EXAMINING CHALLENGES AND
POSSIBLE STRATEGIES
TO STRENGTHEN
U.S. HEALTH SECURITY
PROCEEDINGS OF A WORKSHOP
Anna Nicholson, Lisa Brown, and Justin Snair, Rapporteurs
Forum on Medical and Public Health Preparedness for
Disasters and Emergencies
Board on Health Sciences Policy
Health and Medicine Division
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
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This project was jointly supported by contracts between the National Academy of Sciences and the American College of Emergency Physicians; American Hospital Association; American Red Cross; Association of Public Health Laboratories; Association of State and Territorial Health Officials; Child Care Aware of America; Council of State and Territorial Epidemiologists; East West Protection; Emergency Nurses Association; GlaxoSmithKline; Healthcare Ready; Infectious Diseases Society of America; Meridian Medical Technologies; National Association of Chain Drug Stores; National Association of County & City Health Officials; National Association of Emergency Medical Technicians; Robert Wood Johnson Foundation (Contract No. ID#: 73289); Seqirus; Trauma Center Association of America, U.S. Centers for Disease Control and Prevention (Contract No. 200-2011-38807, TO #54); U.S. Department of Defense (Contract No. HHSP233201400020B/HHSP23337014); U.S. Department of Defense, Uniformed Services University of the Health Sciences (Contract No. HU0001-16-1-0022); U.S. Department of Health and Human Services’ Administration for Children and Families (Contract No. HHSP233201400153P); U.S. Department of Health and Human Services’ National Institutes of Health: National Institute of Allergy and Infectious Diseases, National Institute of Environmental Sciences, and National Library of Medicine (Contract No. HHSN26300084); U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (Contract No. HHSO100201550005A); U.S. Department of Health and Human Services’ U.S. Food and Drug Administration (Contract No. 1R13FD005495-01); U.S. Department of Homeland Security, Office of Health Affairs (Contract No. HSHQDC-15-C-00079); and U.S. Department of Transportation and the National Highway Traffic Safety Administration (Contract No. DTNH22-14-H-00468). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-46375-1
International Standard Book Number-10: 0-309-46375-0
Digital Object Identifier: https://doi.org/10.17226/24856
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Examining challenges and possible strategies to strengthen U.S. health security: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24856.
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PLANNING COMMITTEE ON OPPORTUNITIES FOR THE FUTURE OF HEALTH CARE AND PUBLIC HEALTH PREPAREDNESS, RESPONSE, AND RECOVERY1
THOMAS V. INGLESBY (Chair), Director, Center for Health Security, Johns Hopkins Bloomberg School of Public Health
DAVID M. ABRAMSON, Professor, College of Global Public Health, New York University
MARY CASEY-LOCKYER, Senior Associate, Disaster Health Program Development, American Red Cross
BROOKE COURTNEY, Senior Regulatory Counsel, Office of Counterterrorism and Emerging Threats, U.S. Food and Drug Administration, U.S. Department of Health and Human Services
JON R. KROHMER, Director, National Highway Traffic Safety Administration, U.S. Department of Transportation
EMILY LORD, Executive Director, Healthcare Ready
SUZET M. McKINNEY, Executive Director, Illinois Medical District Commission
JOHN OSBORN, Operations Manager, Assistant Professor, Health Care Systems Engineering, Department of Surgery, Mayo Clinic College of Medicine
TARA O’TOOLE, Senior Fellow, Executive Vice President, In-Q-Tel
RAJIV RAMNATH, Director, National Science Foundation
TIMOTHY L. SELLNOW, Professor, University of Central Florida
W. CRAIG VANDERWAGEN, Co-Founder and Director, East West Protection, LLC
SANDRA WHITEHEAD, Manager, Program and Partnership Development, National Environmental Health Association
LAURA WOLF, Chief, Critical Infrastructure Protection Branch, U.S. Department of Health and Human Services
Health and Medicine Division Staff
JUSTIN SNAIR, Senior Program Officer (until September 2017)
CLAIRE GIAMMARIA, Associate Program Officer
ALEXA EDMIER, Research Assistant
ALEX REPACE, Senior Program Assistant
ANDREW M. POPE, Director, Board on Health Sciences Policy
___________________
1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
Consultants
ANNA NICHOLSON, Doxastic Communications
LAURA RUNNELS, LAR Consulting
FORUM ON MEDICAL AND PUBLIC HEALTH PREPAREDNESS FOR DISASTERS AND EMERGENCIES1
DAN HANFLING (Co-Chair), Clinical Professor, Department of Emergency Medicine; Contributing Scholar, Center for Health Security, Johns Hopkins Bloomberg School of Public Health
SUZET M. McKINNEY (Co-Chair), Executive Director, Illinois Medical District Commission
ROY L. ALSON, Associate Professor, Emergency Medicine, Wake Forest School of Medicine; Representative, American College of Emergency Physicians
