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Report

Ready or Not? Protecting the Public's Health from Disease, Disasters, and Bioterrorism, 2006


Quick Summary

Ready or Not? 2006 finds that five years after September 11, public health emergency preparedness is still not at an acceptable level. Limited progress continues to be but the big-picture goals of adequate preparedness remain unmet. As a result, Americans continue to face unnecessary and unacceptably high levels of risk.

In 2002, Congress passed the Public Health Security and Bioterrorism Act, allocating nearly $1 billion annually to states to bolster public health emergency preparedness. Even after this investment of almost $4 billion, the government health agencies have yet to release state-by-state information to Americans or policymakers about how prepared their communities are to respond to health threats.

Ready or Not? Protecting the Public's Health from Disease, Disasters, and Bioterrorism, 2006
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Recommendations

Five years after 9/11, public health preparedness falls far short of what is required to protect the American people. The nation has made slow progress toward improving basic capabilities, but is nowhere near reaching adequate, let alone “optimally achievable,” levels of preparedness across the 50 states and D.C.

TFAH calls for accelerating public health preparedness efforts, and urges an “all-hazards” approach to help protect against a range of possible threats, including bioterrorism, natural disasters, and a major outbreak of a new, lethal strain of the flu.

To strengthen emergency preparedness, we must focus on five key areas:

  1. Accountability.
  2. Leadership.
  3. Surge capacity and the workforce.
  4. Modernizing technology and equipment.
  5. Partnering more with the public.

ACCOUNTABILITY

Little concrete information is available to the public or policymakers about public health preparedness and remaining vulnerabilities. While the CDC and HRSA have been working toward more clearly defining “performance measures,” there is still not clear enough consensus about how to define and objectively determine standards for public health preparedness. The current measures focus too narrowly on process instead of outcomes or the ability to respond to wide-scale emergencies.  Also, the information collected is largely based on self-reports and is only released in aggregate form, not on a state-by-state (or grantee-by-grantee) basis. Americans are not receiving the information they deserve to know about the safety of their own communities — or what standards they should hold the government accountable for.   

HHS and its agencies should give the high¬est priority to defining measurable, “optimally achievable” basic preparedness standards. These need to be baseline requirements that all states should be held accountable for reaching. The measures should include objective assessments and be able to gauge improvements on an ongoing basis.

†The federal government has chosen to take a “partnership” approach with states and localities for setting measures and goals. While collaboration and different perspectives are important, the “leadership by consensus” approach has resulted in neither leadership nor consensus. At this point, most opinions and differences have been voiced, and it is up to the federal government to break the deadlock and establish standards for the use of federal funds. The federal government should either determine standards or empower a committee of experts to determine the standards, but provide a clear, firm deadline by when they must be completed.

LEADERSHIP 

TFAH calls for increased leadership and oversight of U.S. bioterror and public health preparedness. HHS needs to integrate top-level management of multiple bioterror and public health preparedness programs.

SURGE CAPACITY AND WORKFORCE

Major health emergencies overtax the health systems of affected communities. Local, state, and federal emergency medical and public health planning must integrate academic health centers, large private healthcare systems, and private community hospitals, and consider how to stockpile equipment and other resources. Additionally, there is a massive impending public health workforce shortage that must be immediately addressed.

MODERNIZE TECHNOLOGY AND EQUIPMENT

Basic technology and tools of public health must be modernized to adequately protect the American people.

PARTNERING MORE WITH THE PUBLIC

Planning efforts must do a better job of recognizing that the media, general public, business community, and other audiences will not always conform to procedures or expectations. Plans must be revised to address these challenges and contingencies.

Ready or Not report_5 things the government should do today

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Table of Contents
 

Date added:
Dec 11, 2006
Project:
Pandemic Planning
References:
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References:

