Partnering for preparedness: the project public health ready experience

Effective partnerships between local and state public health agencies and schools of public health have tremendous potential to improve the health of communities nationwide. This article highlights successful collaboration between local public health agencies (LPHA), state health departments, and Academic Centers for Public Health Preparedness (ACPHP) in schools of public health developed through participation in Project Public Health Ready, a program to recognize LPHA emergency preparedness. The project's pilot phase illustrated that LPHAs, state health departments, and ACPHP can effectively work together to improve individual public health worker competency and organizational response capacity in local public health agencies nationwide.     

Developing the academic institution's role in response to bioterrorism: the Iowa Center for Public Health Preparedness.

The terrorist acts during the fall of 2001 triggered renewed concern about the capacity of the nation's public health system to deal with crisis. A critical element of the response ability of the public health system is a prepared workforce. Based on a pre-existing concern about emerging infectious disease, the Centers for Disease Control (CDC), working with the Association of Schools of Public Health, had established a network of university-based Centers for Public Health Preparedness. The events of September 11 accelerated, expanded, and focused this effort. This article discusses this national program, details the activities of the based Center for Public Health Preparedness located at the University of Iowa, and suggests preparedness issues deserving future development.     

Applying educational gaming to public health workforce emergency preparedness

From natural disasters to terrorism, the demands of public health emergency response require innovative public health workforce readiness training. This training should be competency-based yet flexible, and able to foster a culture of professional and personal readiness more traditionally seen in non-public health first-response agencies. Building on the successful applications of game-based models in other organizational development settings, the Johns Hopkins Center for Public Health Preparedness piloted the Road Map to Preparedness curriculum in 2003. Over 1500 employees at six health departments in Maryland have received training via this program through November 2004. Designed to assist public health departments in creating and implementing a readiness training plan for their workforce, the Road Map to Preparedness uses the core competencies of the Centers for Disease Control and Prevention for all public health workers as its basic framework.     

Development and implementation of a public health workforce training needs assessment survey in North Carolina

Assessing the training needs of local public health workers is an important step toward providing appropriate training programs in emergency preparedness and core public health competencies. The North Carolina Public Health Workforce Training Needs Assessment survey was implemented through the collaboration of several organizations, including the North Carolina Center for Public Health Preparedness at the North Carolina Institute for Public Health, the outreach and service unit of the University of North Carolina School of Public Health, the Office of Public Health Preparedness and Response in the North Carolina Division of Public Health Epidemiology Section, and local health departments across the state.     

Integration of academia and practice in preparedness training: the Harvard School of Public Health experience

Given the need for public health professionals well trained in emergency preparedness and response, students in public health programs require ample practical training to prepare them for careers in public health practice. The Harvard School of Public Health Center for Public Health Preparedness has been instrumental in the creation and implementation of a course entitled, "Bioterrorism: Public Health Preparedness and Response." This course features lectures on specific applications of public health practice in emergency preparedness and response. In addition, it provides students the opportunity to operationalize and apply their knowledge during an interactive tabletop exercise. In light of their university affiliations and expertise in providing preparedness training, other Academic Centers for Public Health Preparedness have the opportunity to be instrumental in providing similar training to graduate students of public health.     

Nevada's academic-practice collaboration: public health preparedness possibilities outside an academic center

The Nevada State Health Division developed a local academic-practice partnership with the University of Nevada Reno's Master of Public Health Program to assess the bioterrorism risk communication, information, response, and training needs of professional and public stakeholder groups throughout Nevada. Between October 16, 2002, and April 13, 2004, 22 needs assessment focus groups and 125 key informant interviews were conducted to gather information on the diverse needs of the stakeholders. The themes that emerged from these activities included the need for effective pre-event education and training; a coordinated and responsive public health preparedness infrastructure; honest, accurate, and timely communication in the event of a bioterrorism situation; and appropriate information dissemination methods and technology. The data collected through this needs assessment gave the Nevada State Health Division vital information to plan public health preparedness initiatives. The establishment of local academic-practice partnerships for states without a Centers for Disease Control and Prevention-funded Academic Center for Public Health Preparedness is an effective way for health departments to develop their public health preparedness infrastructure while simultaneously training the future public health workforce.     

