ment; decontamination capabilities; communications equipment, medical equipment, and other supplies; and enhanced emergency-medical-transport and emergency-room capabilities. The program focuses on responses to a biological attack, including early warning and surveillance, mass-casualty care, and plans for the management of mass fatalities. The concept of operations also includes the local jurisdiction’s plan for augmentation of health and medical assistance by the federal, state, and neighboring governments, including the movement of patients (when local health-care systems become overloaded) via the National Disaster Medical System (NDMS). Each major medical center in cities across the nation must have response plans in place. These should include designated hospital areas that can be converted into isolation zones and decontamination areas, triage plans, and ongoing training sessions for disaster response teams among the medical personnel.

The Office of Emergency Preparedness leads the NDMS, a partnership of four federal agencies (HHS, DOD, the VA, and FEMA) and the private sector. The system has three components: direct medical care, patient evacuation, and nonfederal hospital care. NDMS also includes more than 7,000 private sector medical and support personnel organized into 80 disaster-assistance teams. These teams provide immediate medical attention to sick and injured individuals during disasters, as well as mortuary and veterinary care when local emergency-response systems become overwhelmed.

All of these systems (e.g., NDMS and the Metropolitan Medical Response System) should be supplemented with additional local capacities for responding to attacks on humans, animals, and plants. A national, regional, and local planning process should identify human and other resources that could be brought out of reserve during such times. In addition, public health laboratories need to build surge capacities as well as expertise in containment. Microbiology laboratories are the first lines of defense for the detection of new cases of antibiotic resistance, outbreaks of food-borne infection, and a possible bioterrorism event. Maintaining high-quality clinical microbiology laboratories on site or near the institutions and communities that they serve is the best approach at present for managing infectious diseases and detecting resistance to antimicrobial agents. However, a public health reserve system, consisting of certified laboratory personnel with the ability to provide expertise when the health care system becomes overloaded, needs to be created. In addition, before a crisis occurs, it is critical to have in place agreements between public health and emergency response agencies across jurisdictions. Drills using both threats and scenario models can test the full range of capabilities and assure the availability within a short distance of Level 4 public health laboratory capability.

Recommendation 3.11: Create a public health reserve system and develop surge capacity. As part of a broader planning process, create a health reserve system of health care professionals (modeled on the military reserve

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