1 The formal name for “flu” is “influenza.”  Some pub¬lic health officials, including some report reviewers, object to common use of the term “flu.”
2 A. Katz et al., “Preparing for the Unknown, Responding to the Known: Communities and Public Health Preparedness,” Health Affairs 25, no. 4 (July/August 2006): 946-957.
3 J. Monke, “Agroterrorism: Threats and Preparedness,” Congressional Research Service, The Library of Congress, 13 August 2004, www.fas.org/irp/crs/ RL32521.pdf (15 November 2006).
4 B. G. Blackburn, MD et. al., “Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water -¬United States, 2001-2002,” Morbidity and Mortality Weekly Report 53, no. SS08 (22 October 2004): 23-45.
5 Institute of Medicine, The Future of the Public’s Health in the 21st Century (Washington, D.C.:  National Academies Press for the Institute of Medicine, 2002).
6 Robert Wood Johnson Foundation, “Public Health Leaders Recommend Voluntary National Accreditation Program,” Press Release, 21 September 2006, http://www.rwjf.org/newsroom/newsreleases-detail.jsp?id=10433 (6 November 2006).
7 University of North Carolina School of Public Health, “North Carolina Local Health Department Accreditation,” http://www2.sph.unc.edu/nciph/ accred/ (6 November 2006).
8 Ibid.
9 National Network of Public Health Institutes, “Multi-State Learning Collaborative for Performance and Capacity Assessment or Accreditation of Public Health Departments (MLC),” http://www.nnphi.org/ onepagers.pdf (20 November 2006).
10 Ibid.
11 Institute of Medicine, The Future of the Public’s Health in the 21st Century (Washington, D.C.:  National Academies Press for the Institute of Medicine, 2002).
12 Centers for Disease Control and Prevention officials provided this information to TFAH.
13 Ibid.
14 D. Knutson, “Responding to Potential Bioterror Attacks on U.S. Soil,” Transcript from a Presentation at the Defense Forum Foundation Defense and Foreign Policy Forum, 24 May 2005.
15 S. Simonson, “The Role of HHS in Development and Acquisition of Medical Countermeasures Under Project BioShield,” Testimony Before the Committee on Government Reform, U.S. House of Representatives, 14 July 2005, http://hhs.gov/asl/ testimony/t050714b.html (8 September 2005).
16 Trust for America’s Health, A Killer Flu? Scientific Experts Estimate that ‘Inevitable’ Major Epidemic of New Influenza Strain Could Result in Millions of Deaths if Preventive Actions Are Not Taken (Washington, D.C.: Trust for America’s Health, June 2005), http://healthyamericans.org/reports/flu/ (27 September 2005).
17 Centers for Disease Control and Prevention officials provided information directly to TFAH.  Additional information is available at: U.S. Department of Health and Human Services, “Antivirals - State Allocations,” PandemicFlu.gov, 10 October 2006, http://pandemicflu.gov/plan/states/antivirals.htm l (6 November 2006).
18 Centers for Disease Control and Prevention, “Centers for Disease Control and Prevention: Pandemic Flu Q&A,” March 2006.
19 J. Schmit, “States Scrape Up Bird Flu Drug Funds,” USA Today, 8 August 2006.
20 Centers for Disease Control and Prevention provid-ed information directly to TFAH.  Additional infor-mation about CHEMPACK is available at: D. Knutson, “Responding to Potential Bioterror Attacks on U.S. Soil,” Transcript from a Presentation at the Defense Forum Foundation Defense and Foreign Policy Forum, 24 May 2005.
21 Ibid.
22 J. R. Richmond, “The 1, 2, 3s of Biosafety Levels,” Centers for Disease Control and Prevention, Last modified 2 July 1998, http://www.cdc.gov/od/ohs/ symp5/jyrtext.htm (8 November 2005).
23 M. Skeels, “Public Health Labs in a Changing Landscape,” American Society of Microbiology News 65 (2003): 479-483.
24 E. Gursky, T. V. Inglesby, and T. O’Toole, “Anthrax 2001: Observations on the Medical and Public Health Response,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 1, no. 2 (2003): 97-110.
25 Centers for Disease Control and Prevention, “Facts about the Laboratory Response Network,” 11 August 2004, http://www.bt.cdc.gov/lrn/fact¬sheet.asp (14 September 2005).
26 Association of Public Health Laboratories, “Issue Brief: Critical Shortage of LRN Reagents for Analysis of Agents of Biological Terrorism,” February 2006.
27 Centers for Disease Control and Prevention, “Laboratory Network for Chemical Terrorism,” Last modified December 2005, http://www.bt.cdc.gov/ lrn/chemical.asp (23 October 2006).  CDC officials ver¬ified that the number of state labs with Level 1 chemi¬cal capabilities had not increased as of October 2006.