Content and criterion validity evaluation of National Public Health Performance Standards measurement instruments

OBJECTIVE: The Centers for Disease Control and Prevention's National Public Health Performance Standards Program (NPHPSP) has developed instruments to measure the performance of local and state public health departments on the 10 "Essential Services of Public Health," which have been tested in several states. This article is a report of the evaluation of the content and criterion validity of the local public health performance assessment instrument, and the content validity of the state public health performance assessment instrument. METHODS: Health department performance is measured using a set of indicators developed for the 10 Essential Services of Public Health and a model standard for each indicator. Content validity of each model standard in the local instrument was addressed by community partners along the following dimensions: the importance of each standard as a measure of the associated Essential Service, its completeness as a measure, and its reasonableness for achievement. All standards for each Essential Service were then judged in terms of their completeness in measuring performance in that service. Content validity of the state instrument was evaluated in a group interview of health department staff members from three states. Criterion validity of the local instrument was assessed for a sample of eight public health departments in Florida and six in New York by examining documentary evidence for selected responses. Criterion validity was also evaluated for a sample of Florida local public health departments and one Hawaii public health department by comparing state health department staffs' judgments of performance against the instrument score. RESULTS: Criterion validity was upheld for a summary performance score on the local instrument, but was not upheld for performance judgments on individual Essential Services. The NPHPSP standards based on the Essential Services have validity for measuring local public health system performance, according to community partners. The model standards are valid measures of state performance, according to state public health departments in three states. CONCLUSIONS: Within the scope of the validity evaluations completed, the NPHPSP state and local performance assessment instruments were found to be valid measures of public health performance.     

The Common Ground Preparedness Framework: A Comprehensive Description of Public Health Emergency Preparedness

Currently, public health emergency preparedness (PHEP) is not well defined. Discussions about public health preparedness often make little progress, for lack of a shared understanding of the topic. We present a concise yet comprehensive framework describing PHEP activities. The framework, which was refined for 3 years by state and local health departments, uses terms easily recognized by the public health workforce within an information flow consistent with the National Incident Management System. To assess the framework''s completeness, strengths, and weaknesses, we compare it to 4 other frameworks: the RAND Corporation''s PREPARE Pandemic Influenza Quality Improvement Toolkit, the National Response Framework''s Public Health and Medical Services Functional Areas, the National Health Security Strategy Capabilities List, and the Centers for Disease Control and Prevention''s PHEP Capabilities.“All models are wrong, some models are useful.”—George Box1Public health emergency preparedness (PHEP) has been defined as “the capability of the public health and health care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities.”2^(p24) However, compared with more traditional public health activities such as food safety inspections, outbreak investigations, community health assessments, immunization clinics, and environmental monitoring, PHEP activities are not clearly defined.2–4We present a framework describing what public health agencies do to prepare for, respond to, and recover from public health emergencies. The framework was developed through a collaboration of state and local health departments, brought together by the Public Health Informatics Institute with funding from the Robert Wood Johnson Foundation to define business processes related to PHEP.The Common Ground Preparedness Framework (CGPF) adds to other PHEP frameworks by more explicitly capturing how public health agencies prepare for and respond to public health emergencies. Combining comprehensiveness with specificity, it is especially useful in describing PHEP to both public health agencies and their partners in emergency response. It also provides a framework for incident action plans and after-action assessments, resource distribution, information systems, and training.     

A federal agency's role in fulfilling the public health core functions: the childhood lead poisoning prevention program model.

The Institute of Medicine identified 3 core functions of public health: assessment, policy development, and assurance. Federal, state, and local public health agencies all have an obligation to provide these vital functions to ensure conditions in which people can be healthy. However, the few publications that provide core function applications only focus on applications at the local or state levels. The Centers for Disease Control and Prevention's Childhood Lead Poisoning Prevention Program uses a comprehensive public health approach. This article describes the Centers for Disease Control and Prevention's leading role in applying the core public health functions to prevent childhood lead poisoning.     

The role of states in ensuring essential public health services: development of state-level performance measures.

The Association of State and Territorial Health Officials (ASTHO) has worked with other public health partners across the country to develop National Public Health Performance Standards, nationally recognized measures by which state public health systems can compare themselves with similar systems across the country. The lead federal agency is the Centers for Disease Control and Prevention (CDC), and other partners include the Public Health Foundation, the American Public Health Association, the National Association of City and County Health Officials, and the National Association of Local Boards of Health. Both challenges and opportunities emerged during the development of the state public health system standards.     

Partnership for front-line success: a call for a national action agenda on workforce development.

