Department of Health and Human Services 
 
 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
HHS P H
    UBLIC  EALTH AND 
 
M S
  EDICAL  ERVICES 
 
E S
MERGENCY  UPPORT 
 
 
P  
REPAREDNESS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
November 2012 
OEI-04-11-00260 
 
  EXECUTIVE SUMMARY:  HHS PUBLIC HEALTH AND MEDICAL SERVICES 
EMERGENCY SUPPORT PREPAREDNESS 
OEI-04-11-00260 
 
 
WHY WE DID THIS STUDY  
 
In 2010, the Council of the Inspectors General on Integrity and Efficiency published An 
IGs Guide for Assessing Federal Response Capabilities, which recommended that 
Federal agencies assess their emergency preparedness.  Within the Department of Health 
and Human Services (HHS), the Office of the Assistant Secretary for Preparedness and 
Response (ASPR) organizes HHSs resources and response as the Coordinator and 
Primary agency responsible for Emergency Support Function-8 (ESF-8), Public Health 
and Medical Services.  HHS also has responsibilities as a Support agency for nine 
additional ESFs.       
 
HOW WE DID THIS STUDY 
 
We reviewed ASPRs and other Federal agencies documentation and information 
request responses regarding HHS participation in ESF preparedness activities.  We 
determined the total number of incidents to which HHS deployed resources in 2010 and 
2011 and reported responses from ASPR and States regarding HHSs response to three 
selected incidents. 
 
WHAT WE FOUND 
 
HHS has participated in preparedness activities to fulfill its Coordinator, Primary, and 
Support agency ESF responsibilities.  However, other ESF Coordinator and Primary 
agencies did not always report having a clear understanding of HHSs Support agency 
role and available resources during incident response.  Further, HHS deployed resources 
for 28 incidents in 2010 and 2011 and demonstrated its ability to effectively fulfill its 
ESF-8 responsibilities for 3 incidents we reviewed in 2010 and 2011.  However, States 
reported receiving multiple requests from HHS for the same information, which were 
burdensome during incident response. 
 
WHAT WE RECOMMEND 
 
We recommend that ASPR:  (1) continue to increase communication with the ESF 
Coordinator and Primary agencies it serves as a Support agency, and (2) coordinate HHS 
requests from HHS Staff Divisions and Operating Divisions to reduce the burden on 
States during incident response.  ASPR concurred with both recommendations. 
 
 
 
 
 
  TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................6 
Findings......................................................................................................10 
HHS has participated in preparedness activities to fulfill its  
Coordinator, Primary, and Support agency ESF responsibilities ..........10 
HHS deployed resources to 28 incidents in 2010 and 2011 and 
demonstrated its ability to effectively fulfill its ESF responsibilities  
for 3 selected incidents we reviewed in 2010 and 2011 ......................17 
Conclusion and Recommendations ............................................................24 
Agency Comments and Office of the Inspector General Response .....26 
Appendixes ................................................................................................27 
A:  Emergency Support Functions .......................................................27 
B:  Seventeen Core Functional Areas of Emergency Support  
Function-8 ............................................................................................31 
C:  National Planning Scenarios ..........................................................36 
D:  The National Planning Scenario Playbooks and Emergency 
Support Function-8 ..............................................................................37 
E:  Department of Health and Human Services Response to Three 
Selected Incidents in 2010 and 2011 ....................................................39 
F:  2010 and 2011 Incidents to Which the Department of Health and 
Human Services Deployed Resources .................................................50 
G:  Agency Comments .........................................................................51 
Acknowledgments......................................................................................57 
 