28 Centers for Disease Control and Prevention, “Emergency Preparedness and Response: Chemical Agents,” http://www.bt.cdc.gov/agent/ agentlistchem.asp (15 November 2006). The number of toxins that could be “weaponized” was provided to TFAH by CDC officials for the report Public Health Laboratories: Unprepared and Overwhelmed (Washington, D.C.: Trust for America’s Health, June 2003), http://healthyamericans.org/reports/files/ LabReport.pdf (15 November 2006).
29 Association of Public Health Laboratories, “Laboratory Response Network,” http://www.aphl.org/programs/ emergency_preparedness/lab_response_network.cfm (15 November 2006).
30 According to officials at the Association of Public Health Laboratories.
31 Centers for Disease Control and Prevention, “Pandemic Influenza Guidance Supplement to the 2006 Public Health Emergency Preparedness Cooperative Agreement Phase II,” 10 July 2006, http://www.bt.cdc.gov/planning/coopagreement/p df/phase2-panflu-guidance.pdf (7 November 2006).
32 M. Crosse, Director, Health Care, Government Accountability Office, “Influenza Pandemic: Challenges Remain in Preparedness,” Testimony Before the Subcommittee on Health, Committee on Energy and Commerce, House of Representatives, 26 May 2005, www.gao.gov/new.items/d05760t.pdf (7 November 2006).
33 Centers for Disease Control and Prevention, “Overview of Influenza Surveillance in the United States,” Fact Sheet, 26 June 2006, www.cdc.gov/flu/weekly/pdf/flu-surveillance-overview.pdf (7 November 2006).
34 Centers for Disease Control and Prevention, FluSurge2.0 Beta Test Software, http://www.cdc.gov/ flu/flusurge.htm  (30 October 2006); and E. Toner et. al., “Hospital Preparedness for Pandemic Influenza,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 4, no. 2 (2006).
35 U.S. Department of Homeland Security, “National Response Plan,” Last updated 25 May 2006, http://www.dhs.gov/xlibrary/assets/NRP_FullText. pdf (15 November 2006). 
36 Kaiser Family Foundation, “State Health Facts,” http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi, (30 October 2006); and National Center for Health Statistics, Health, United States, 2005, With Chartbook on Trends in the Health of Americans (Hyattsville, MD: National Center for Health Statistics, 2005).
37 D. S. Shapiro, “Surge Capacity for Response to Bioterrorism in Hospital Clinical Microbiology Laboratories,” Journal of Clinical Microbiology 41, no. 12 (December 2003): 5372-5376.
38 Health Resources and Services Administration, “National Bioterrorism Hospital Preparedness Program: FY 2005 Continuation Guidance,” https://grants.hrsa.gov/webexternal/FundingOppDe tails.asp?FundingCycleId=821DC9C4-10B2-487E-8C7B-CC25D18CBA0B&ViewMode=EU&GoBack =&PrintMode=&OnlineAvailabilityFlag=True&pageN umber=1&Popup=#Purpose (15 November 2005).
39 Agency for Healthcare Research and Quality, “Optimizing Surge Capacity: Hospital Assessment and Planning,” Bioterrorism and Health System Preparedness, Issue Brief No. 3 AHRQ Publication No. 04-P008, January 2004,  http://www.ahrq.gov/news/ ulp/btbriefs/btbrief3.htm (8 November 2005).
40 Association of State and Territorial Health Officials, States of Preparedness: Health Agency Progress 2006 (Washington, D.C.: Association of State and Territorial Health Officials, 2006). <http://www.astho.org/pubs/ Statesof Preparedness2006.pdf> (20 November 2006).
41 “Ten Great Public Health Achievements - United States, 1900-1999,” Morbidity and Mortality Weekly Report 48, no. 12 (2 April 1999): 241-243.
42 Centers for Disease Control and Prevention, “Key Facts About the Flu: An Overview,” http://www.cdc.gov/ flu/keyfacts.htm (30 October 2006).
43 Centers for Disease Control and Prevention, “Children and the Flu Vaccine,”  http://www.cdc.gov/ flu/protect/children.htm (16 November 2006).
44 CDC officials supplied this information to TFAH.
45 Centers for Disease Control and Prevention, “Behavioral Risk Factor Surveillance System, Prevalence Data, Nationwide (States and DC) - 2005 vs 2004, Immunization,” http://apps.nccd.cdc.gov/ brfss/display_c.asp?yr_c=2004&yr=2005&cat=IM&stat e=UB&bkey=20059912&qkey=4407&qtype=C&grp=0 &SUBMIT2=Compare (30 October 2006).
46 L. M. Matteson, “Using Seasonal Influenza Clinics for Public Health Preparedness Exercises: Existing Programs Can Provide an Opportunity to Practice Emergency Response,”  American Journal of Nursing 106, no. 10 (October 2006).
47 Ibid.
48 Ibid.