Despite more than a decade of dialogue on the critical needs and challenges in public health workforce development, progress remains slow in implementing recommended actions. A life-long learning system for public health remains elusive. The Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry in collaboration with other partners in federal, state, local agencies, associations and academia is preparing a national action agenda to address front-line preparedness. Four areas of convergence have emerged regarding: (1) the use of basic and crosscutting public health competencies to develop practice-focused curricula; (2) a framework for certification and credentialing; (3) the need to establish a strong science base for workforce issues; and (4) the acceleration of the use of technology-supported learning in public health.     

Building academic-practice partnerships: the Center for Public Health Preparedness at the Columbia University Mailman School of Public Health, before and after 9/11.

The Center for Public Health Preparedness at the Columbia University Mailman School of Public Health is part of a national network of academic centers established by the Centers for Disease Control and Prevention to strengthen links between public health practice and academe, especially for public health workforce development. Since its inception in Fall 2000, the Center has been working in partnership with the New York City Department of Health & Mental Hygiene (DOHMH) on planning and competency-based training in emergency preparedness (including bioterrorism and infectious diseases) and evaluation. Initial programs with DOHMH included development of a 3-hour orientation to basic emergency preparedness for their workforce. In the wake of 9/11 and the anthrax events, Center members gave over two dozen presentations at community forums, seminars, and clinical rounds, and over 100 press interviews, provided lay language information through community forum presentations and the School's Web site, and developed a database of volunteers for surge capacity. Subsequent programs include bioterrorism response training for clinicians and emergency medical services personnel, incident command for public health, and a study of evacuation from the World Trade Center on 9/11.     

Public health and terrorism preparedness: cross-border issues

On December 15, 2003, the Centers for Public Health Preparedness at the University of Minnesota and the University of Iowa convened the "Public Health and Terrorism Preparedness: Cross-Border Issues Roundtable." The purpose of the roundtable was to gather public health professionals and government agency representatives at the state, provincial, and local levels to identify unmet cross-border emergency preparedness and response needs and develop strategies for addressing these needs. Representatives from six state and local public health departments and three provincial governments were invited to identify cross-border needs and issues using a nominal group process. The result of the roundtable was identification of the needs considered most important and most doable across all the focus groups. The need to collaborate on and exchange plans and protocols among agencies was identified as most important and most doable across all groups. Development of contact protocols and creation and maintenance of a contact database was also considered important and doable for a majority of groups. Other needs ranked important across the majority of groups included specific isolation and quarantine protocols for multi-state responses; a system for rapid and secure exchange of information; specific protocols for sharing human resources across borders, including emergency credentials for physicians and health care workers; and a specific protocol to coordinate Strategic National Stockpile mechanisms across border communities.     

The Centers for Disease Control's perspective of the introduction of Aedes albopictus into the United States

The Asian "tiger mosquito" Aedes albopictus has become established in the southern United States. The Centers for Disease Control has taken a number of steps to respond to the problem. Appropriate state and international agencies have been informed, and data on biology, public health importance and identification have been prepared and distributed to state and local agencies. Studies on insecticide susceptibility and vector competence are in progress, as is surveillance throughout the southeast, in cooperation with state and local agencies. The introduction of Ae. albopictus presents a major challenge to the mosquito control community.     

All-hazards preparedness in an era of bioterrorism funding.

OBJECTIVES: All-hazards preparedness was evaluated in North Carolina's 85 local health departments (LHDs). METHODS: In regional meetings, data were collected from LHD teams from North Carolina's LHDs using an instrument constructed from Centers for Disease Control and Prevention's preparedness indicators and from the Local Public Health Preparedness and Response Capacity Inventory. RESULTS AND CONCLUSIONS: Levels of preparedness differ widely by disaster types. LHDs reported higher levels of preparedness for natural disasters, outbreaks, and bioterrorist events than for chemical, radiation, or mass trauma disasters. LHDs face challenges to achieving all-hazards preparedness since preparation for one type of disaster does not lead to preparedness for all types of disasters. LHDs in this survey were more prepared for disasters for which they were funded (bioterrorism) and for events they faced regularly (natural disasters, outbreaks) than they were for other types of disasters.     