  OBJECTIVES 
1.  To determine whether the Department of Health and Human Services 
(HHS) has prepared to provide public health and medical services to 
fulfill its emergency support responsibilities. 
2.  To report the total number of emergencies and disasters (i.e., incidents) 
to which HHS deployed resources in 2010 and 2011 and describe 
HHSs response to three selected incidents.  
BACKGROUND 
In 2010, the Council of the Inspectors General on Integrity and Efficiency 
(CIGIE), a group of Inspectors General (IG) from agencies across the 
Federal Government, created An IGs Guide for Assessing Federal 
Response Capabilities (IGs Guide).1  The IGs Guide recommends that 
IGs assess their Federal agencys emergency preparedness capabilities.2  It 
provides a framework for Offices of Inspectors General to conduct 
independent assessments of their department or agencys (agency) incident 
response capabilities.  The IGs Guide is based on the National Response 
Framework (NRF), Emergency Support Functions, and the National 
Planning Scenarios.3  Recent incidents such as Hurricane Sandy 
emphasize the need for Federal agencies to assess their emergency 
response capabilities. 
NRF 
When an incident occurs that exceeds or is expected to exceed State, 
territory, tribal, or local resources, these entities may request Federal 
assistance.4  The Federal Government uses the NRF, which was developed 
through coordination of the Department of Homeland Security (DHS), to 
organize and coordinate its response and provide supplementary resources 
to affected areas.  The NRF establishes a comprehensive, national,  
 
1 
CIGIE comprises all Inspectors General whose offices are established under the Inspector 
General Act of 1978 (5 U.S.C. App.), those that are Presidentially appointed/Senate 
confirmed, and those that are appointed by agency heads (designated Federal entities).  
CIGIE, Mission and Organization.  Accessed at http://www.ignet.gov/cigie1.html#mission on 
July 11, 2012.   
2 
The IGs Guide includes researchable questions that agencies can use as a starting point to 
frame their assessments.  However, all questions included in the IGs Guide may not be 
applicable to all agencies.  CIGIE, An IGs Guide for Assessing Federal Response 
Capabilities (August 2010).  Accessed at 
http://www.ignet.gov/randp/igguidefederalresponse0810.pdf on April 12, 2011. 
3 
CIGIE, op. cit., pp. 78. 
4
 States include U.S. districts and territories. 
1 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260) 
  all-hazards approach to domestic incident responses.5  An all-hazards 
approach focuses on general capability-based planning that can be applied 
to a variety of incidents.6, 7  Federal agencies may also move resources 
close to an area or event where an incident may occur in anticipation of 
needs.8  For example, HHS deployed medical personnel to East Coast 
States in anticipation of Hurricane Irenes landfall. 
The NRF serves as a guide for organizing efforts of Federal, State, tribal, 
and local governments, as well as nonprofit and for-profit private-sector 
organizations (e.g., American Red Cross, private businesses).  The NRF 
outlines each Federal agencys role during an incident and organizes 
agencies within 15 Emergency Support Functions (ESF).9 
ESFs 
The 15 ESFs within the NRF assign responsibilities to agencies.10  
Appendix A provides a listing of each ESF and identifies assigned 
responsibilities. 
ESFs are activated by a declaration from the President or a Federal agency 
based on the needs resulting from an incident.11  Once ESFs are activated, 
agencies with ESF responsibilities can provide requested resources to 
affected States, territories, tribes, and localities.12  States, territories, tribes, 
and localities are not required to request or accept Federal resources 
during an incident response.  If these entities request Federal resources, 
the ESF Coordinator and Primary agencies consider the requests and 
provide resources as they are available and necessary.  
 
