Fraser and Fisher, 2001). These include surveillance and reporting by health care providers (e.g., physicians, nurse practitioners, physicians’ assistants) who identify unusual symptoms or patterns. On the one hand, the West Nile virus experience underscored the value of alert and knowledgeable health care providers who can respond rapidly to suspicious symptoms and of established and tested reporting mechanisms (GAO, 2000). On the other hand, analysis of the early response to the West Nile outbreaks showed that lines of communication between health care providers and public health agencies were unclear, and there was confusion about “what to report, when, and to whom” (GAO, 2000). In a more recent example provided by the monkeypox outbreak, local health authorities and CDC were apparently only notified about the initial rash 13 days later (Mitchell, 2003). The “disconnect” between the health care and public health communities is a detriment to readiness to protect the population’s health against threats. The health care sector, including private health care practices, hospitals, health care systems, health care organizations, and insurers, constitutes a major stakeholder in bioterrorism preparedness because it often serves as the first line of defense in a disease outbreak and it employs a substantial proportion of potential responders to a public health threat (including the majority of personnel vaccinated against smallpox) (GAO, 2000; Covert, 2001; Fraser and Fisher, 2001; IOM, 2002). This explains why communication and collaboration between the health care and public health communities are essential to bioterrorism preparedness. The Health Resources and Services Administration (HRSA) National Bioterrorism Hospital Preparedness Program Cooperative Agreement Guidance for FY 2003 describes areas where collaboration is needed between public health agencies and hospitals, as well as other health care partners. The crosscutting guidance provided in this document also is included in the CDC Guidance (CDC, 2003b).

It was not entirely clear from the HRSA and CDC crosscutting guidance whether all hospitals and health care providers in a jurisdiction are expected to participate in planning for preparedness and in implementing and testing plans. Nevertheless, the preparedness efforts of state and local public health agencies should engage all hospitals and health care systems, not just those participating in the vaccination program (IOM, 2003d). Hospitals and health care systems that declined to participate in the vaccination program have cited valid reasons, such as concerns about liability and potential risk to patients. However, it is important that these organizations ensure that their emergency preparedness plans incorporate contingencies for responding to bioterrorism. It is necessary that the health care community (and any relevant partners), at a minimum, conduct or oversee the following activities:



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