– Executive Summary –


For over 15 years, public health departments have been receiving federal funding to prepare for responses to public health emergencies.[1]  Public health departments submit written response plans as stipulated by grant requirements, but these plans are not examined for their ability to carry out a successful emergency response.  Nor are they adequately assessed for their operational content; as a result, when tested in a real-world emergency, the response incurs considerable delays with mitigation and reaching a recovery phase.  In fact, several real-world public health emergencies were not planned for, which led to a delay during their respective response.  This lack of planning placed a further burden not only on the public health system, but on other responder systems such as healthcare, the fire service, and emergency medical services.  The diseases that caused these public health emergencies were in existence for many decades and had there been a clear, definable set of planning components that pre-identified gaps, this would have led to a better response outcome.  

It is entirely possible to measure and assess the quality of public health preparedness plans and it is being done in certain, more restricted, settings. Seventy-two health departments in the United States receive additional funding via the CDC’s Cities Readiness Initiative.[2] These jurisdictions are required to submit written plans specific to medical countermeasures distribution and dispensing to the public.[3]  More important, these particular written plans are measured for operability on a biannual basis.[4]  Taking this best practice and applying it with an all-hazards approach for all health departments can lead to response plans that expeditiously resolve a public health emergency. The mere submission of plans does not make public health better prepared.


Public health departments cannot continue to receive funding without producing defensible documentation that demonstrates their ability to efficiently respond to a public health emergency.  Response plans must be thoroughly measured and assessed for operational content, either through real-world incidents or planned exercises.  This thesis introduces a resource for public health departments that will help to develop functional response plans.  As a result, the U.S. government can demonstrate fiscal accountability while defending the nation against intentional, accidental, and natural threats.


Over the last ten years, there have been three global public health emergencies:  the 2009 novel H1N1 pandemic influenza, the 2015 Ebola virus, and the 2016 Zika virus.[5]  These incidents serve as case studies to assess for lessons learned and identify planning gaps.  Two of the three emergencies—the Ebola virus and the Zika virus—did not have any preparedness plans prior to the response; yet they were emerging in other countries decades before arriving in the United States.[6]  Health officials were blindsided when the novel H1N1 influenza virus emerged in the spring of 2009.  Preparedness planning practitioners were expecting H5N1 avian flu to have a global impact in the world.[7]  As a result, response plans were written to that effect and did not address the possibility of a novel, non-avian flu emerging with virulent spread.  While not every possible aspect can be planned for every disease, there are basic planning considerations regardless of the specific disease or pathogen in question.

A review of the literature reveals evidence of these planning gaps, and even the absence of plans altogether.  Subsequently, further review exposed the impacts that the significant gaps had on previous emergency responses.  Equally, research conducted for this thesis found a model practice in the CDC’s Cities Readiness Initiative (CRI) local technical assistance review process that resulted in a successful deployment of medical countermeasures during the H1N1 novel influenza virus response.[8] Each disease from the case studies rendered different types of planning resources.  Multiple guidance documents, planning checklists, and CDC websites were researched in order to extract pertinent and relative planning elements to insert into a prototype tool.  While there were several different checklists for pandemic flu planning, each was in a different webpage location and had to be combined in order to be useful and create a comprehensive plan.  Guidance documents for Zika and Ebola were labeled as archived content and did not include usable checklists but provided planning considerations, including actionable lists.   


This research determined that without pre-established response plans and without a comprehensive list of planning elements, public health practitioners struggle through an emergency response.   Further exploration found that planning resources are scattered and not user-friendly.  In other words, public health planners are forced to hunt through various resources and websites to piece together components to develop a response plan.  In addition, these resources are guidelines and/or planning templates that have not been formally tested for practicality.  They are not mandated, but rather mere suggestions and guidelines to consider for plan writing.  There is no auditing process that ensures the crucial components to a successful response are contained in its associated plan. With no standardization, planners are left to their own devices and varied interpretation methods in order to create a plan.

