Requirements: Identify the question you decide to answer at the top of your post. Prompt responses should answer the question an
Requirements: Identify the question you decide to answer at the top of your post. Prompt responses should answer the question and elaborate in a meaningful way using 2 of the weekly class readings (250 words of original content). Do not quote the readings, paraphrase and cite them using APA style in text citations. You can only use ONE multimedia source for your minimum 2 sources each week. The readings must be from the current week. The more sources you use, the more convincing your argument. Include a reference list in APA style at the end of your post, does not count towards minimum word content.
Select ONE of the following:
1) Why is influenza such a complex virus to deal with? How do agencies deal with this challenge? What are the lessons learned from the H1N1 US experience?
2) Compare the Mitigation, Preparedness and Response actions of the H1N1 pandemic and the Coronavirus Pandemic in the US. Use class readings for the H1N1 and ONLY academic and official sources about the coronavirus. No news outlets or blogs or non academic sources allowed.
Commentary
CDC’s Evolving Approach to Emergency Response
Stephen C. Redd and Thomas R. Frieden
The Centers for Disease Control and Prevention (CDC) transformed its approach to preparing for and responding to
public health emergencies following the anthrax attacks of 2001. The Office of Public Health Preparedness and Re-
sponse, an organizational home for emergency response at CDC, was established, and 4 programs were created or greatly
expanded after the anthrax attacks: (1) an emergency management program, including an Emergency Operations Center;
(2) increased support of state and local health department efforts to prepare for emergencies; (3) a greatly enlarged
Strategic National Stockpile of medicines, vaccines, and medical equipment; and (4) a regulatory program to assure that
work done on the most dangerous pathogens and toxins is done as safely and securely as possible. Following these
changes, CDC led responses to 3 major public health emergencies: the 2009-10 H1N1 influenza pandemic, the 2014-16
Ebola epidemic in West Africa, and the ongoing Zika epidemic. This article reviews the programs of CDC’s Office of
Public Health Preparedness, the major responses, and how these responses have resulted in changes in CDC’s approach
to responding to public health emergencies.
The Centers for Disease Control and Prevention(CDC) was established in 1946 with the primary purpose of supporting state and local public health agen- cies, particularly in responding to disasters and infectious disease outbreaks.1 The capacity to respond to health emergencies in order to protect the public has remained an essential function of CDC. Over the decades, disease out- break investigations have evolved to include larger and more complex events, and CDC’s role has remained that of providing support to state and local health departments while sometimes taking a leadership or coordination role with complex or interstate investigations. For international investigations, CDC has worked with ministries of health that requested assistance as well as with the World Health Organization.2
Within weeks of the 9/11 World Trade Center attack, CDC responded to a biological attack with anthrax in- volving numerous domestic jurisdictions. The anthrax at- tack required CDC to provide the public with frequent updates on the progress of the investigation. The volume of information and the expectations of the public created a need for CDC to operate at an unprecedented scale and tempo.3 To meet the challenges identified in the response to the anthrax attacks, CDC created a new organizational unit and approach to respond to large, complex public health emergencies, whether naturally occurring, inten- tional, or accidental. CDC’s approach to emergency re- sponse continues to evolve.
In addition to the potential for bioterror attacks, such as the anthrax attack, 2 global trends required that CDC
Stephen C. Redd, MD, is Director, Office of Public Health Preparedness and Response, and Thomas R. Frieden, MD, MPH, is CDC Director, both at the Centers for Disease Control and Prevention, Atlanta, Georgia. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Department of Health and Human Services.
Health Security Volume 15, Number 1, 2017 ª Mary Ann Liebert, Inc. DOI: 10.1089/hs.2017.0006
41
develop an expanded capability to respond at speed and scale to future emergencies.4 First, the speed and volume of long-distance travel have increased substantially. Over the past 75 years, the widespread availability of air travel has reduced the time for intercontinental travel from weeks to hours.5 Along with shorter travel times, the volume of in- tercontinental travel has increased exponentially. With in- creased and faster global travel, the opportunity for a person infected with a pathogen to travel to another part of the world within hours has become increasingly likely.6 Sec- ond, global population increases concentrated in Africa, the Indian subcontinent, and East Asia have resulted in a dra- matic increase in the number of cities with populations over 10 million.7 Ease of travel and urbanization, particularly the concentration of poverty in urban areas, is creating the opportunity for an increasing number of large infectious disease epidemics affecting multiple urban areas.
