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INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

Committee on Research Priorities in Emergency Preparedness and Response for Public Health Systems

January 22, 2008

Richard Besser, M.D.

Director

Coordinating Office for Terrorism Preparedness and Emergency Response

Centers for Disease Control and Prevention

1600 Clifton Road, NE Atlanta, GA 30333

Dear Dr. Besser:

On behalf of the Institute of Medicine (IOM) Committee on Research Priorities in Emergency Preparedness and Response for Public Health Systems, we are pleased to report our conclusions and recommendations. As requested, the report delineates a set of near-term research priorities for emergency preparedness and response in public health systems that are relevant to the specific expertise resident at schools of public health and related fields. We understand that these priorities will be used by the Coordinating Office for Terrorism Preparedness and Emergency Response (COTPER) to develop research funding opportunity announcements that must be issued and filled, according to congressional mandate, during the 2008 fiscal year.


As described in the committee’s statement of task, the committee considered areas of interest specifically articulated in the Centers for Disease Control’s (CDC’s) Advancing the Nation’s Health: A Guide for Public Health Research Needs, 2006–2015, with special attention given to:

  • Protecting vulnerable populations in emergencies (improving the identification of health vulnerability and evaluating interventions to lessen the risk of poor health outcomes);

  • Strengthening response systems (developing and evaluating integrated systems of emergency public health services and incident management);



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Committee on Research Priorities in Emergency Preparedness and Response for Public Health Systems January 22, 2008 Richard Besser, M.D. Director Coordinating Office for Terrorism Preparedness and Emergency Response Centers for Disease Control and Prevention 1600 Clifton Road, NE Atlanta, GA 30333 Dear Dr. Besser: On behalf of the Institute of Medicine (IOM) Committee on Research Priorities in Emergency Preparedness and Response for Public Health Systems, we are pleased to report our conclusions and recommendations. As requested, the report delineates a set of near-term research priorities for emergency preparedness and response in public health systems that are relevant to the specific expertise resident at schools of public health and related fields. We understand that these priorities will be used by the Coordinating Office for Terrorism Preparedness and Emergency Re- sponse (COTPER) to develop research funding opportunity announce- ments that must be issued and filled, according to congressional mandate, during the 2008 fiscal year. As described in the committee’s statement of task, the committee consid- ered areas of interest specifically articulated in the Centers for Disease Control’s (CDC’s) Advancing the Nation’s Health: A Guide for Public Health Research Needs, 2006–2015, with special attention given to: • Protecting vulnerable populations in emergencies (improving the identification of health vulnerability and evaluating interventions to lessen the risk of poor health outcomes); • Strengthening response systems (developing and evaluating inte- grated systems of emergency public health services and incident management); 1

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2 RESEARCH PRIORITIES • Preparing the public health workforce (developing and evaluat- ing strategies and tools to train and exercise the public health workforce to meet responsibilities for detection, mitigation, and recovery in varied settings and populations); • Improving timely emergency communications (evaluating char- acteristics of effective risk communication in emergency settings and system enhancements to improve effective information ex- change across diverse partners and populations under emergency conditions); and • Improving information management to increase use (scenario modeling and forecasting; information and knowledge manage- ment tools to improve the availability and usefulness during cri- sis decision making). The committee conducted a public meeting and workshop (December 18–20, 2007), with invited experts giving their views on research priori- ties in emergency preparedness and response for public health systems. Based on the committee’s expert judgment, as well as information ex- changed in the public meeting and workshop, we identified four top- priority research areas. The committee recommends that COTPER give priority to the following four areas of research in its upcoming funding solicitation for Centers for Public Health Preparedness (CPHPs): Recommendation 1: Enhance the Usefulness of Training CPHPs should conduct research that will create best practices for the design and implementation of training (e.g. simulations, drills, and exercises) and facilitate the translation of their results into improvements in public health preparedness. Recommendation 2: Improve Communications in Preparedness and Response CPHPs should conduct research that will identify and develop communications in relation to preparedness and response that effectively exchange vital and accurate in- formation in a timely manner with diverse audiences.