Declining Trends in Local Health Department Preparedness Capacities

Objectives. We examined local health department (LHD) preparedness capacities in the context of participation in accreditation and other performance improvement efforts.Methods. We analyzed preparedness in 8 domains among LHDs responding to a preparedness capacity instrument from 2010 through 2012. Study groups included LHDs that (1) were exposed to a North Carolina state-based accreditation program, (2) participated in 1 or more performance improvement programs, and (3) had not participated in any performance improvement programs. We analyzed mean domain preparedness scores and applied a series of nonparametric Mann–Whitney Wilcoxon tests to determine whether preparedness domain scores differed significantly between study groups from 2010 to 2012.Results. Preparedness capacity scores fluctuated and decreased significantly for all study groups for 2 domains: surveillance and investigation and legal preparedness. Significant decreases also occurred among participants for plans and protocols, communication, and incident command. Declines in capacity scores were not as great and less likely to be significant among North Carolina LHDs.Conclusions. Decreases in preparedness capacities over the 3 survey years may reflect multiple years of funding cuts and job losses, specifically for preparedness. An accreditation program may have a protective effect against such contextual factors.Federal, state, and local public health agencies have made substantial investments in improving state and local health department (LHD) preparedness capacities and capabilities to effectively prevent, detect, or respond to public health emergencies.1 A lack of valid and reliable data collection instruments as well as evolving preparedness standards has made it difficult to determine the impact of these investments.2,3 As recently as 2011, the Centers for Disease Control and Prevention released 15 public health preparedness capabilities designed to serve as national public health preparedness standards to assist state health departments and LHDs with strategic planning.4 In addition, few studies have examined the impact of LHD contextual factors and participation in improvement efforts on the performance of preparedness capacities.5 We examined LHD preparedness capacities in the context of participation in performance improvement efforts over a 3-year period using a validated survey instrument.6LHDs are essential to emergency preparedness and response activities. They have statutory authority to perform key functions including community health assessments and epidemiologic investigations, enforcement of health laws and regulations, and coordination of the actions of the agencies in their jurisdictions that make up the local public health system.7 Preparedness also involves specialized functions such as incident command, countermeasures and mitigation, mass health care delivery, and management of essential health care supply chains.8 The Centers for Disease Control and Prevention organized these functions into capabilities or standards that are supported by foundational capacities or resources elements in the 15 public health preparedness capabilities.4Despite the considerable investment in public health preparedness after the September 11, 2001, attacks on the United States and the anthrax attack, funding for public health preparedness declined 38% between federal fiscal years 2005 and 2012.9 Although LHDs received funding supplements in 2009 and 2010 to address the H1N1 virus and through the American Recovery and Reinvestment Act,10 median per capita revenues for LHD preparedness activities in the most recently completed fiscal year, 2013, declined to $1.15 from $2.07 in 2010.11,12 In 2012, approximately half of LHDs reported reducing or eliminating services, with preparedness being among the most common services to be affected.12 The specific impact of these and other funding reductions on preparedness capacities has yet to be formally studied.After more than a decade of focused effort, gaps and variation in the performance of preparedness activities remain.6,12 Heterogeneity in the composition and structure of public health systems continues to be an important source of variation in preparedness, as in other aspects of public health practice.14,15 Other factors affecting LHD general performance and preparedness include LHD governance structure, community, and organizational characteristics, such as funding, leadership characteristics, and partnerships.7,16,17Over the past decade, efforts to improve public health infrastructure, and performance more generally, have gathered momentum. These efforts included development and use of the National Public Health Performance Standards Program instruments, the implementation of state-based accreditation programs and the Public Health Accreditation Board, and initiatives to encourage the use of performance management and quality improvement tools.18-22 The Public Health Accreditation Board is charged with developing and managing national voluntary public health accreditation for tribal, state, local, and territorial health departments. The national accreditation final standards, released in 2011, include a specific emergency preparedness standard as well as additional standards that are linked to preparedness measures.23The National Public Health Performance Standards Program provides a framework to assess the capacity and performance of public health systems and public health governing bodies and identify areas for system improvement. LHDs and their partners use tailored instruments to assess the performance of their public health system against model standards, including preparedness standards, which are based on the 10 essential services (National Public Health Performance Standards Program version 2.0; NPHPS Partners, Atlanta, GA). More than 400 public health systems and governing entities used the version 2 assessment instruments (Centers for Disease Control and Prevention, http://www.cdc.gov/nphpsp/archive.html).Preparedness performance improvement programs have also been implemented to address variation. Project Public Health Ready is a standards-based recognition program with 300 LHDs (27 states) recognized as meeting all the Project Public Health Ready requirements individually or working collaboratively as a region since 2004.24 To achieve recognition, LHDs must meet nationally recognized standards in all-hazards preparedness planning, workforce capacity development, and demonstration of readiness through exercises or real events. In addition, the Institute of Medicine has recommended that an accreditation program could be a performance monitoring and accountability system for agency preparedness.25,26One previous study examined the effects of performance and accreditation programs on LHD performance of 8 preparedness domains on a validated instrument.5 Controlling for LHD characteristics, a significant positive effect on domain scores was found for LHDs that participated in the North Carolina state-based accreditation program and select performance improvement programs (National Public Health Performance Standards, the Public Health Accreditation Board beta test, Project Public Health Ready) when compared with a national matched comparison group that did not participate in any program. Findings, however, were limited to 1 year of survey data—2010. In this article, we explore trends in preparedness capacities in the present climate of declining resources for public health preparedness activities.     