5 
DHS, National Response Framework, January 2008 (which superseded the National 
Response Plan, 2004), pp. 1, 28.  Accessed at 
http://www.fema.gov/pdf/emergency/NRF/NRF-core.pdf on March 7, 2011. 
6
 DHS, National Preparedness Guidelines, September 2007, p. 3.  Accessed at 
http://www.fema.gov/pdf/emergency/NRF/NRF-core.pdf on June 21, 2011.  DHS, National 
Response Framework, p. 31. 
7 
DHS, Presidential Policy Directive8.  Accessed at 
http://www.dhs.gov/xabout/laws/gc_1215444247124.shtm on November 7, 2011.  In March 
2011, Presidential Policy Directive-8 (i.e., PPD-8) was released; it emphasizes integrated, 
risk-based preparedness planning for all agencies and organizations involved in incident 
response.  The NRF is being revised as a result of PPD-8.  
8
 DHS, National Response Framework, p. 11. 
9 
DHS, National Response Framework, pp. 34. 
10 
Ibid., p. 29.  The ESFs can be found at http://www.fema.gov/emergency/NRF/#. 
11 
Upon the advice of the Federal Emergency Management Agency (FEMA) Administrator, 
the President may declare a disaster.  ESFs are activated on the basis of the needs caused by 
the incident.  42 U.S.C.  5170, 5191.  A Federal agency may also declare a disaster or 
emergency (e.g., the Secretary of HHS may declare a public health emergency) and activate 
ESFs to which the agency is assigned.  Public Health Service Act,  319 (42 U.S.C.  247d); 
DHS, National Response Framework., p. 60. 
12 Ibid., pp. 2426. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  2 
  Each ESF divides Federal responsibilities among agencies on the basis of 
their capabilities.  Federal agencies are designated as Coordinator, 
Primary, and/or Support agencies.  Each ESF has one Coordinator agency, 
but may have one or more Primary agencies and multiple Support 
agencies and organizations.13  For example, ESF responsibilities require 
that, as a Coordinator and Primary agency, HHS provide medical 
personnel when an incident occurs.  As a Support agency, the Department 
of Agriculture may provide food safety and inspection services for the 
same incident.  For-profit and nonprofit private-sector organizations, 
hereinafter referred to as organizations, may also provide assistance as 
Support organizations in an ESF response.   
Throughout the preparedness, response, and recovery phases of an 
incident, the Coordinator agency is responsible for managing and 
organizing the resources provided by Primary and Support agencies and 
organizations.14  Primary agencies provide specific resources identified in 
the ESF (e.g., medical personnel to an affected area) and collaborate with 
other Federal, State, territory, tribal, and local governments and 
organizations that have other available resources.  Support agencies and 
organizations are assigned ESF responsibilities on the basis of their ability 
to provide supplementary resources to the Primary agency responsible for 
the ESF.15     
Coordinator, Primary, and Support agencies and organizations engage in a 
variety of activities to prepare for an incident.  Federal emergency 
preparedness guidance documents outline these five preparedness 
activities, which generally include:   
  developing written incident response plans (e.g., scenario 
playbooks, field operations guides, strategies to obtain and deploy 
staff and equipment);  
  participating in training and exercises;16   
  purchasing equipment and procuring contracts to support incident 
response;  
 
13
 The same agency within an ESF is often assigned to be both Coordinator and a Primary 
agency and leads ESF responses based on its capabilities.  For example, HHS serves as a 
Coordinator and a Primary agency for ESF-8. 
14
 DHS, Emergency Support Function Annexes Introduction, pp. iiiv. 
15 Ibid. 
16 
Exercises include tabletop and live exercises.  Tabletop exercises use HHS plans and 
representations of people and resources to simulate incident response.  Live exercises also use 
HHS plans but involve personnel and volunteer participants to simulate incident response. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  3 
    coordinating internally as well as externally with other ESF 
agencies; and  
  conducting situational and readiness assessments.17, 18  
These activities are referred to as preparedness activities hereinafter.   
HHSs ESF Responsibilities  
HHS is the Coordinator and Primary agency for ESF-8, Public Health and 
Medical Services.  As such, it manages the Federal response to an incident 
for activities in these areas.  HHS also provides public health and medical 
services as a Support agency for nine additional ESFs (see Appendix A). 
ESF-8 is the mechanism for coordinated Federal assistance to supplement 
State, tribal, and local resources in response to a public health and medical 
disaster. 19  HHS conducts national situational and readiness assessments 
to prepare to respond to States public health and medical needs when 
incidents occur.  Further, HHS may provide ESF support to States, 
territories, tribes, and localities in the form of technical and situational and 
readiness assessment assistance, when requested.  Within HHS, the Office 
of the Assistant Secretary for Preparedness and Response (ASPR) 
organizes HHSs preparedness resources and response activities.20   
Specifically, ASPR coordinates with HHS Staff Divisions (e.g., ASPR, 
Assistant Secretary for Health (ASH)) and Operating Divisions (e.g., 
Center for Disease Control and Prevention (CDC), Food and Drug 
Administration (FDA)) to ensure that HHS is prepared to provide public 
health and medical resources when incidents occur.21  
 