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LETTER REPORT 3 Recommendation 3: Create and Maintain Sustain- able Preparedness and Response Systems CPHPs should conduct research that will identify the factors that affect a community’s ability to successfully respond to a crisis with public health consequences, and the systems and infrastructure needed to foster construc- tive responses in a sustainable manner. Recommendation 4: Generate Criteria and Metrics to Measure Effectiveness and Efficiency CPHPs should conduct research that will generate crite- ria for evaluating public health emergency preparedness, response, and recovery and metrics for measuring their efficiency and effectiveness. The committee acknowledges that—and indeed intends for—these areas to generate overlapping research initiatives. All research projects con- ducted under this initiative should address or be aware of issues regard- ing vulnerable populations, workforce, behavioral health, and the use and integration of new technologies as appropriate to the proposed area of study. In addition, research that is conducted in all of these areas needs to be translational—designed to result in practical, applicable, and sustain- able outcomes that produce a more robust public health system for pre- paredness. Finally, research must be both multidisciplinary and crossdisciplinary. Centers should be strongly encouraged to seek collabo- ration and integration with expertise that may be outside the traditional arena of schools of public health. For example, disciplines may include social and behavioral sciences, engineering, economics, ethics, business, and law, for example. The committee also acknowledges that the priority area on creating crite- ria and metrics to measure effectiveness and efficiency is a particularly challenging one and overlaps with the other three research needs. It is included as a separate research priority because of its central importance to the production of sound evidence regarding the state of public health preparedness. The committee discussed the importance of creating crite- ria for public health preparedness that would resemble the approach taken to describe the health-care delivery system in the 2001 IOM report Crossing the Quality Chasm report (IOM, 2001). Decisions about work- force needs, technology, and other resources depend critically on the re-

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4 RESEARCH PRIORITIES liable and valid evaluation of public health preparedness systems. Thus there is a need for specific endeavors that focus on research and devel- opment of well-defined measures for use in the assessment of public health preparedness systems. The committee wishes to thank you for the opportunity to be of assis- tance to the Centers for Disease Control and Prevention and its Coordi- nating Office for Terrorism Emergency Preparedness and Response as they work to protect the nation’s health. Kenneth I. Shine, M.D., Chair Martha N. Hill, Ph.D., R.N., Vice Chair Committee on Research Priorities in Emergency Preparedness and Response for Public Health Systems

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LETTER REPORT 5 BACKGROUND In response to the Pandemic and All Hazards Preparedness Act (PAHPA) (Public Law 109–417, 2006, § 101 et seq.) there is an immedi- ate and critical need to define research priorities for the Centers for Pub- lic Health Preparedness (CPHP) at schools of public health. The Coordinating Office for Terrorism Preparedness and Emergency Re- sponse (COTPER) of the Centers for Disease Control and Prevention (CDC) charged the Institute of Medicine (IOM) committee responsible for this study with the task of delineating a set of near-term research pri- orities for emergency preparedness and response in public health systems relevant to the expertise resident at schools of public health and related fields (Box 1). These priorities will be used by COTPER to help develop a research agenda that will be used to inform research funding opportu- nity announcements for an enhanced CPHP program. This letter report is not intended to obviate or substitute the need for a broader research agenda, but is focused on articulating near-term research priorities for public health systems research. In accord with PAHPA, the research agenda, funding opportunity announcements, and initial funding must be completed by the end of fis- cal year 2008. As a framework for their deliberations, the committee’s statement of task required that they consider the areas of interest articu- lated in the CDC’s Advancing the Nation’s Health: A Guide for Public Health Research Needs, 2006–2015 (CDC, 2006), with special attention given to • protecting vulnerable populations in emergencies; • strengthening response systems; • preparing the public health workforce; • improving timely emergency communications; and • improving information management to increase use. COTPER requested that the identified research priorities focus on an all-hazards approach and not agent-specific activities. Furthermore, it asked that the committee consider other federal preparedness frame- works—such as applicable Homeland Security Presidential Directives; the President’s National Science and Technology Council, Subcommittee on Disaster Reduction; Department of Health and Human Services (DHHS) guidelines and policies; the CDC’s Advancing the Nation’s