49 D. Cochran, “Drill gives county shot in the arm: Thousands quickly inoculated against flu Health offi-cials confident an even larger mass immunization possible,” The Billings Gazette, 28 October 2006.
50 L. M. Matteson, “Using Seasonal Influenza Clinics for Public Health Preparedness Exercises: Existing Programs Can Provide an Opportunity to Practice Emergency Response,”  American Journal of Nursing 106, no. 10 (October 2006).
51 Ibid.
52 Health Department, Town of Belmont, Massachusetts, “Flu Vaccine Distribution Very Different This Year,” http://www.town.belmont.ma.us/Public_Documents/ BelmontMA_Health/index (30 October 2006).
53 US Department of Health and Human Services, Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. (Washington, DC: US Government Printing Office, November 2000).
54 Centers for Disease Control and Prevention, “Pneumococcal Polysaccharide Vaccine: What You Need To Know,” 29 July 1997.
55 American Lung Association, “Pneumonia Fact Sheet,” http://www.lungusa.org/site/pp.asp?c =dvLUK9O0E&b=35692 (3 November 2006).
56 Centers for Disease Control and Prevention, “Pneumococcal Polysaccharide Vaccine: What You Need To Know,” 29 July 1997.
57 Ibid.
58 A. M. Minino et al., “Deaths: Preliminary Data for 2004,” National Vital Statistics Report 54, no. 19 (28 June 2006), National Center for Health Statistics.
59 C. J. DeFrances and M. N. Podgornik, “2004 National Hospital Discharge Survey,” Advance Data From Vital and Health Statistics no. 371 (4 May 2006), National Center for Health Statistics.
60 Centers for Disease Control and Prevention, “Behavioral Risk Factor Surveillance System, Prevalence Data, Immunization - 2005, Adults Aged 65+ Who Have Ever Had a Pneumonia Vaccination,” http://apps.nccd.cdc.gov/brfss/list.asp?cat=IM&yr =2005&qkey=4408&state=All (26 October 2006).
61 “Progress in Improving State and Local Disease Surveillance — United States, 2000-2005,” Morbidity and Morality Weekly Report 54, no. 33 (26 April 2005): 822¬
825.
62 Health Resources and Services Administration, “What Is Behind HRSA’s Projected Supply, Demand, and Shortage of Registered Nurses?” September 2004.
63 The Quad Council of Public Health Nursing Organizations, “The Public Health Nursing Shortage: A Threat to the Public’s Health,” November 2006, http://www.astdn.org/downloadablefiles/Quad%20 Council%20Final%20Shortage%20Paper.pdf (16 November 2006); and Association of State and Territorial Health Officials, “Public Health Workforce Shortage: Public Health Nurses,” Issue Brief, April 2005, http://www.astho.org/pubs/PHNursesIssue Brief121405.pdf (16 November 2006).
64 The Quad Council of Public Health Nursing Organizations, “The Public Health Nursing Shortage: A Threat to the Public’s Health,” November 2006, http://www.astdn.org/download-ablefiles/Quad%20Council%20Final%20Shortage%20Paper.pdf (16 November 2006).
65 Founded in 1903, CNA represents more than 65,000 members in 165 facilities throughout California, and thousands more across the country through the National Nurses Organizing Committee, which was founded by CNA. http://www.calnurses.org/about-us/ 
66 California Nurses Association, “Motivated by Katrina
-National RN Response Network Launches,” Press Release, 25 August 2006.
67 S. Trossman, RN, “Nurses come together to provide care for Gulf Coast population, colleagues,” The American Nurse (November/December 2005).
68 Association of State and Territorial Health Officers, “State Public Health Employee Worker Shortage Report:  A Civil Service Recruitment and Retention Crisis,” November/December 2003, http://www.astho.org/?template=2workforce_devel-opment.html (15 October 2005).
69 N. Lurie et al., “Public Health Preparedness: Evolution or Revolution?” Health Affairs 25, no. 4 (July/August 2006).
70 Medical Reserve Corps, “About the Medical Reserve Corps,” http://www.medicalreservecorps.gov/About (3 November 2006).
71 Ibid.
72 Ibid.
73 Medical Reserve Corps, “Find MRC Units,” http://www.medicalreservecorps.gov/FindMRC.asp (3 November 2006).
74 Medical Reserve Corps, “NACCHO-MRC Capacity Building Cooperative Agreement,” September 2006, http://www.medicalreservecorps.gov/File/MRC_Co operative_Agreement_FAQ.pdf (3 November 2006). 
75 S. A. Lister, “Hurricane Katrina: The Public Health and Medical Response,” Congressional Research Service 21 September 2005. 
76 C. Franco et al., “Systemic Collapse: Medical Care in the Aftermath of Hurricane Katrina,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 4, no. 2 (2006).
77 Ibid.
