Public Health Preparedness: Where We’ve Been, Where We Are, and Where We’re Going

September 09, 2021 | Haley Burrous

office-team-strategy-planning_1200x740.pngEach September, the United States observes National Preparedness Month, a month dedicated to raising awareness of public health preparedness. Preparedness—a field that readies our nation to respond to a range of emergencies—is a newer public health discipline, advanced by lessons learned from each response to a public health threat. While significant progress has been made over the past 20 years, the COVID-19 pandemic has shed light on the need to strengthen state and local capabilities to address future emergencies. The history of public health preparedness is worth understanding, as each current and future response is impacted by lessons from the past.

Development of a Field

There is a human health component to most emergencies that warrants the direct involvement of the public health sector. However, prior to Sept. 11, 2001, public health preparedness activities were sparse. The concept of preparedness was often affiliated with non-public health disciplines like law enforcement and emergency medical services. Day-to-day preparedness activities in public health were not coordinated in a single office, but instead were spread across health agencies in offices like epidemiology and infectious disease. Finally, funding for the field was inconsistent. Jurisdictions often only developed plans for specific threats unique to their region. Many health agencies were only just awakening to the concept of public health preparedness as a distinct field.

The success of modern-day public health preparedness is largely rooted in policy and funding developments since Sept. 11, 2001 and the anthrax attacks one month later. Within the past twenty years, the scope of public health preparedness has grown and the mission has expanded to prioritize an all-hazards approach to emergency management. This mission is recognized in federal regulations that sustain and strengthen all-hazards preparedness in public health activities.

In 2002, the Office of Public Health Emergency Preparedness (OPHEP) was established to coordinate activities related to preparing against acts of bioterrorism and other public health threats. In December 2006, in the wake of Hurricane Katrina, the Pandemic and All-Hazards Preparedness Act (PAHPA) was passed to strengthen the nation’s capacity to prepare for and respond to emergencies.

The passing of PAHPA led to significant changes within the Department of Health and Human Services (HHS), including the replacement of OPHEP with the office of the Assistant Secretary for Preparedness and Response (ASPR), and the enhancement of other essential programs and services, including the medical countermeasures enterprise and hospital preparedness program. Enacting PAHPA expanded grant programs for state, territorial, and local preparedness activities and created new standards to measure the success of these efforts. The original law underwent reauthorization in 2013 and 2019, continuing the essential programs established under PAHPA.

Public health preparedness at the state, local, and territorial levels is primarily funded through two federal cooperative agreements: the hospital preparedness program (HPP) and Public Health Emergency Preparedness (PHEP). Together, these grants from ASPR and CDC provide funding to support 62 recipients’ healthcare and public health preparedness systems. HPP and PHEP funding is allocated to 50 states, four localities, and eight territories and freely associated states. Each recipient is expected to use the funding over a five-year period to build preparedness capacity while meeting the capabilities laid out in each funding agreement. The HPP and PHEP grant programs offer tailored guidance, technical assistance, and evaluation capacity to ensure that jurisdictions are prepared to address public health threats.

Preparedness in Action

The scope of work in public health preparedness differs across federal, state, territorial, tribal, local, and organizational levels. While there is not a one-size-fits-all response to emergencies, one assumption can be made: public health emergencies typically begin and end locally. This means that local health agencies are often the first to respond, followed by support by the state and federal level as local resources and capabilities are depleted.

Local, state, and territorial health agencies plan and prepare for threats based on several domains of preparedness outlined under the PHEP and HPP cooperative agreements. These cooperative agreements work to advance jurisdictions’ capabilities across many areas, including:

  • Resilience
  • Incident management
  • Information management
  • Countermeasures and mitigation
  • Surge management
  • Bio surveillance activities
  • Continuity of healthcare
  • Healthcare readiness

Health agencies plan for a variety of incidents, including planned events, moderate-sized emergencies, and large or "black sky" crises. There are several crucial staff members that oversee the day-to-day activities of the preparedness department, including PHEP and HPP grant managers and medical countermeasures coordinators. During incident response, roles are expanded through the incident command system, a standardized approach to emergency response coordination. Preparedness departments prepare for threats and risks—regardless of their size—through a cycle of developing, exercising, evaluating, and improving preparedness plans.

When a response overwhelms local and state capacities, stakeholders at the federal level become involved. Agencies like CDC, ASPR, and FEMA have unique, indispensable roles in large-scale emergencies.

CDC distributes preparedness funding for states and territories through cooperative agreements and supplemental funding streams. CDC also conducts research and develops critical resources and guidance necessary to respond to emerging health threats. ASPR, much like CDC, provides funding to states and territories through the HPP cooperative agreement to prepare for emerging public health threats. ASPR works with hospitals, healthcare coalitions, and government agencies to improve readiness. FEMA provides states and territories with a critical connection to emergency management during response. FEMA also offers emergency management trainings, funding assistance during disasters, and logistical support, among other roles.

National associations like ASTHO assist in coordinating state, territorial, local, and federal agencies for emergencies. ASTHO’s preparedness program helps strengthen public health by identifying and prioritizing policy and programmatic needs of state and territorial public health agencies and collaborating with partners across levels of government.

Through a sizable preparedness portfolio, ASTHO provides jurisdictions with opportunities to bolster public health preparedness capabilities through guidance, resources, trainings, participation in peer networks, and engagement in special projects. Throughout all phases of the COVID-19 response, ASTHO has connected jurisdictions with federal health agencies, provided timely information through daily COVID-19 briefs, generated products highlighting promising practices in response, and offered technical assistance to states and territories.

Looking Towards the Future

The field of public health preparedness has evolved significantly in recent years, and it will surely do so again as we respond to new and unique public health threats. ASTHO is hopeful that lessons learned from the COVID-19 response will inform the field as we continue strengthening public health preparedness programs across the nation.

ASTHO is currently leading states through a process to reshape the existing PHEP framework into a more resilient, adaptable, and inclusive system. We are optimistic that this project will result in improved preparedness capabilities and clarify the roles of local, state, territorial, and federal agencies in responding to public health threats.

ASTHO will continue to support states and territories as they prepare for and respond to public health threats.