Technological advances in medicine and public health have created new tools to diagnose and quickly respond to public health emergencies. Rapid and specific diagnostic methods, vastly improved communication systems, and evolving therapeutic and vaccine technologies create oppor- tunities to detect and respond to health emergencies that were unimaginable in the past. Unfortunately, these same scientific and technologic advances allow the possibility to create more deadly or transmissible pathogens that could be released, intentionally or not, into the community.8
In this article we describe how CDC’s emergency re- sponse preparations and execution have evolved with these changing realities and expectations, with a particular focus on changes beginning with the 2009 H1N1 pandemic.
Creation of the Office of Public
Health Preparedness and Response
After the 2001 anthrax attacks, the nation readied itself for additional bioterror attacks. Government policy- makers and public health officials created lists of mi- croorganisms and chemical and biological toxins that could be used as terror agents. Government funding created a scientific-medical-production enterprise to de- velop medical countermeasures—diagnostics, vaccines, and therapeutics—to address these threats.9
The concerns and activities following the 2001 attacks were similar to those that led to the 1951 creation of the CDC Epidemic Intelligence Service, a 2-year training program in field epidemiology, as part of a response to fears of an attack with bioweapons during the Cold War.1 In 2002 CDC created a new organization—the Office of Terrorism Preparedness and Emergency Response, later the Coordinating Office for Terrorism Preparedness and Emergency Response, predecessors to the current Office of Public Health Preparedness and Response (OPHPR)— with responsibility for preparing for large-scale emergen- cies, including terrorism attacks. The office combined 3
smaller existing programs: support of state and local emer- gency preparedness activities, the Strategic National Stock- pile, and the regulatory program for select agents and toxins. In addition, the Bernie Marcus Foundation, through the CDC Foundation, funded renovations and equipment pro- curement for CDC’s first Emergency Operations Center.10
Each division or program in the Office of Public Health Preparedness and Response has specific responsibilities to as- sure that CDC and the nation’s public health system is as ready as possible to respond to future health threats (Table 1).
Regulatory Program on Select Agents and Toxins The mission of the Division of Select Agents and Toxins (DSAT) is to assure that work done with dangerous path- ogens and toxins in the United States is done as safely and securely as possible (Table 1). The Federal Select Agent Program consists of CDC’s DSAT and the US Department of Agriculture’s Agriculture Select Agent Services Program. Examples of select agents and toxins include the organisms that cause anthrax, smallpox, and bubonic plague, as well as the toxins ricin and botulinum neurotoxin. The program has an enabling mission: to assure that laboratories working with select agents and toxins are able to do their work, to create new knowledge to detect and respond to the threats these pathogens and toxins could cause.11 As of November 2016, 279 laboratories were registered with the Federal Select Agent Program (a decrease from a high of 336 lab- oratories in 2006); 241 are registered with CDC’s Select Agent and Toxins program and 38 with USDA’s Agri- culture Select Agent Services Program. The CDC Select Agent Program conducted 183 inspections in 2015, in- cluding 72 unannounced inspections. Since its inception, the program has denied 361 individuals access to select agent laboratories through the Security Risk Assessment process, which includes background investigations con- ducted by the FBI.
The underlying challenge for the Federal Select Agent Program is to balance competing priorities: (1) transpar- ency to the public regarding the work and safety of the laboratories registered with the program with the need to protect information about the work from those that might use such information to cause harm; (2) the regulatory burden necessary to assure safety and security with fostering an environment where the greatest scientific output is possible; and (3) ultimately, assuring that the benefits of the research justify its inherent risks. Even the most stringent regulations cannot ensure that work with select agents and toxins has zero risk; the program works to keep risk to the minimum possible. Determining whether potential benefit outweighs irreducible risks is complex and requires recon- ciling numerous points of view.
Within the purview of the regulatory program, work continues to improve in the following areas: (1)
CDC’S EVOLVING APPROACH TO EMERGENCY RESPONSE
42 Health Security
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Volume 15, Number 1, 2017 43
T ab
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. (C
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)
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in g
sy st
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44 Health Security
standardizing the inspection process through ongoing ef- forts to improve training of inspectors, (2) improving the science of biosafety and biosecurity, and (3) preparing for biosafety and biosecurity risks of the future as a result of the ongoing revolution in biology. These ongoing advances in biology, including sequencing technologies and synthetic biology, will make regulation and oversight in these areas increasingly complex.