17
 Information pertinent to this review was taken from the IGs Guide and consolidated into 
the five prepared activities.  CIGIE, loc. cit. 
18 
DHS, Emergency Support Function Annexes Introduction, pp. iiiv; DHS, National 
Response Framework; DHS, National Preparedness Guidelines. 
19 
DHS, ESF-8Public Health and Medical Services Annex, p. 1.  Accessed at 
http://www.fema.gov/pdf/emergency/NRF/NRFesf08.pdf on May 13, 2011. 
20
 HHS is made up of the Office of the Secretary, which is divided into 16 Staff Divisions, 
and 11 Operating Divisions.   Operating and Staff Divisions perform tasks that include 
research, public health work, food and drug safety, grants funding, and health insurance.  Staff 
Divisions provide direct support to the Secretary of HHS.  For example, ASPR supports the 
Secretarys mission through its preparedness and response efforts.  HHS, HHS Operating and 
Staff Divisions.  Accessed at http://www.hhs.gov/about/ on May 15, 2012.    
21 
ASPR, Office of the Assistant Secretary for Preparedness and Response.  Accessed at 
http://www.phe.gov/about/aspr/Pages/default.aspx on May 11, 2011. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  4 
  HHSs ESF-8 responsibilities include 17 core functional areas of public 
health and medical services (e.g., assessment of public health and medical 
needs, health surveillance, and medical care personnel).22, 23   
Appendix B contains detailed descriptions of the 17 core functional areas 
as they appear in the NRF. 
HHS as the ESF-8 Coordinator and Primary Agency.  HHS is charged 
with continually assessing and coordinating its resources and capabilities 
to ensure that it is prepared to fulfill its responsibility for the 17 core 
functional areas of public health and medical services.24, 25  If HHS does 
not have the resources or capability to fulfill the 17 core functional areas, 
it can request assistance from designated Support agencies and 
organizations.  Sixteen ESF Support agencies and organizations are tasked 
with providing supplementary resources to HHS, as needed.26, 27 
HHS as an ESF Support Agency.  When an incident occurs and HHS is not 
the Coordinator or Primary agency, it provides supplementary resources, 
as needed, for nine additional ESFs (see Appendix A).  HHS provides 
public health and medical services as a Support agency similar to those 
that it provides as a Primary agency for ESF-8.  For example, if ESF-10 
(Oil and Hazardous Materials Response) is activated, the Environmental 
Protection Agency (EPA), as the ESF-10 Primary agency, can request that 
HHS provide supplementary medical personnel.28, 29  Seven of the nine 
ESFs list which public health and medical services HHS must be prepared 
to provide as a Support agency.30 
 
22
 DHS, ESF-8 Annex, pp. 48. 
23 
ESF-8 includes a core functional area entitled Worker Safety and Health.  The Department 
of Labor is the lead Federal agency for this core functional area, and HHS serves as a Support 
agency.  Therefore, the Worker Safety and Health core functional area is not included in our 
list of HHSs 17 core functional areas of ESF-8. 
24
 DHS, Overview:  ESF and Support Annexes Coordinating Federal Assistance In Support of 
the National Response Framework.  Accessed at 
http://www.fema.gov/pdf/emergency/NRF/NRFoverview.pdf on November 4, 2011. 
25 
DHS, ESF-8 Annex, p. 9. 
26
 Ibid., pp. iv, 10.  
27 
ASPR, Response Coordination.  Accessed at 
http://www.phe.gov/Preparedness/responders/soc/Pages/coordination.aspx on June 22, 2011.  
28 
ASPR, Response Coordination; DHS, Emergency Support Function Annexes Introduction, 
p. iv. 
29 
DHS, ESF-10 Oil and Hazardous Materials Response Annex.  Accessed at 
http://www.fema.gov/pdf/emergency/NRF/NRFesf10.pdf on August 24, 2011. 
30 
DHS, NRF Resource Center.  Accessed at http://www.fema.gov/emergency/NRF/# on 
August 24, 2011.  The following ESFs list resources that HHS should be prepared to provide 
as a Support agency during an ESF response:  ESF-3, - 6, - 7, - 9, -10, -11, and -14.  ESF-5 
and -15 call for general HHS public health and medical support. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  5 
  National Planning Scenarios   
DHS created the 15 National Planning Scenarios to illustrate the potential 
scope, magnitude, and complexity of a range of major events for which the 
nation should be prepared.  The 15 National Planning Scenarios are one of 
four parts of the National Preparedness Guidelines.31  DHS created the 
National Preparedness Guidelines to assist Federal, State, and local 
governments and organizations in coordinating incident preparedness and 
response.  Agencies may also develop written plans to address incidents 
that may require unique plans and resources.32   
Similar to the NRF, the 15 National Planning Scenarios provide guidance 
on preparedness efforts for a range of potential incidents.33  The NRF 
provides general guidance regarding collaboration during incident 
response, and the scenarios provide guidance specifically regarding 
preparedness and response to incidents, such as a major hurricane.  See 
Appendix C for a complete list of the 15 National Planning Scenarios. 
METHODOLOGY 
Scope 
We determined whether HHS has prepared to fulfill its Coordinator and 
Primary agency ESF-8 responsibilities.  We also determined whether HHS 
addressed the 15 National Planning Scenarios through its participation in 
preparedness activities.  Further, we determined whether HHS participated 
in preparedness activities with other ESF Coordinator and Primary 
agencies for the nine additional ESFs it serves as a Support agency.   
We also reported the total number of incidents to which HHS deployed 
resources in 2010 and 2011.  We then took an indepth look at three 
selected incidents to which HHS responded.   
We used the IGs Guide as a framework for our evaluation and addressed 
categories from the guide that pertained to HHSs responsibilities.  We 
reviewed the following categories:  participating in activities regarding the 
15 National Planning Scenarios, developing written plans, participating in 
training and exercises, purchasing equipment and procuring contracts, 
 