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6 RESEARCH PRIORITIES BOX 1 Statement of Task In response to a request from the Centers for Disease Control and Preven- tion’s (CDC’s) Coordinating Office for Terrorism Preparedness and Emer- gency Response (COTPER), the Institute of Medicine will convene an ad hoc committee to conduct a fast-track study and issue a letter report to the direc- tor of COTPER. The report will delineate a set of near-term research priori- ties for emergency preparedness and response in public health systems that are relevant to the specific expertise resident at schools of public health. These priorities will be used by COTPER to develop research funding an- nouncements and requests for applications that must be issued and filled, according to congressional mandate, during the 2008 fiscal year. The com- mittee will be responsible for identifying appropriate research opportunities and a list of three to five top-priority research areas, each of which may also include related short-term research opportunities-all with measurable out- comes and impact over the next 3 to 5 years. As a framework for delibera- tions, the committee will consider areas of interest specifically articulated in the CDC’s Advancing the Nation’s Health: A Guide for Public Health Re- search Needs, 2006-2015, with special attention given to • protecting vulnerable populations in emergencies (improving the identi- fication of health vulnerability and evaluating interventions to lessen the risk of poor health outcomes); • strengthening response systems (developing and evaluating strategies and tools to train and exercise the public health workforce to meet re- sponsibilities for detection, mitigation, and recovery in varied settings and populations); • preparing the public health workforce (developing and evaluating strate- gies and tools to train and exercise the public health workforce to meet responsibilities for detection, mitigation, and recovery in varied settings and populations); • improving timely emergency communications (evaluating characteristics of effective risk communication in emergency settings and system en- hancements to improve effective information exchange across diverse partners and populations under emergency conditions); and • improving information management to increase use (scenario modeling and forecasting; information and knowledge management tools to im- prove the availability and usefulness during crisis decision making). The identified research priorities for public health systems should not focus on agent-specific research questions such as development of high- throughput diagnostic tests or medical countermeasures.

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LETTER REPORT 7 Health guide for research, preparedness goals and objectives, and rele- vant Department of Homeland Security programs—to focus on research and development that advances capabilities of the CDC/DHHS mission in public health preparedness systems. Origin of the CDC-Funded Centers for Public Health Preparedness The CPHPs originated in 1999, when former CDC Director Dr. Jeffrey Koplan instructed the then-Public Health Practice Program Office to develop an agency-wide plan to address the CDC’s training and con- tinuing education needs.1 The plan was to establish a cohesive, integrated approach to training that focused on the domestic public health work- force, a group that was found to have little formal training in public health, particularly in bioterrorism. This led to the establishment of CPHPs, whose purpose was to leverage existing expertise and educa- tional materials developed by academic public health institutions and create linkages to public health practice (Council on Linkages between Academia and Public Health Practice, 2000). In December 2007, 27 CPHPs were located within accredited schools of public health (CDC, 2007). A June 2004 Cooperative Agree- ment announcement, which was used as a funding mechanism for the Centers, listed three major goals for them: 1. Strengthen public health workforce readiness through implemen- tation of programs for life-long learning. 2. Strengthen capacity at state and local levels for terrorism prepar- edness and emergency public health response. 3. Develop a network of academic-based programs that contribute to national terrorism preparedness and emergency response ca- pacity by sharing expertise and resources across state and local jurisdictions (69 C.F.R. 30927, et seq.). However, in response to the PAHPA legislation, the CPHP program is undergoing a change in emphasis. The legislation requires that accred- 1 Personal communication, L. Biesiadecki, Association of Schools of Public Health, December 17, 2007.