Summary of the workshop on methodologies for environmental public health tracking of air pollution effects

The US Centers for Disease Control and Prevention established the Environmental Public Health Tracking (EPHT) program to support state and local projects that characterize the impact of the environment on health. The projects involve compiling, linking, analyzing, and disseminating environmental and health surveillance information, thereby engaging stakeholders and guiding actions to improve public health. One of the EPHT objectives is to track the public health impact of ambient air pollution with analyses that are timely and relevant to state and local stakeholders. To address methodological issues relevant to this objective, in January 2008, government officials and researchers from the USA, Canada, and Europe gathered in Baltimore, Maryland for a 2-day workshop. Using commissioned papers and presentations on key methodological issues as well as examples of previous air pollution impact assessments, work group discussions produced a set of consensus recommendations for the EPHT program. These recommendations noted the need for data that will encourage local stakeholders to support continued progress in air pollution control. The limitations of using only local data for analyses were also noted. To improve local estimates of air pollution health impacts, methods were recommended that “borrow strength” from other evidence. An incremental approach to implementing such methods was recommended. The importance and difficulty of communicating uncertainties in local health impact assessments was emphasized, as was the need for coordination among different agencies conducting health impact assessments.     

Genomics and public health: development of Web-based training tools for increasing genomic awareness

In 2001, the Centers for Disease Control and Prevention funded three Centers for Genomics and Public Health to develop training tools for increasing genomic awareness. Over the past three years, the centers, working together with the Centers for Disease Control and Prevention's Office of Genomics and Disease Prevention, have developed tools to increase awareness of the impact genomics will have on public health practice, to provide a foundation for understanding basic genomic advances, and to translate the relevance of that information to public health practitioners' own work. These training tools serve to communicate genomic advances and their potential for integration into public heath practice. This paper highlights two of these training tools: 1) Genomics for Public Health Practitioners: The Practical Application of Genomics in Public Health Practice, a Web-based introduction to genomics, and 2) Six Weeks to Genomic Awareness, an in-depth training module on public health genomics. This paper focuses on the processes and collaborative efforts by which these live presentations were developed and delivered as Web-based training sessions.     

The Road Map to Preparedness: a competency-based approach to all-hazards emergency readiness training for the public health workforce

Facing limited time and budgetary resources, state and local health departments need a practical, competency-based training approach to meet the all-hazards readiness requirements of their employees. The Road Map to Preparedness is a training tool designed to assist health departments in providing comprehensive, agency-tailored readiness instruction to their employees. This tool uses an incentive-based, game-like, experiential learning approach to meet the Centers for Disease Control and Prevention's nine core competencies for all public health workers while facilitating public health employees' understanding and acceptance of their emergency response roles. A corresponding evaluation tool, the Road Map to Preparedness Evaluation, yields metrically-driven assessments of public health employee readiness competencies. Since its pilot in 2003, the Road Map to Preparedness has met with enthusiastic response from participating health departments in the mid-Atlantic region. In addition to its public health impact, the Road Map offers future promise as a tool to assist organizational emergency response training in private sector and non-public health first-responder agency settings.     

National Public Health Performance Standards: workforce development and agency effectiveness in Florida.

The Florida Department of Health (FDOH) was the first state to pilot test both the Centers for Disease Control and Prevention (CDC) state agency and local Public Health System Performance Standards. The standards were found to be complementary and supportive of the FDOH quality performance improvement system, which had been in place for a decade, and the new Quality Management initiative. The pilot test found uneven performance across the state's county health departments and identified several areas, especially workforce development, that required additional efforts. The FDOH, in collaboration with the Center for Leadership in Public Health Practice at the College of Public Health in the University of South Florida, have collaborated and will continue to collaborate to design and deliver training in critical workforce development areas.