31
 The four parts that make up the National Preparedness Guidelines are:  National 
Preparedness Vision, National Planning, Universal Task List, and Target Capabilities List.  
DHS, National Preparedness Guidelines, pp. iii, 31.  Accessed at 
http://www.dhs.gov/files/publications/gc_1189788256647.shtm on June 25, 2012.  DHS, 
National Response Framework, pp. 31, 73. 
32
 ASPR, Playbooks Introduction.  Accessed at 
http://www.phe.gov/Preparedness/planning/playbooks/rdd/Pages/default.aspx on April 20, 
2012, p. 3.   
33 
DHS, National Preparedness Guidelines, p. 31. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  6 
  coordinating internally among HHS Staff and Operating Divisions and 
externally with other ESF agencies, and conducting situational and 
readiness assessments.  We did not include categories from the IGs Guide 
regarding financial accountability and recovery operations.34 
Data Collection and Analysis 
HHS as a Coordinator and Primary Agency.  We requested information 
and collected documentation (e.g., After-Action Reports describing events 
that occurred in the National Level Exercise and service contracts 
procured by HHS for development of an Internet application) from ASPR 
regarding participation in preparedness activities to fulfill HHSs 
Coordinator and Primary responsibilities for the 17 core functional areas 
of ESF-8.  We also requested information and collected documentation 
from ASPR on HHSs participation in preparedness activities to respond to 
the 15 National Planning Scenarios.  ASPR coordinated with other HHS 
Staff Divisions and Operating Divisions, as needed, to fulfill our request.  
We analyzed HHSs responses and documentation to determine whether 
HHS participated in preparedness activities to fulfill the 17 core functional 
areas of ESF-8.  If HHS had addressed a core functional area by 
participating in each of the five preparedness activities at least once (i.e., 
developing written incident response plans, participating in training and 
exercises, purchasing equipment and procuring contracts, coordinating 
internally and externally, and conducting situational and readiness 
assessments), we considered HHS as having prepared for that core 
functional area.  We then report the number of core functional areas in 
which HHS had prepared.  Further, we describe each of the five 
preparedness activities, how HHS engaged in them, and the core 
functional areas that correlated with them.  
We also analyzed HHSs responses and documentation to determine 
whether HHS has participated in each of the five preparedness activities at 
least once to address the 15 National Planning Scenarios.  
HHS as a Support Agency.  We coordinated with ASPR to identify 
appropriate points of contact for the ESF Coordinator and Primary 
agencies for the nine additional ESFs.  We requested and received 
information from these Coordinator and Primary agencies for all nine 
ESFs.  We collected documentation from the ESF Coordinator or one or 
 