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8 RESEARCH PRIORITIES ited schools of public health that wish to receive funding to establish a center must perform work in one of three areas:2 1. Development, implementation, and dissemination of compe- tency-based programs to train public health practitioners, inte- grating and emphasizing “essential public health security capabilities” 2. Evaluation of the public health preparedness and response needs of the school’s community and development (if necessary) and dissemination of relevant education materials as well as evalua- tion of the effectiveness of new training and materials 3. Public health systems research that is consistent with an agenda to be developed by the Secretary of DHHS (Public Law 109– 417; 120 STAT. 2861) The first two areas of work are consonant with Centers’ duties pre- scribed in the earlier Cooperative Agreements. However, the third—the public health systems research requirement—is new. Legislators realized that the Act “reflected new priorities in public health preparedness” (U.S. Senate, 2006, p. 5) and inserted this narrative into the report accompany- ing it: The committee finds that public health systems research is a priority because there has been tremendous financial investment made to date for public health preparedness with no evidence-based measures for evaluating progress or preparedness. Over time, this research will contribute sufficiently to the knowledge base to further develop benchmarks and standards (pp. 16–17). The reference to this new area of focus, public health systems for preparedness, provides the impetus for the subsequent findings and recommendations. 2 The committee was informed by COTPER that the CDC has interpreted the congres- sional intent in this manner; that is, to have separate centers focusing on research on pub- lic health systems or the other two areas. However, in testimony received by the committee, it was stated that some individuals outside COTPER and the CDC believe the intent of Congress was to expand the mission of the CPHPs to include a focus on all three areas, not just one.

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LETTER REPORT 9 METHODS To conduct this expert assessment and identify a set of research pri- orities, the committee met from December 18 through 21, 2007. This meeting was held in conjunction with a day-and-a-half long public meet- ing and workshop (see Appendix B). (Note: Some workshop speakers used slides in their presentations. Slides are available at http://www.iom. edu/PHSRpriorities.) The purpose of the workshop was to hear from ex- perts about the importance, feasibility, and “ripeness” of areas of interest, focusing on broad, integrative research needs that would be helpful in creating successful systems for preparedness and response and then evaluating them. In addition, the committee also heard from relevant stakeholder organizations, including federal agencies and representatives from the key components of the public health system, to inform the committee about relevant ongoing and planned initiatives. This letter report is based on the committee’s expert judgment and assessment of research priorities in emergency preparedness and response for public health systems. Definitions Public Health Emergency Preparedness Before identifying research priorities in emergency preparedness and response for public health systems, the committee believed that it was necessary to establish a definition of “public health emergency prepared- ness.” It chose to adopt the definition proposed by Nelson and colleagues in a 2007 editorial in the American Journal of Public Health: Public health emergency preparedness (PHEP) is the ca- pability of the public health and health-care systems, communities, and individuals to prevent, protect against, quickly respond to, and recover from health emergen- cies, particularly those whose scale, timing, or unpre- dictability threatens to overwhelm routine capabilities. Preparedness involves a coordinated and continuous process of planning and implementation that relies on measuring performance and taking corrective action (Nelson et al., 2007, p. S9).

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10 RESEARCH PRIORITIES The committee recognizes that public health emergency prepared- ness, response, and recovery takes place in the context of scalable local, state, tribal, and federal response systems composed of traditional emer- gency response agencies, public safety agencies, and other governmental and nongovernmental organizations. Moreover, it recognizes that effec- tive response requires that particular attention be paid to interfaces among these many interconnected response systems. The committee also referred to the key elements of preparedness described in Nelson et al. (2007) (see Box 2). Thus, for the purposes of this report, the committee uses the term “preparedness” to include the full breadth of preparedness- related activities, that is, the activities that range from prevention to re- covery that are performed by all relevant organizations, including the many levels of governmental and community organizations. Public Health and Public Health System Considering preparedness in the context of the entirety of the public health system (as is required by the committee’s charge to identify re- search priorities for preparedness and response in public health systems) also requires the definitions of “public health” and a “public health sys- tem.” To that end, the committee adopted the definition of public health from the landmark 1988 IOM report The Future of Public Health, which defined public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy” (IOM, 1988, p. 1). The 2002 IOM report The Future of the Public’s Health in the 21st Century describes the concept of a “public health system” as “a complex network of individuals and organizations that have the potential to play critical roles in creating the conditions for health” (IOM, 2002, p. 28). It also lists various factors in a public health system, and explains that they can both act individually and together to affect health. Figure 1 illustrates these factors, which include communities, health-care delivery systems, employers and business, the media, homeland security and public safety, academia, and the governmental public health infrastructure. As high- lighted in the 2002 IOM report, there are other less obvious actors that can play a significant role “by influencing and even generating the mul- tiple determinants of health” (IOM, 2002). Included in this perspective are not only the individual and organizational participants, but also the relevant critical infrastructures that are associated with each. Although