78 The share of public health spending is from an analysis by Senator Bill Frist, MD which appeared in the November/December 2002 issue of Health Affairs. The spending data was compiled from the public health services that are included in the National Health Accounts (NHA) which is generated by the Centers for Medicare and Medicaid Services.  The NHA does not include all programs that can be considered as related to public health such as environmental health, sanita-tion and water programs, and the Women, Infants and Children Food Supplemental Program.
79 B. Frist, “Public Health and National Security:  The Critical Role of Increased Federal Support,” Health Affairs 21, no. 6 (November/December 2002).
80 “Public Health:  Costs of Complacency,” Governing (February 2004).
81 National Conference of State Legislatures, State Budget Actions: FY 2005 and FY 2006 (Denver, Colorado: National Conference of State Legislatures, March 2006): and Population Division, U.S. Census Bureau, “Table 1: Annual Estimates of the Population for the United States and States, and for Puerto Rico: April 1, 2000 to July 1, 2005,” 22 December 2005.
82 Institute of Medicine, The Future of the Public’s Health in the 21st Century (Washington, D.C.:  National Academies Press for the Institute of Medicine, 2002).
83 A. Katz et al., “Preparing for the Unknown, Responding to the Known: Communities and Public Health Preparedness,” Health Affairs 25, no. 4 (July/August 2006): 946-957.
84 N. Clark, “Message from [School of Public Health] Dean Noreen Clark,” Advancing Global Public Health. University of Michigan. <http://www.polio. umich.edu/clark/> (21 November 2006).
85 Centers for Disease Control and Prevention, Public Health Infrastructure -- A Status Report (Atlanta, Georgia: Centers for Disease Control and Prevention, 2001); Institute of Medicine, The Future of the Public’s Health in the 21st Century (Washington, D.C.:  National Academies Press for the Institute of Medicine, 2002); and Government Accountability Office, HHS Bioterrorism Preparedness Programs: States Reported Progress But Fell Short of Program Goals in 2002, GAO-04-360R (Washington, D.C.: Government Accountability Office, 10 February 2004).
86 Other sectors, such as hospitals and Emergency Medical Services (EMS), have faced challenges in devel¬oping measures for massive emergencies requiring major surge capacity, however, these sectors do have baseline “optimally achievable” measures for ongoing service and many other forms of emergencies.
87 “Public Health Emergency Preparedness, Cooperative Agreement,” Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 15 July 2006.
88 T. Hargrove.  “A Russian Roulette of Food Poisoning in American States,” Scripps Howard News Service, 21 November 2006. < http://www.knoxnews.com/ kns/national/article/0,1406,KNS_350_5160343,00. html> (21 November 2006).
89 G. Pezzino, M.Z. Thompson, and M. Edgar,  “A Multi-State Comparison of Local Public Health Preparedness Assessment Using a Common, Standardized Tool,” National Network of Public Health Institutes, Illinois Public Health Institute, Kansas Public Health Institute, and Michigan Public Health Institute, August 2006.
90 Ibid.
91 Letter sent to David M. Walker, Comptroller General of the Government Accountability Office from the Senate Committee on Homeland Security and Governmental Affairs, 30 October 2006.
92 Office of Inspector General, US Department of Health and Human Services, “Review of Arkansas Department of Health’s Public Health Preparedness and Response for Bioterrorism Program Funds,” August 2005, http://oig.hhs.gov/oas/reports/ region6/60500025.pdf (8 November 2005).
93 Office of Inspector General,  US Department of Health and Human Services, “Audit of Costs and Reporting of Funds Under the Public Health Preparedness and Response for Bioterrorism Program District of Columbia,” 21 June 2005, http://oig.hhs.gov/oas/reports/region3/30400353.pdf (8 November 2005).
94 Office of Inspector General, US Department of Health and Human Services, “Audit of the State of Massachusetts’ Costs and Reporting of Funds Under the Public Health Preparedness and Response to Bioterrorism Program for the Period August 31, 1999 --August 30, 2004,” 4 March 2005, http://oig.hhs.gov/oas/reports/region1/10401503.pdf (8 November 2005).
95 Office of Inspector General, US Department of Health and Human Services, “Audit of Costs and Reporting of Funds Under the Public Health Preparedness and Response to Bioterrorism Program by North Carolina Department of Health and Human Services,” 27 July 2005, http://oig.hhs.gov/oas/ reports/region4/40401002.pdf (8 November 2005).