STACEY J. ARNESEN, Branch Chief, Disaster Information Management Research Center, National Library of Medicine, National Institutes of Health, U.S. Department of Health and Human Services
PAMELA BLACKWELL, Director, Center for Emergency Preparedness and Response, Cobb/Douglas Boards of Health; Representative, National Association of County & City Health Officials
ERIC C. BLANK, Senior Director, Public Health Programs and Systems, Association of Public Health Laboratories
JAMES S. BLUMENSTOCK, Chief, Health Security, Association of State and Territorial Health Officials (since October 2017)
KATHRYN BRINSFIELD, Assistant Secretary of Health Affairs and Chief Medical Officer, Office of Health Affairs, U.S. Department of Homeland Security (until January 2017)
MARY CASEY-LOCKYER, Senior Associate, Disaster Health Program Development, American Red Cross (since May 2017)
BROOKE COURTNEY, Senior Regulatory Counsel, Office of Counterterrorism and Emerging Threats, U.S. Food and Drug Administration, U.S. Department of Health and Human Services
RICHARD N. DANILA, Epidemiology Program Manager, Deputy State Epidemiologist, Minnesota Department of Health; Representative, Council for State and Territorial Epidemiologists (until October 2017)
DAVID EISENMAN, Director, Center for Public Health and Disasters, David Geffen School of Medicine and the Fielding School of Public Health, University of California, Los Angeles (since August 2017)
BRUCE EVANS, Fire Chief, Upper Pine River Fire Protection District; Representative, National Association of Emergency Medical Technicians
___________________
1 The National Academies of Sciences, Engineering, and Medicine’s forums do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
LARRY (DAVE) FLUTY, Acting Assistant Secretary, Office of Health Affairs, U.S. Department of Health and Human Services (since January 2017)
ROBERTO GARZA, Acting Deputy Director, Office of Public Health Preparedness and Response, Administration of Children and Families, U.S. Department of Health and Human Services (since May 2017)
JOHN L. HICK, Associate Medical Director, Emergency Medical Services; Medical Director, Emergency Medicine, Hennepin County Medical Center
ROBERT KADLEC, Office of Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services (since October 2017)
CLAUDIA M. KELLY, Senior Director, Value Access and Policy, Seqirus
THOMAS KIRSCH, Director, National Center for Disaster Medicine Public Health; Professor, Military and Emergency Medicine, Uniformed Services University of the Health Sciences, U.S. Department of Defense
GEORGE W. KORCH, Acting Assistant Secretary for Preparedness and Response, Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services (until October 2017)
MICHAEL G. KURILLA, Director, Office of Biodefense Research Affairs; Associate Director, BioDefense Product Development, National Institute of Allergy and Infectious Diseases, National Institutes of Health, U.S. Department of Health and Human Services
DREW E. LEWIS, Medical Lead, Clinical Research and Medical Operations, Meridian Medical Technologies (since February 2017)
EMILY LORD, Executive Director, Healthcare Ready (until May 2017)
NICOLETTE A. LOUISSAINT, Director, Programming, Healthcare Ready (since June 2017)
NICOLE LURIE, Assistant Secretary for Preparedness and Response, Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services (until January 2017)
FREDA GAIL LYON, Vice President, Emergency Services, WellStar Health System; Representative, Emergency Nurses Association
AUBREY K. MILLER, Captain, U.S. Public Health Service; Senior Medical Advisor, Office of the Director, National Institute of Environmental Health Sciences, National Institutes of Health, U.S. Department of Health and Human Services
JOHN OSBORN, Operations Manager, Assistant Professor, Health Care Systems Engineering, Department of Surgery, Mayo Clinic College of Medicine
TARA O’TOOLE, Senior Fellow, Executive Vice President, In-Q-Tel
ANDREW T. PAVIA, Professor, Division Pediatric Infectious Diseases, University of Utah; Representative, Infectious Diseases Society of America
JENNIFER PIPA, Senior Director of Recovery Operations, American Red Cross (until April 2017)
ALONZO PLOUGH, Vice President, Research-Evaluation-Learning; Chief Science Officer, Robert Wood Johnson Foundation
TERRY RAUCH, Program Director, Defense Medicine Research and Development, Office of the Assistant Secretary of Defense for Health Affairs, U.S. Department of Defense (since June 2017)
STEPHEN C. REDD, Director, Office of Public Health Preparedness and Response, U.S. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services
MARY J. RILEY, Director, Office of Human Services Emergency Preparedness Response; Captain, U.S. Public Health Service, Administration for Children and Families, U.S. Department of Health and Human Services (until February 2017)
ANDREW R. ROSZAK, Senior Director of Emergency Preparedness, Child Care Aware of America (until January 2017)