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LETTER REPORT 11 BOX 2 Key Elements of Preparedness, as Defined by Nelson et al. (2007) A prepared community is one that develops, maintains, and uses a realistic preparedness plan that is integrated with routine practices and has the following components: Preplanned and coordinated rapid-response capability 1. Health risk assessment. Identify the hazards and vulnerabilities (e.g., community health assessment, populations at risk, high-hazard industries, physical structures of importance) that will form the basis of planning. 2. Legal climate. Identify and address issues concerning legal authority and liability barriers to effectively monitor, prevent, or respond to a public health emergency. 3. Roles and responsibilities. Clearly define, assign, and test responsibilities in all sectors, at all levels of government, and with all individuals, and ensure each group’s integration. 4. Incident Command System (ICS). Develop, test, and improve decision making and response capability using an integrated ICS at all response levels. 5. Public engagement. Educate, engage, and mobilize the public to be full and active participants in public health emergency preparedness. 6. Epidemiology functions. Maintain and improve the systems to monitor, detect, and investigate potential hazards, particularly those that are environmental, radiological, toxic, or infectious. 7. Laboratory functions. Maintain and improve the systems to test for potential hazards, particularly those that are environmental, radiological, toxic, or infectious. 8. Countermeasures and mitigation strategies. Develop, test, and improve community mitigation strategies (e.g., isolation and quarantine, social distancing) and countermeasure distribution strategies when appropriate. 9. Mass health-care. Develop, test, and improve the capability to provide mass health-care services. 10. Public information and communication. Develop, practice, and improve the capability to rapidly provide accurate and credible information to the public in culturally appropriate ways. 11. Robust supply chain. Identify critical resources for public health emergency response and practice and improve the ability to deliver these resources throughout the supply chain. Expert and fully staffed workforce 1. Operations-ready workers and volunteers. Develop and maintain a public health and health-care workforce that has the skills and capabilities to perform optimally in a public health emergency. 2. Leadership. Train, recruit, and develop public health leaders (e.g., to mobilize resources, engage the community, develop interagency relationships, and communicate with the public).

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18 RESEARCH PRIORITIES Enhancing the Usefulness of Training Recommendation 1: Enhance the Usefulness of Training CPHPs should conduct research that will create best practices for the design and implementation of training (e.g., simulations, drills, and exercises) and facilitate the translation of their results into improvements in public health preparedness. Public health preparedness systems should have the goal of creating a sustained, replicable capability through formal education, experiential learning, practice, and experience to plan for, detect, respond to and re- cover from all hazards. However, the current state of such systems often falls short of this goal. Training—which includes exercises, drills, the use of simulation methods, after action analysis of real-life events—does not readily translate into day-to-day public health practice. There are no agreed-upon competencies, standards, or performance measures for pub- lic health emergency preparedness; however, many groups have begun to work in this area and these efforts need to be validated and expanded. The role of public health in the all-hazards continuum is not well de- scribed, making it difficult to design training that is relevant and applica- ble to practice. At times heavily resource-dependent training and drills are conducted with little or no grounding in conceptual models to guide development and implementation, and with little or no evaluation of their cost-effectiveness. To address these deficiencies, the committee believes that it is necessary to • better define the public health emergency response system and its performance outcomes; • clarify the roles and responsibilities of public health emergency preparedness and response systems within and across local, state, tribal, and federal public health systems and the larger emer- gency response system; • create measurable, meaningful input, process, and outcome per- formance measures; and • evaluate how training, as defined above, improves the profi- ciency and performance of public health response systems.