34
 HHS OIGs Office of Audit Services conducts audits specifically addressing financial 
accountability.  In September 2011, DHS introduced the National Disaster Recovery 
Framework in which HHS has specific recovery responsibilities separate from what is 
included in the IGs Guide.  DHS, National Disaster Recovery Framework.  Accessed at 
http://www.fema.gov/pdf/recoveryframework/ndrf.pdf on August 13, 2012.  
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  7 
  more of the ESFs Primary agencies regarding HHSs involvement in 
planning and response activities as a Support agency.35 
We analyzed responses and documentation from HHS and the information 
provided by other ESF Coordinator and Primary agencies to determine 
whether HHS has prepared to fulfill its Support agency responsibilities.   
HHSs Support to States During 2010 and 2011 Incidents.  We requested 
and received from ASPR the total number of incidents to which HHS 
deployed resources in 2010 and 2011.  We also requested that ASPR 
identify selected incidents to which HHS deployed resources and to which 
it responded as an ESF-8 Coordinator and Primary agency in 2010 and 
2011.  Because some incidents require resources from only a portion of the 
17 core functional areas, we asked that ASPRs list include the smallest 
number of incidents that collectively required resources from all 17 core 
functional areas.  ASPR identified three incidents:  Red River flooding in 
North Dakota in March 2010; a tornado in Joplin, Missouri, in May 2011; 
and Hurricane Irene along the East Coast in August 2011.  ASPR 
identified  
17 States that were affected by these incidents.36  We then requested 
information from State officials about their requests for and receipt of 
HHS support during these incidents.  All 17 States responded to our 
request.   
We also analyzed State responses to open-ended questions about HHSs 
response during incidents, the resources HHS provided, and any successes 
or challenges the States experienced in working with HHS.  We report 
whether States indicated that HHS provided them resources and present 
examples of the States experiences working with HHS.  We also 
requested information from ASPR regarding the ESF-8 resources provided 
by HHS to States affected by these incidents.    
Limitations 
We assessed HHSs preparedness activities based on self-reported data 
from Federal agencies and States.  We did not independently verify HHSs 
reported preparedness activities.  We did not determine HHSs capability 
to respond to an incident, or whether the reported response was sufficient. 
 
35
 Each ESF may have more than one Coordinator and Primary agency.  We requested 
information from all ESF Coordinator and Primary agencies for which HHS is a Support 
agencya total of 18 points of contact.  We received responses from at least one Coordinator 
or Primary agency for each ESF that HHS supports.  We received multiple responses from 
agencies for some ESFs.  The total number of responses was 13. 
36
 The Red River flooding affected North Dakota.  The Joplin tornado affected Missouri.  
States affected by Hurricane Irene were Connecticut, Delaware, the District of Columbia, 
Maryland, Massachusetts, New Jersey, New York, North Carolina, Pennsylvania, Puerto Rico, 
Rhode Island, South Carolina, U.S. Virgin Islands, Vermont, and Virginia. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  8 
  Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  9 
  FINDINGS 
HHS has participated in preparedness activities to 
fulfill its Coordinator, Primary, and Support agency 
ESF responsibilities 
The ESF framework within the NRF describes HHSs responsibility to 
fulfill the 17 core functional areas of ESF-8 as a Coordinator, Primary, and 
Support agency.  HHS has led and supported other agencies in five 
preparedness activities that Federal guidance documents describe as 
important to being prepared to respond to an incident.  These five 
preparedness activities are developing written plans; participating in 
training and exercises; purchasing equipment and procuring contracts to 
support incident response; coordinating internally among HHS as well as 
externally with other ESF agencies; and conducting situational and 
readiness assessments.   
HHS has developed written incident response plans  
HHS has created incident 
response plans for all 17 core 
functional areas of ESF-8.   
Further, HHSs National Planning 
Scenario playbooks and other 
written incident response plans 
address all the core functional 
areas.   
Specifically, HHS has developed 
playbooks for 14 of the 15 
National Planning Scenarios (see 
Appendix D).  Although no 
playbook has been written for the 
cyber security National Planning 
Scenario, HHS included incident 
response plans for cyber security  
  Photo provided by ASPR   
The Hurricane Playbook describes HHSs public 
health and medical services written incident 
response plans. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  10 
  in the 2010 Health Care and Public Health Sector Specific Plan and the 
2010 Sector Annual Report.37    
HHS has prepared other written incident response plans and technical and 
health care preparedness guidance documents that address topics 
including:  the Hospital Preparedness Program, medical movement of 
evacuees, National Veterinary Response Teams, disaster behavioral health, 
and National Disaster Medical System (NDMS) (i.e., medical personnel).  
HHS has also published the National Health Security Strategy and 
Implementation Plan, which outline a national vision and actions 
regarding public health and medical preparedness, response, and recovery 
capabilities. 
HHS has participated in incident response training and 
exercises 
HHS has participated 
in at least one training 
activity and exercise 
to ensure it is 
prepared to fulfill its 
responsibilities in all 
17 core functional 
areas of ESF-8. 
Exercises in a 
realistic setting 
provide personnel 
opportunities to use 
Photo provided by FEMA  
Health  care  workers rush to decontaminate a simulated victim   training and hone 
during an exercise at the Center for Domestic  Preparedness in  
skills they will need 
Anniston, Alabama.  These students were attending the  
Hospital Emergency Response Training for Mass Casualty   during incident 
Incidents course. 
response. For 
example, the U.S. Public Health Service (USPHS) has trained personnel to 
provide mass care (i.e., sheltering, feeding operations, emergency first aid, 
bulk distribution of emergency items, and collecting and providing 
information on victims to family members) to people affected by an 
incident.  USPHS maintains teams of trained personnel that can address 
specific needs during a response. 
 