96 Office of Inspector General,  US Department of Health and Human Services, “Audit of Costs and Reporting of Funds Under the Public Health Preparedness and Response to Bioterrorism Program, Ohio Department of Health,”  4 February 2005, http://oig.hhs.gov/oas/reports/region5/ 50400051.htm (8 November 2005).
97 US Department of Health and Human Services, “Budget in Brief, Fiscal Year 2006,” http://www.hhs.gov/budget/06budget/FY2006Bud getinBrief.pdf (17 November 2006).
98 S. Lister, “An Overview of the U.S. Public Health System in the Context of Emergency Preparedness,” Congressional Research Service  (17 March 2005).
99 Government Accountability Office, HHS Bioterrorism Preparedness Programs: States Reported Progress But Fell Short of Program Goals in 2002, GAO-04-360R (Washington, D.C.: Government Accountability Office, 10 February 2004).
100 Government Accountability Office, Information Technology: Federal Agencies Face Challenges in Implementing Initiatives to Improve Public Health Infrastructure, GAO-05-308 (Washington, D.C.: Government Accountability Office, June 2005).
101 Hospital Resources and Services Administration, “National Bioterrorism Hospital Preparedness Program,” http://www.hrsa.gov/bioterrorism/ (1 November 2006).
102 Occupational Safety and Health Administration, “OSHA Guidance Update on Protecting Employees from Avian Flu (Avian Influenza) Viruses,” OSHA 3323-10N 2006.
103 Ibid.
104 H. Parker, “Agricultural Bioterrorism: A Federal Strategy to Meet the Threat,” McNair Paper 65 (Washington, D.C.: National Defense University, 2002).
105 D. Pimentel, L. Lach, R. Zuniga, and D. Morrison, “Environmental and Economic Costs Associated with Non-indigenous Species in the United States,” BioScience 50 (2000):53-65.
106 W. Branigin et al., “Tommy Thompson Resigns From HHS Bush Asks Defense Secretary Rumsfeld to Stay,”  The Washington Post, 3 December 2004.
107 W. Heffernan et al., “Consolidation in the Food and Agriculture System,” Report to the National Farmers Union  5 February 1999. 
108 Ibid.
109 Ibid.
110 B. Lautner, “Industry Concerns and Partnerships to Address Emerging Issues,” Annals of the New York Academy of Sciences 894 (December 1999): 76-79.
111 J. Monke, “Agroterrorism: Threats and Preparedness,” Congressional Research Service 13 August 2005.
112 General Accountability Office, Homeland Security: Much is Being Done to Protect Agriculture From a Terrorist Attack, but Important Challenges Remain, GAO-05-214 (Washington, D.C.: Government Accountability Office, March 2005).
113 Ibid.
114 L. Sander, “Nebraska Woman’s Death Brings to 3 Those Attributed to Spinach,” The New York Times, 7 October 2006.
115 Ibid.
116 A. Shin, “E. Coli Detected Near Spinach,” The Washington Post, 13 October 2006.
117 Centers for Disease Control and Prevention, “Escherichia coli O157:H7,” http://www.cdc.gov/ NCIDOD/DBMD/diseaseinfo/escherichiacoli_g.h tm#What%20is%20Escherichia%20coli%20O157: H7 (17 October 2006).
118 Ibid.
119 M. Burros, “Tainted Spinach Brings Demands for New Rules,” The New York Times, 27 September 2006.
120 Ibid.
121 US Food and Drug Administration, “Lettuce Safety Initiative,” 23 August 2006, http://www.cfsan.fda.gov/ ~dms/lettsafe.html (17 October 2006).
122 Ibid.
123 M. Burros, “Produce is Growing Source of Food Illness,” The New York Times, 16 September 2006.
124 Associated Press, “Florida: Another Link to Botulism,” The New York Times, 7 October 2006.
125 Centers for Disease Control and Prevention, “Botulism,” http://www.cdc.gov/NCIDOD/DBMD/ diseaseinfo/botulism_g.htm#What%20is%20 botulism (17 October 2006).
126 Ibid.
127 Stanford Graduate School of Business, “Caution About a Bioterror Attack on the U.S. Milk Supply,” News Release, June 2005, http://www.gsb.stan-ford.edu/news/research/pubpolicy_wein_bioter-ror.shtml.
128 Ibid.
129 R. Weiss, “Report Warns of Threat to Milk Supply: Release of Study Citing Vulnerability to Bioterrorism Attack was Opposed by U.S. Officials,” The Washington Post, 29 June 2005.
130 B. Knickerbocker, “Third Mad Cow Case in US Raises Questions about Testing,” Christian Science Monitor, 15 March 2006.
131 “First Apparent U.S. Case of Mad Cow Disease Discovered,” CNN.com, 24 December 2003, http://www.cnn.com/2003/US/12/23/mad.cow/ (16 October 2006).