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LETTER REPORT 19 Among the specific research questions that have merit are • What training modalities build lasting capacity and improved performance? о Why are these modalities successful? • What education and training promote administrative and opera- tional collaboration and cooperation between public health and the health-care system? • What are the characteristics of training simulations that produce the capabilities needed to enhance system performance in a cost- effective manner? • What are the advantages and disadvantages of computer simula- tions compared to other training in enhancing system and spe- cific personnel performance? • What is the evidence that persons involved in different training modalities perform at a higher level, and for how long is this higher level of performance sustained? What is the frequency of training necessary to maintain desired skills? • Which subsets of the public health workforce can best benefit from various training modalities and why? • Which, and how valid are, training modalities that address the needs of special populations, including children and vulnerable populations, and that account for the effect of public health cri- ses and disasters on behavioral health? • Which, and how valid are, training modalities that prepare the workforce and the public to better respond to emergencies and to limit the effect of the additional stressors they engender? • Which, and how valid are, training modalities that improve in- formation management and visualization4 to improve decision analysis and outcomes? • How valid are case studies and standardized assessment tools for after-action reporting when applied retrospectively to actual pub- lic health emergency events? To address such questions, the committee recommends that tools and measures be developed that will allow process and performance meas- 4 Visualization refers to techniques that allow data to be understood by seeing patterns that are detected by statistical methods, such as pattern recognition methods, and/or sim- ply understood by seeing how geospatial relationships look on a map.

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20 RESEARCH PRIORITIES ures of training modalities for evaluation, analysis and comparison of types of training and experience models. Cost-effective simulation tech- niques should be given priority, based upon their ability to improve sys- tem performance, enhance personnel proficiency, and provide sustainability. Improving Timely Emergency Communications Recommendation 2: Improve Communications in Preparedness and Response CPHPs should conduct research that will identify and develop communications in relation to preparedness and response that effectively exchange vital and accurate in- formation in a timely manner with diverse audiences. This recommendation considers all aspects of effective communica- tion, including the importance of content, channels, mechanisms, target audiences, and other relevant components. Successful emergency com- munications is a crucial element in effective emergency management and should assume a central role from the start. It establishes public confi- dence in the ability of an organization or government to address an emergency, and to achieve a satisfactory outcome. Effective emergency communication is also integral to the larger process of information ex- change aimed at eliciting trust and promoting understanding of the rele- vant issues or actions. However, while emergency communication is an integral component, pre-emergency preparedness communication, in- cluding risk communication, also plays a significant role in the develop- ment of resilient communities and sustainable response systems. Effective preparedness and emergency communication aids emergency management by building, maintaining or restoring trust; improving knowledge and understanding; guiding and encouraging appropriate atti- tudes, decisions, actions and behaviors; and encouraging collaboration and cooperation. The committee believes that research in this area should concentrate on two topics: (1) evaluating the characteristics of effective risk commu- nication in pre-emergency and emergency settings, and (2) developing system enhancements to improve effective information exchange across diverse populations and entities in pre-emergency and emergency situations.

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LETTER REPORT 21 Among the research questions that would generate practical, applica- ble, and sustainable results on the first topic—the evaluation of effective risk communication in pre-emergency and emergency settings—are • What are the criteria and metrics for effective risk communica- tion in emergency situations with (1) the public health work- force, (2) emergency response partners, (3) the media, (4) the public, and (5) vulnerable populations? (See also research opportunities associated with Recommendation 4: Criteria and Metrics.) • Which risk communication messages motivate people, especially vulnerable populations, to take protective action and engage in appropriate behaviors related to emergencies at different scales? • To what extent can market research techniques be used to test the effectiveness and cultural competence of risk communication messages developed for the emergency scenarios identified in the Department of Homeland Security’s National Response Plan (DHS, 2007) and other relevant preparedness frameworks? • To what extent can research techniques be used to improve the cultural competence of frontline responders and others involved disaster policy and decision-makers to improve the success and outcome of the community response in emergencies? • How can new technologies (e.g., Internet and web-based tech- nologies, and cellular/text messaging) be better used to fill risk communication gaps in emergency settings, including those ex- perience by vulnerable populations? • How does one optimize and leverage the use of existing channels of risk communication in emergency settings to reach diverse audiences, including nonprofit organizations, faith-based organi- zations, schools, business community, and relevant professional associations? What are the existing risk communication capaci- ties of these community partners in pre-emergency and emer- gency settings? • What are the barriers preventing effective translation of pre- emergency and emergency communication strategies to practi- tioners? о What organizational changes are required to implement ef- fective communication strategies?

