wisconsin upped its funding by 7.0%, and North Carolina by increased its funding by 2.1%. Mississippi's public health funding increased by a modest 0.1% during that period.

Although all but 3 states were able to notify and immediately assemble public health staff within the 60-minute goal, enabling a nimble response, both Idaho and West Virginia could carry out the exercise in a blistering 5 minutes. Connecticut, which took 70 minutes to accomplish the same goal, was among the trio of states that exceeded the allotted time.

Just Hawaii and Nebraska met the US Department of Health and Human Services' goal of vaccinating 90% of preschoolers against pertussis. North Dakota and Maryland, however, came close to meeting the goal, with 89.7% and 89.5% vaccination rates among the targeted age group, respectively. Although Wisconsin vaccinated 88.4% of children against pertussis and Washington State vaccinated 85.5% of children, the report notes that parents can opt out of the vaccinations in both states. Compared with 2011, the number of pertussis cases in 2012 increased 4-fold in Wisconsin and 6-fold in Washington State.

Paul Kuehnert, MS, RN, senior program officer and director, public health team, Robert Wood Johnson Foundation, told reporters that the Washington and Wisconsin outbreaks, in particular, have their roots in shifting parental attitudes toward childhood vaccination and the erosion of core public health services because of funding cuts.

The outbreak has "reenergized many health departments," and vaccination rates are beginning to improve, Kuehnert said. "It goes to the point of how important it is to maintain these core address ongoing routine issues, like vaccinations, that in turn tie into capacity during emergencies to quickly respond," he added.

Although the nation has made strides in such areas as preparedness planning and coordination, public health laboratories, and vaccine manufacturing, those achievements have been tempered by a 38% reduction since FY 2005 in the federal funds that states and local health departments rely on to respond to health emergencies.

In addition, 29 states slashed their public health budgets from FY 2010-2011 to FY 2011-2012, and public health budgets in 23 states dropped for 2 or more years in a row. State and local health departments have shed more than 45,700 jobs since 2008, leaving 13 state public health departments without sufficient personnel to work five 12-hour days for 6 to 8 weeks, as is needed to effectively respond to an infectious disease outbreak.

Dr. Levi called budget cuts and complacency the biggest threats to public health preparedness.

"This has a huge impact on public health preparedness," he told reporters. "This means that the progress that has been made in the past 10 years is starting to erode."

Asked about whether public health departments should simply learn to do more with less, Dr. Levi told reporters that with emergency preparedness, "it's a pay now or pay later situation." Investments in capacity, made up front, ultimately save money. "The government checkbooks open up in the middle of a disaster, and appropriately so. But a lot of that money could have been saved" through earlier investment, he said.

Amid such dire news, the Robert Wood Johnson Foundation's Kuehnert pointed to a bright spot: New Jersey's response to Superstorm Sandy.

The state of New Jersey carried out a coordinated public health response, leveraging staff, volunteers, and first responders. A hotline was established within days of the storm, staffed by public health experts answering questions about food safety and the toxic mold and tainted floodwater left in the storm's midst. Public health workers also worked overtime in hospitals, nursing homes, and medical centers, relying on generator power and performing life-saving transplants. Twenty-seven states offered equipment and the assistance of more than 2500 people through a national interstate mutual aid agreement. Because many residents lacked electricity, local health departments had to be creative, Kuehnert said, distributing hand sanitizer and offering tetanus shots via mobile screening trucks and spreading information via radio interview to reach residents with hand-crank storm radios.

"The response to Sandy really has been inspiring," he told reporters. "It provides a very clear set of examples" of the vital role that public health plays during emergencies.

"Ready or Not?" Trust for America's Health and the Robert Wood Johnson Foundation. Full text