While there was a lack of standardization and consistency in the planning guidance, there was one practice that provided successful response outcomes for CRI recipients.  The local technical assistance review for CRIs offered a set of prescribed planning elements that were required content for their medical countermeasures response plans.[9]  Taking this concept, planning elements were placed into the prototype auditing tool, and lessons learned from the three case studies were tested against it.   The results revealed that the lessons learned could have been avoided if the audit tool was in place prior to the disease outbreak.  Due to the complexity of diseases, especially novel and emerging ones, there are unknowns that are impossible to prepare for.  However, there are basic fundamentals of disease proliferation and emergency response that health practitioners can be prepared for, which are included in the prototype. 


 Results from the case studies confirm public health is not prepared for novel, emerging diseases.  The nation’s public health infrastructure lacks formalized, pre-established decision-making processes.  Therefore, when responding to these emergencies, public health consistently experiences barriers that prevent a swift resolution.  However, the following recommendations to the CDC will improve upon the current planning practices and ensure the nation is better prepared for the next significant public health emergency.

1. Consolidate Planning Tools into One Document Per Hazard in One Retrievable Location

Public health preparedness planners are able to draft concise, operational response plans when resources for each hazard are succinct and explanatory.  When all planners are utilizing the same resources, there is consistency during emergency responses.  Placing these resources at the federal level provides access to all state, territorial, tribal, and local health departments.

2. Adopt an All-Hazards Audit Tool to Measure Response Plans

Utilizing an all-hazards audit tool ensures that plans are measured consistently throughout the country.  The tool will assess the status of preparedness levels of each health department that receives grant funding.  The tool will designate each listed planning requirement as completed, in progress, or not started.  This enables the health departments to quickly identify their planning gaps and prioritize their mitigation measures. 

3. Monitor Preparedness Plans On a Biannual Basis 

Establishing a schedule in association with an auditing process ensures that there is forward progress to improve the preparedness levels for all health departments.  Utilizing the data from the audit results allows the CDC to assess the need for more grant funding and would possess tangible evidence to support this request to the U.S. government.  Consistent use of the audit tool would provide the CDC with invaluable feedback that includes identifying when the tool and planning resources require updates; and when health departments are unable to achieve completion status in a reasonable time and need further assistance.  This practice confirms accountability of grant requirements and maintains fiscal responsibility to the U.S. government and its citizens.

[1] “CDC’s Public Health Emergency Preparedness Program: Every Response Is Local,” Center for Preparedness and Response, October 7, 2021, https://www.cdc.gov/phpr/whatwedo/phep.htm.

[2] “Cities Readiness Initiative,” State and Local Readiness, December 18, 2020, https://www.cdc.gov/cpr/readiness/mcm/cri.html.

[3] “Operational Readiness Review,” State and Local Readiness, November 2, 2021, https://www.cdc.gov/cpr/readiness/orr.html.

[4] Centers for Disease Control and Prevention, Public Health Emergency Preparedness (PHEP) Operational Readiness Review Guidance, Budget Period 1 Supplemental July 1, 2018 to June 30, 2019 (Atlanta, GA: Centers for Disease Control and Prevention, 2018), 177, https://www.cdc.gov/cpr/readiness/00_docs/CDC_ORR_Guidance_September2018_Final_508_9.11.18.pdf.

[5] As of this writing, the novel coronavirus pandemic response, (COVID-19) is ongoing; it is too early to have relevant data from this outbreak.

[6] Alexandra Phelan and Lawrence O. Gostin, “On Zika Preparedness and Response, the US Gets a Failing Grade,” Health Affairs (blog), April 28, 2016, https://www.healthaffairs.org/do/10.1377/hblog20160428.054662/full/.

[7] Association of Public Health Laboratories, Lessons from a Virus: Public Health Laboratories Respond to the H1N1 Pandemic (Silver Springs, MD: Association of Public Health Laboratories, 2011), 29, https://www.aphl.org/aboutAPHL/publications/Documents/ID_2011Sept_Lessons-from-a-Virus-PHLs-Respond-to-H1N1-Pandemic.pdf.

[8] Centers for Disease Control and Prevention, Division of Strategic National Stockpile: Local Technical Assistance Review Tool Users Guide (Atlanta, GA: Centers for Disease Control and Prevention, 2010), 3, https://health.mo.gov/emergencies/sns/pdf/Local-TAR-Guide-January2010.pdf.

[9] Centers for Disease Control and Prevention, 3.

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