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22 RESEARCH PRIORITIES Research questions relevant to the second topic—system enhance- ments to improve effective information exchange across diverse popula- tions in pre-emergency and emergency settings—include • What are the criteria and metrics for system enhancements to improve effective information exchange within and across di- verse partners and populations under pre-emergency and emer- gency conditions? (See also research opportunities associated with Recommendation 4: Criteria and Metrics.) • How can information technology innovations (e.g., wireless technologies, electronic health records, systems integration, emergency medical response) strengthen emergency response systems by improving situational awareness, data sharing, and decision support for the public health workforce? • How can challenges to information technology adoption (e.g., robustness, reliability, bandwidth limitations) be overcome for routine as well as emergency response use? • How do we measure the value of “relationships” or “connec- tivity” of public health with traditional and nontraditional part- ners in information exchange in emergency settings? • What are effective mechanisms for enhancing systems of infor- mation exchange to reach into vulnerable and special needs communities in pre-emergency and emergency settings? Creating and Maintaining Sustainable Preparedness and Response Systems Recommendation 3: Create and Maintain Sustain- able Preparedness and Response Systems CPHPs should conduct research that will identify the factors that affect a community’s ability to successfully respond to a crisis having public health consequences, and the systems and infrastructure needed to foster con- structive responses. Systems of public health preparedness, response, and recovery should be organized to cope with a wide range of threats, including catastrophic health events and use the all-hazards approach. These sys- tems should be accountable for achieving performance expectations. To

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LETTER REPORT 23 prevent, protect against, quickly respond to, and recover from health emergencies, they should include local, state, tribal, and federal public health agencies; practitioners from emergency response and health-care systems; communities (e.g., private-sector and civic entities, for exam- ple); and individuals. Although crises and disasters having public health consequences may vary in their scale, timing, and predictability, they all have the potential to overwhelm routine response capabilities and disrupt the provision of daily life and health-care services. While some research has been performed to examine how the different components of the sys- tem should interact and be organized, much more research is required to identify and develop the optimal components, arrangement, and inter- faces of the public health system. Preparedness systems also require infrastructure to support a multi- agency, multiprofessional, inclusive, coordinated and continuous process of planning, testing/exercising, and implementing that relies on measur- ing performance and taking corrective action. Effective response systems must have a complex matrix that includes broad use of social, behavioral, engineering, legal, business, economic, ethical, and media expertise, among other disciplines. Thus, to be useful, research requires multi- disciplinary, interdisciplinary and/or cross-disciplinary expertise that reaches beyond the traditional boundaries of schools of public health. However, such public health preparedness systems are not systematically in place, and therefore the research is required to identify how this matrix should be developed so that the public health preparedness system as effective and efficient as possible. History is full of with examples of communities responding to disas- ters and catastrophic events, with the quality of response ranging from exemplary to dysfunctional. These examples can inform more productive responses in the future. However, lessons can also be learned from other fields not traditionally a part of the public health system, including op- erations research, systems engineering, and the business sector. The major issue to be addressed is what are the preparatory activities that public health officials can take—working with communities, agen- cies, and organizations—to maximize effective outcomes of the emer- gency response system that will have both planned and emergent self- organizing components? Research is needed to identify those factors that impact the community's ability to respond in a manner that allows for the best outcome. Among the research questions that would generate practi- cal, applicable, and sustainable results are

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24 RESEARCH PRIORITIES • What are the critical elements of a public health system that make it scalable and thereby capable of responding to different levels of emergency? • What are the lessons to be learned from other academic, profes- sional, and international fields of research and practice (e.g., op- erations research, systems engineering, and the business sector) that can and should be integrated into the public health system? • What strategies, if any, should be established improved coordination of the public health system with other critical infrastructures? • To what extent does training (e.g., simulations, drills, and exer- cises) demonstrate the efficacy and capabilities of communities to become integrated into the response system? (See also re- search opportunities associated with Recommendation 1: En- hance the Usefulness of Training.) • Can historical accounts, after-action reports, lessons learned, and similar data from real life events increase the understanding of how communities best respond, and if so how can this knowl- edge be better integrated into the public health preparedness system? • To what extent do coordinated pre-event preparedness activities impact the efficacy and capability of the public health system to integrate into the broader response system, including public, community, and private sectors? о How can these findings be better integrated into the public health preparedness system? • How can research results and findings be best applied to ensure a more effective and rapid response across all scales of emergen- cies, from small community to national events? • Are there ways to collect and maintain data during events for later analysis that are not time or resource intensive and do not disrupt response? • How can the “tipping points” that require abrupt changes to al- ternative response systems be identified, and how are these alter- native systems sustained?