132 W. Leiss, William, “Canadian Policy Options to Prevent Future Economic Madness from ‘Mad Cow’ Disease,” Working Paper, June 2004; and J. Gransbery, “Beef import battle: U.S. cattle industry at odds over mad cow disease,” Billings Gazette, 28 January 2005.
133 Food and Agriculture Organization of the United Nations, The State of Food and Agriculture
2001 (Rome, Italy: Food and Agriculture Organization of the United Nations, 2001).
134 Ibid.
135 The Department for Environment, Food and Rural Affairs and The Department For Culture, Media and Sport, United Kingdom, “Economic Cost of Foot and Mouth Disease in the UK.: A Joint Working Paper,” March 2002, http://www.defra.gov.uk/ corporate/ inquiries/lessons/fmdeconcost.pdf (17 November, 2006).
136 T. McGinn and J. Hoffman, “Crimson Sky FMD Terrorist Attack Outcome,” North Carolina Department of Agriculture and Consumer Services, Emergency Programs Division, September 2002.
137 Government Accountability Office, Foot and Mouth Disease: To Protect US Livestock, USDA Must Remain Vigilant and Resolve Outstanding Issues, GAO-02-0808 (Washington, D.C.: Government Accountability Office, July 2002).
138 R. Larsen, “Homeland Security: A Strategic Perspect¬ive,” Transcript, Foreign Policy Association, 31 October 2002, http://www.fpa.org/topics_info2414/topics_ info_show.htm?doc_id=128505 (4 August 2005).
139 Government Accountability Office, Homeland Security: Much is Being Done to Protect Agriculture From a Terrorist Attack, but Important Challenges Remain, GAO-05-214 (Washington, D.C.: Government Accountability Office, March 2005).
140 Harvard School of Public Health Center for Public Health Preparedness et al., Preparing for Public Health Emergencies: Meeting the Challenges of Rural America, Conference Proceedings and Recommendations, Saint Paul, Minnesota, 27-28 September 2004.
141 H. H. Tilson, “Rural Preparedness Challenges: Framing the Issues,” Preparing for Public Health Emergencies: Meeting the Challenges of Rural America, Conference Proceedings and Recommendations, Saint Paul, Minnesota, 27-28 September 2004.
142 L. J. Dyckman, Food Safety: U.S. Needs a Single Agency to Administer a Unified, Risk-Based Inspection System, GAO/T-RCED-99-256 (Washington, D.C.: General Accountability Office, 4 August 1999); and Committee to Ensure Safe Food from Production to Consumption, Institute of Medicine, Ensuring Safe Food: From Production to Consumption, 1998 (Washington, D.C.: National Academy Press, 1998).
143 A. Kaufmann, “Postal Anthrax, United States, 2001: Delivering Risk Communications in Times of Crisis,” Case Study, Managing Effective Risk Response: an Ecological Approach (MERREA), 2003.
144 A. Kaufmann and M. Meltzer, “The Economic Impact of a Bioterrorist Attack: Are Prevention and Postattack Intervention Programs Justifiable?” Emerging Infectious Diseases 3, no. 2. (April-June 1997).
145 L. Wein et al., “Emergency Response to an Anthrax Attack,” Proceedings of the National Academy of Sciences, 100, no. 7 (2003): 4346-4351.
146 A. Kaufmann and M. Meltzer, “The Economic Impact of a Bioterrorist Attack: Are Prevention and Postattack Intervention Programs Justifiable?” Emerging Infectious Diseases 3, no. 2. (April-June 1997).
147 Ibid.
148 The Center for Biosecurity, “Anthrax Appraisal 5 Years Later: Top 10 Accomplishments and Remaining Challenges,” 22 September 2006.
149 Ibid.
150 Government Accountability Office, Federal Agencies Have Taken Some Steps to Validate Sampling Methods and to Develop a Next-Generation Anthrax Vaccine, GAO-06-756T (Washington, D.C.: Government Accountability Office, 9 May 2006).
151 Ibid.
152 Ibid.
153 Ibid.
154 Ibid. 
155 E. Lipton, “Bid to Stockpile Bioterror Drugs Stymied by Setbacks,” The New York Times, 18 September 2006.
156 R. Merle, “Anthrax Vaccine Testing Called Off: VaxGen Contract in Doubt as FDA Raises Concerns,” The Washington Post, 4 November 2006.
157 “Government Extends Deadline by Which VaxGen is Required to Resolve Clinical Hold.” VaxGen Press Release, 16 November 2006. http://www.vax-gen.com/zoo_prframe.html?load=www.b2i.us%2Ff rame.asp%3FBzID%3D923%26to%3Drl%26Nav% 3D0%26S%3D0%26L%3D1 (20 November 2006).
158 Ibid.
159 K. Davis, S. R. Collins, M. M. Doty, A. Ho, and A. L. Holmgren, “Health and Productivity Among U.S. Workers,” Commonwealth Fund Issue Brief, (2005) http://www.cmwf.org/usr_doc/856_Davis_hlt_pro-ductivity_USworkers.pdf (27 November 2006).
160 E. A. Blackwelder, “Protecting the Homeland: Fighting Pandemic Flue from the Front Lines,” Testimony before the Subcommittee on Prevention of Nuclear and Biological Attack and the Subcommittee on Emergency Preparedness, Science, and Technology, U.S. House of Representatives, (8 February 2006).