Emergency Operations at CDC The Division of Emergency Operations manages CDC’s Emergency Operations Center (EOC). The division’s mission is to serve as a hub for communication, decision making, and operations during emergency activations and to plan and train for that function. When activated, the EOC serves as a tempo- rary home for responders: scientists, communication specialists, laboratory experts, and program managers from throughout CDC who are deployed to respond to a specific emergency. Since April 2009, the start of the H1N1 pandemic response, CDC’s EOC has been activated over 91% of the time.12
By activating the EOC, CDC is able to perform many of the functions it was not able to carry out during the 2001 anthrax attack: managing a scalable system for travel and shipping of equipment; recruiting and managing volunteer responders; assuring a uniform system of deployment, including pre- deployment, during deployment, and postdeployment activi- ties; and providing software tools to visualize data, thereby improving situational awareness. Although the health and safety of deployed staff have always been of concern during responses, the risks in the Ebola response led to the creation of a Deployment Risk Mitigation Unit, which provided a focal point for assuring a standard approach to safety and security training for staff deployed in responses.
The division has taken on an important new activity: training future incident commanders to lead CDC emer- gency responses. The training is based on the real-world experiences of large emergency responses in which CDC has played a leading role. The intent is to provide a setting for experiential learning in initiating a response, making recommendations or decisions, and understanding the needs of senior leaders during a large emergency response and how to meet those needs.
Improving emergency response capacity globally is a sec- ond, related function the division has undertaken as part of the Global Health Security Agenda.13 CDC staff have led emergency management training sessions in 40 countries since 2014. This training has been put to use in 6 countries in 2015 and 2016, where ministry of health officials have acti- vated their emergency operations centers 11 times to respond to emergencies ranging from cholera and influenza outbreaks to a train derailment. The training sessions and establishment of emergency operations centers have resulted in earlier and more effective responses to health emergencies. For those emergencies that have the potential to spread, more effective responses overseas protect Americans.
The Strategic National Stockpile The Strategic National Stockpile’s purpose is to assure that medical material needed to respond to a public health emergency is available when, where, and in the quantity needed to respond effectively. The stockpile’s inventory includes vaccines, medications, chemical antidotes, ancillary supplies needed to administer the countermeasures, me- chanical ventilators, respirators, and other medical equip- ment. The stockpile is a part of the Public Health Emergency Medical Countermeasure Enterprise, an interagency com- mittee led by the Department of Health and Human Ser- vices’ (HHS) Assistant Secretary of Preparedness and Response. The Public Health Emergency Management Countermeasure Enterprise is charged with developing and implementing the medical countermeasure strategy from basic science, to product development, licensing, stock- piling, distribution, and dispensing.14 As of November 2016, the stockpile contains material worth approximately $7 billion, with annual funding of $575 million in 2016.
State and Local Readiness The Division of State and Local Readiness is responsible for assuring that state, local, tribal, and territorial health de- partments are as ready as possible to respond to any health emergency. The division manages the Public Health and Emergency Preparedness cooperative agreement and pro- gram, with annual funding of $660 million in 2016. This cooperative agreement funds personnel in state and local jurisdictions responsible for emergency response, planning and exercising, and costs associated with small-scale re- sponses (as a means of testing and improving systems that would be needed in larger responses). Through this pro- gram, state and local health departments have become part of the emergency response structure in their jurisdictions. This functionality includes the ability to rapidly mobilize for an event that requires a large-scale response. The co- operative agreement also supports the Laboratory Response Network, which has the capability to detect pathogens that might be used in a bioterror attack. The network has proved adaptable in quickly adding diagnostic tests to de- tect novel infectious diseases. Risk communication staff are now available in state and local health departments to assure that the public is informed about emerging health threats.
Experience in Responding
to Large-Scale Emergencies
In the years since the restructuring of emergency response at CDC, public health emergencies have become in- creasingly frequent. Since 2001, CDC has mounted major responses to the SARS epidemic, Hurricane Ka- trina, and more recently to the H1N1 influenza pan- demic and Ebola and Zika virus epidemics (Table 2).15
REDD AND FRIEDEN
Volume 15, Number 1, 2017 45
T ab
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