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LETTER REPORT 25 Generating Effectiveness Criteria and Metrics Recommendation 4: Generate Criteria and Metrics to Measure Effectiveness and Efficiency CPHPs should conduct research that will generate crite- ria for evaluating public health emergency preparedness, response and recovery, and metrics for measuring their efficiency and effectiveness. The nation has invested large amounts of financial and human capital in enhancing the public health system’s ability to prepare for, respond to, and recover from emergency events. However, it is difficult to measure objectively the progress that has been made and the preparedness gaps. A critical need exists for validated criteria and metrics that enable public health systems to achieve continuous improvement and to demonstrate the value of society’s investment. The committee believes that work in this area should concentrate on the following issues: 1. What are the appropriate criteria for evaluating public health emergency preparedness, response, and recovery? Priority areas include (1) the public health workforce; (2) infor- mation management; (3) emergency communications; (4) vul- nerable populations; and (5) response systems. The criteria should include components of planning, structure, process, and continuous improvement. The legal and ethical implications of recommended criteria should be analyzed. Likewise, recommen- dations should address how each criterion is applicable at the lo- cal, tribal, state, and federal levels. 2. What are the appropriate metrics to quantify achievement with respect to these criteria, and how can they be validated? Metrics should be practical, clear, and accessible to practitioners and the public. They should be designed to drive and reward continuous quality improvement, measuring both efficiency and effectiveness. Among the research questions that would generate practical, applica- ble, and sustainable results in the development of criteria and metrics are • What are appropriate criteria for decision-making processes in planning, response, and recovery? These include criteria for im-

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26 RESEARCH PRIORITIES plementation, testing, and improvement of the decision-making process. The criteria should take into account existing practice, experience, and theory. • What are appropriate criteria for the application of continuous quality improvement of the structure and process of planning, re- sponse, and recovery? • What are appropriate criteria for planning and implementation of clear and accessible communication with the public, recognizing the specific needs of vulnerable populations? (See also Recom- mendation 2: Communications.) • What are appropriate criteria to quantify the effectiveness with which the public health system addresses the social and behav- ioral impacts of events in planning, response, and recovery? • What are appropriate criteria to measure the public’s expecta- tions, experience and satisfaction with respect to public health emergency planning response and recovery efforts? • To what extent, if any, will accreditation standards for state and local health departments contribute to an agency’s preparedness as it relates to capacity and performance? Finally, the committee discussed the importance of creating criteria for public health preparedness that would resemble the approach taken to describe the health-care delivery system in the 2001 IOM report Cross- ing the Quality Chasm (IOM, 2001). CONCLUSIONS Although the overall success of this research initiative will necessi- tate substantially more resources than those currently available, the committee believes the thrust of this activity is extremely important and potentially powerful for the field of public health preparedness. The pro- posed research projects seek to provide evidence on which important decisions about the nature and distribution of public health preparedness resources can be based. By insisting on well-described metrics, the re- search offers the chance for more rational decisions about these resource requirements as well as the opportunity to undertake continuous quality improvement in the preparedness field. This initiative needs to bring research rigor to the analysis of existing data about previous events and test hypotheses that can further advance

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LETTER REPORT 27 the field. It will stimulate important new collaborations between two groups: (1) traditional public health researchers and practitioners, and (2) collaborators from a variety of other disciplines not previously engaged in public health systems of research. Through the engagement of those who provide public health prepar- edness services in the community, this initiative offers the opportunity for research that is practical, applicable, and sustainable. In so doing, it will strengthen the growing relationships between academic public health and public health practitioners, in addition to the broader public and other emergency preparedness practitioners. The committee is convinced that the creative energies of those in academia and in the public health community can provide a body of well-researched evidence that will contribute to the best possible system for maintaining the health and wel- fare of the American people.

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