161 R. D. Lasker, MD, Testimony Before The Council of the District of Columbia Committee on the Judiciary, 25 October 2004, http://www.cacsh.org/pdf/Lasker TestimonyOct252004.pdf (8 November 2005).
162 R. J. Blendon et al., “Pandemic Influenza and the Public: Survey Findings,” Harvard School of Public Health Project on the Public and Biological Security, Presented at the Institute of Medicine, 26 October 2006, http://www.hsph.harvard.edu/panflu/IOM_ Avian_flu.ppt (1 November 2006).
163 Ibid.
164 Ibid.
165 Ibid.
166 American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American Academy of Pediatrics Committee on Medical Liablity, and Task Force on Terrorism, “The Pediatrician and Disaster Preparedness,” Pediatrics 117, no. 2 (February 2006).
167 Ibid.
168 Agency for Healthcare Research and Quality, “Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians,” Publication no. 06(07)-0056-1, September 2006, www.ahrq.gov/research/ pedprep/pedtersum.htm (17 November 2006).
169 Ibid.
170 Ibid.
171 R. P. Olympia et al., “The Preparedness of Schools to Respond to Emergencies in Children: A National Survey of School Nurses,” Pediatrics 116, no. 6 (December 2005).
172 Ibid.
173 Ibid.
174 Ibid.
175 Trust for America’s Health, Ready or Not? Protecting the Public’s Health From Diseases, Disasters, and Bioterrorism 2005 (Washington, D.C.: Trust for America’s Health, December 2005).
176 US Department of Homeland Security in cooperation with the US Department of Transportation, “Nationwide Plan Review: Phase 2 Report,” 16 June 2006, www.dhs.gov/xlibrary/assets/Prep_Nationwide PlanReview.pdf (3 November 2006).
177 Ibid.
178 Ibid.
179 Ibid.
180 Ibid.
181 Government Accountability Office, September 11: Monitoring of World Trade Center Health Effects Has Progressed, but Program for Federal Responders Lags Behind, GAO-06-481T (Washington, D.C.: Government Accountability Office, 28 February 2006).
182 G. I. Banguch et al., “Pulmonary Function after Exposure to the World Trade Center Collapse in the New York City Fire Department,” American Journal of Respiratory and Critical Care Medicine 174 (2006).
183 R. Herbert et al., “The World Trade Center Disaster and the Health of Workers: Five Year Assessment of a Unique Medical Screening Program,” Environmental Health Perspectives 114, no. 12 (December 2006): 1853-1858.
184 Ibid.
185 R. M. Brackbill et al., “Surveillance for World Trade Center Disaster Health Effects Among Survivors of Collapsed and Damaged Buildings,” Morbidity and Mortality Weekly Report 55, no. SS02 (7 April 2006): 1-18.
186 Ibid.
187 Ibid.
188 S. A. Lister, “Hurricane Katrina: The Public Health and Medical Response,” Congressional Research Service, 21 September 2005. 
189 Ibid.
190 Ibid.
191 Department of Health and Human Services, “HHS Announces $1.2 Billion in Funding To States For Bioterrorism Preparedness,” News Release, 7 June 2006, http://www.hhs.gov/news/press/2006press/ 20060607.html (30 October 2006).
192 Ibid.
193 Department of Health and Human Services, “Guidelines for Bioterrorism Funding Announced,” News Release, 9 May 2003, http://www.hhs.gov/news/ press/2003pres/ 20030509.html (8 November 2005).
194 Centers for Disease Control and Prevention, “Program Announcement 99051: Continuation Guidance for Cooperative Agreement on Public Health Preparedness and Response for Bioterrorism,” 14 June 2004, http://www.bt.cdc.gov/ planning/continuationguidance/pdf/guidance_int ro.pdf (12 September 2005).
195 S. Lister, “An Overview of the U.S. Public Health System in the Context of Emergency Preparedness,” Congressional Research Service, 17 March 2005, http://www.fas.org/sgp/crs/homesec/RL31719.pd f (8 November 2005).
196 Ibid.
197 Ibid.
198 Ibid.
199 Health Resources and Services Administration, “National Bioterrorism Hospital Preparedness Program: FY 2005 Continuation Guidance,” 1 July 2005, http://www.gnyha.org/394/file.aspx (20 November 2006).
200 Health Resources and Services Administration, “What Is Behind HRSA’s Projected Supply, Demand, and Shortage of Registered Nurses?” September 2004.
201 Ibid.
202 Ibid.
203 Ibid.
204 Ibid.
205 Ibid.
206 Centers for Disease Control and Prevention, FluSurge2.0 Beta Test Software, http://www.cdc.gov/ flu/flusurge.htm (30 October 2006).
207 US Census Bureau, Current Population Survey Data 2005, http://dataferrett.census.gov/. 

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