Ready or Not: New Report on Protecting the Public's Health

Noam H. Arzt, Ph.D.The Trust for America's Health (TFAH) released its 2019 edition of what it hopes will be an annual report, Ready or Not: Protecting the Public's Health from Diseases, Disasters and Bioterrorism last February. The ground-breaking report warns about key global challenges ahead, like the risk of a flu pandemic; the impact of weather pattern changes due to climate change; the dangers of antimicrobial resistance, and others, and tries to offer advice on how to prepare for them.

In Section 1 of the report, titled Health Threats: A Review of 2018, the authors review a litany of disease outbreaks, and severe weather and natural disaster events. They note the incidents, actions, and corresponding research findings, meetings, and events related to each. On the policy front, they note the September 2018 release by the White House of its National Biodefense Strategy (see earlier article on this topic). The Centers for Disease Control and Prevention (CDC) released another report,  Public Health Emergency Preparedness and Response Capabilities, in October 2018 (updated in January 2019). This section of the TFAH report also reviews the various activities of the Blue Ribbon Study Panel on Biodefense.

The authors of the TFAH report conclude this section stating that, "From a historic seasonal flu season to extreme weather that upended millions of lives, 2018 offered plenty of evidence that much more work must be done to ensure the health and safety of all Americans. Some policy advancements strived to address these challenges, such as the National Biodefense Strategy and the Global Health Strategy Agenda renewal. These represented positive steps in an increasingly dangerous world." (p. 9)

Relying on data from 2017 and 2018, this report reviews preparedness in the US on a state-by-state basis (Section 2). The reports uses ten indicators of state readiness:

1. Adoption of the Nurse Licensure Compact which permits registered nurses and licensed practical nurses to practice with a single multistate license across participating states (31 states currently participate)
2. Hospital participation in healthcare coalitions (on average 89% of hospitals belonged to coalitions)
3. Public Health Accreditation Board (PASB) (most states are accredited)
4. Emergency Management Accreditation Program (EMAP) (most states are accredited)
5. State public health funding trends across a variety of programs
6. Community water system safety (few Americans drink water from unsafe systems)
7. Access to paid time off which reduced infectious disease exposure and preventive care (about half of American workers have this)
8. Flu vaccination rates (well below the recommended level in all states)
9. Patient safety in hospitals which is affected by errors, injuries, accidents and hospital-acquired infections (most hospitals do not score well)
10. State public health laboratory surge capacity (almost every state well positioned)

States are grouped based on an assessment of their progress (or lack or progress) on each of ten top -priority indicators. A majority of states have made positive strides in strengthening their ability to respond to emergencies, and most have achieved accreditation in the areas of public health, emergency management, or both. But less than a third of hospitals have earned a top-quality patient safety grade, and some indicators like seasonal flu vaccine rate have declined over the past several years. While more than half of states increased their overall funding for public health, a significant number showed a reduction which will put their ability to respond in jeopardy. And flu vaccination rates continue to be well below the recommended level.

The recommendations from TFAH are divided into a eleven priority areas (Section 3):

1. Funding a modern public health and emergency preparedness infrastructure through increases in core public health funding to CDC as well as the states, and allowing more flexible approaches to use of emergency funding from the Federal government
2. Bolstering global health security through a sustained, long-term Federal investment
3. Improving leadership and coordination, especially at the Federal level
4. Accelerating development and distribution of medical countermeasures to better prepare the US for a flu pandemic or other unknown bio threat
5. Improving disease surveillance, primarily through more adequate funding to CDC
6. Ensuring a qualified public health workforce through more funding for recruitment and training, as well as more flexibility in hiring at all levels during an emergency
7. Readying the healthcare system to respond and recover, primarily through better hospital preparedness
8. Preparing for environmental threats and extreme weather through better planning and readiness
9. Building resilient communities and promoting health equity through more collaborative public health-community planning, and a greater emphasis on mental health
10. Stopping outbreaks and superbugs through more prudent use of antibiotics and ongoing research
11. Improving vaccination rates across the lifespan through more awareness and education, fewer exemptions, and ongoing investment in vaccine infrastructure.

The priority area of most interest to me is improving disease surveillance. This includes recommendations for fully funding a multiyear strategic budget for surveillance systems as well as encouraging the Centers for Disease Control and Prevention (CDC) to implement their own plans for surveillance and data management (September 2018). As indicated above, to support that work, in October 2018 (updated in January 2019) CDC released another report, Public Health Emergency Preparedness and Response Capabilities. Based on an original set of fifteen capabilities that CDC identified for state, local, and tribal agencies, this report updates and refreshes the original capabilities model. Information sharing is a key capability (#6), as is Public Health Surveillance and Epidemiological Investigation (#13).

CDC seems to be committed to modernizing and improving its surveillance and data management capabilities, but it has a long way to go. Future funding continues to be tenuous, but there are some indications in Washington that this may change. CDC structure and process continue to promote redundant, siloed and stovepiped systems over more integrated ones. Overall informatics coordination continues to be a problem, but despite these limitations some excellent work continues to be done.

It is this focus on state and local jurisdictions that is most important as this is where the essential parts of emergency preparedness and response happen. State, local and tribal public health agencies need to be given the tools and funding to develop their workforce and capacity to prepare and react. Open source software can be a critical component of affordable, quality systems positioned to assist in disaster response, like our own Reportable Conditions Knowledge Management System (RCKMS) which began deploying to state and local jurisdictions in Fall 2018.