SARA E. ROSZAK, Director, Research, National Association of Chain Drug Stores
ROSLYNE SCHULMAN, Director, Policy Development, American Hospital Association
RICHARD A. SERINO, Distinguished Visiting Fellow, National Preparedness Leadership Initiative; Senior Advisor, Harvard University School of Public Health
ALAN SINISCALCHI, Surveillance Coordinator for Influenza, Bioterrorism, and Public Health, State of Connecticut Department of Public Health; Representative, Council of State and Territorial Epidemiologists
MONCEF M. SLAOUI, Chairman, Global Vaccines, GlaxoSmithKline (until May 2017)
DAVID J. SMITH, Deputy Assistant Secretary of Defense, Health Readiness, Policy and Oversight, U.S. Department of Defense (until May 2017)
W. CRAIG VANDERWAGEN, Co-Founder and Director, East West Protection, LLC
JENNIFER WARD, President, Trauma Center Association of America
COLE WEEKS, Deputy Director, Office of Human Services Emergency Preparedness and Response, Administration for Children and Families, U.S. Department of Health and Human Services (until May 2017)
JOHN WIESMAN, Secretary of Health, Office of the Secretary, Washington State Department of Health; Representative, Association for State and Territorial Health Officials
GAMUNU WIJETUNGE, EMS Specialist, Office of Emergency Medical Services, National Highway Traffic Safety Administration, U.S. Department of Transportation
MATTHEW K. WYNIA, Director, Center for Bioethics and Humanities, University of Colorado Denver
Health and Medicine Division Staff
JUSTIN SNAIR, Senior Program Officer (until September 2017)
LISA BROWN, Program Officer
MORGAN BONAME, Associate Program Officer (until January 2018)
CLAIRE GIAMMARIA, Associate Program Officer (from February 2017)
JOANNA ROBERTS, Research Associate (until August 2017)
ALEXA EDMIER, Research Assistant (until November 2017)
ALEX REPACE, Senior Program Assistant
ANDREW M. POPE, Director, Board on Health Sciences Policy
Reviewers
This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process.
We thank the following individuals for their review of this proceedings:
KATIE SCHEMM DWYER, National Association of County & City Health Officials
DOUG HALLEY, CrossTown Connect
PUNEET KHAN, The Cadmus Group LLC
LEESA LIN, Harvard T.H. Chan School of Public Health
GAMUNU WIJETUNGE, National Highway Traffic Safety Administration, U.S. Department of Transportation
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by ELI Y. ADASHI, Brown University.
He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.
Contents
Organization of the Proceedings
2 A BRIEF OVERVIEW OF HEALTH SECURITY THREATS AND PROGRAMS
3 PROPOSED PRIORITIES AND PERSISTENT CHALLENGES RELATED TO HEALTH SECURITY
Health Care and Public Health Critical Infrastructure Protection
Funding for Health Security Programs
Intersection Between Domestic and Global Health Security
Vulnerable Populations and Community Resilience
4 UNDERLYING ISSUES IN HEALTH SECURITY
Adaptive and Technical Challenges
Competing Priorities and Perceptions
Difficulty Defining Goals and Interpreting Progress
Lack of Understanding and Awareness by Those with Authority
Lack of Institutional Memory and Long-Term Connectivity
Reliance on Activation of Redundant Systems
5 POTENTIAL STRATEGIES FOR STRENGTHENING THE NATION’S HEALTH SECURITY
Promoting a Culture of Learning and Sharing
Building the Evidence Base for Policy and Operations
Encouraging the Integration of Systems
Optimizing the Exchange of Information
Acronyms and Abbreviations
ASPR |
Assistant Secretary for Preparedness and Response |
BARDA |
Biomedical Advanced Research and Development Authority |
CBRN |
chemical, biological, radiological, or nuclear |
CDC |
U.S. Centers for Disease Control and Prevention |
CIP |
Critical Infrastructure Protection |
DHS |
U.S. Department of Homeland Security |
DoD |
U.S. Department of Defense |
EHR |
electronic health record |
EMS |
emergency medical services |
FDA |
U.S. Food and Drug Administration |
FEMA |
Federal Emergency Management Agency |
FY |
fiscal year |
GHSA |
Global Health Security Agenda |
HHS |
U.S. Department of Health and Human Services |
HIE |
health information exchange |
HPP |
Hospital Preparedness Program |
ICS |
incident command system |
IHR |
International Health Regulations |
IRB |
institutional review board |
IT |
information technology |
JHSPH |
Johns Hopkins Bloomberg School of Public Health |
MCM |
medical countermeasure |
MERS-CoV |
Middle Eastern respiratory syndrome coronavirus |
MRC |
Medical Reserve Corps |
NACCHO |
National Association of County & City Health Officials |
NIH |
National Institutes of Health |
NLM |
National Library of Medicine |
PHEF |
public health emergency fund |
PHEMCE |
Public Health Emergency Medical Countermeasure Enterprise |
PHEP |
Public Health Emergency Preparedness |
PULSE |
patient unified lookup system for emergencies |
ROI |
return on investment |
USAID |
U.S. Agency for International Development |
WHO |
World Health Organization |