37
 DHS and HHS, 2010 Sector CIKR Protection Annual Report for the Health Care and 
Public Health Sector. Accessed at 
http://www.phe.gov/Preparedness/planning/cip/Documents/2010cikrannualreport.pdf on  
April 20, 2012; ASPR, Health Care & Pubic Health Sector  Specific Plan. Accessed at 
http://www.phe.gov/Preparedness/planning/cip/Pages/ssp.aspx on April 20, 2012. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)   11 
  In 2010 and 2011, HHS reported that it conducted or participated in  
60 live and tabletop exercises.38  Three of the seven tabletop exercises that 
HHS conducted in 2011 focused on an anthrax dispersal scenario.  These 
exercises did not require participants to simulate the incident response.  
Instead, using visual aids for illustration, participants were invited to 
discuss roles and responsibilities that would be needed during a response.     
Additionally, 11 live anthrax dispersal scenario exercises in 2010 and 2011 
included other Federal and State agencies and organizations.  The 
exercises exposed gaps and demonstrated strengths in planning, training, 
and resources and allowed participants to examine policy and operational 
needs in responding to an aerosolized anthrax dispersal scenario. 
HHS and other Federal, State, tribal, and local governments and 
organizations participated in the National Level Exercise, a live annual 
exercise in which participants 
simulated incidents in real 
time.  The 2011 National 
Level Exercise focused on an 
earthquake scenario in which 
participants simulated an 
appropriate response.  For 
example, personnel used 
tangible resources and set up 
evacuation and alternative 
water supply stations.  Local 
responders communicated 
their needs to State and 
Federal agencies, which 
collaborated to provide 
resources for the response.  In 
Photo by SSG Brad Staggs 
Missouri National Guard members participated in  addition, HHS communicated 
the 2011 National Level Exercise, which took place 
with private-sector partners 
at Muscatatuck Urban Training Complex in 
Butlerville, Indiana.  and shared situational 
awareness information that assisted in rapid local response.  For example, 
HHS collaborated with organizations such as the American Red Cross to 
provide resources for medical surge response efforts. 
 
38
 HHS conducted and participated in 27 live and 3 tabletop exercises in 2010 and 23 live and 
7 tabletop exercises in 2011.   
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  12 
  HHS has purchased equipment and procured contracts to 
support incident response 
HHS has purchased at least one piece of equipment and procured contracts 
to fulfill its responsibilities in each of the 17 core functional areas of  
ESF-8.  Such equipment and contracts cover a wide range of areas.  For 
example, HHS has purchased equipment and procured contracts to 
assemble and maintain Disaster Medical Assistance Team (DMAT) caches.  
Items needed for the caches include pharmaceuticals, ventilators, 
defibrillators, communications equipment, and electronic medical record 
software.  Service contracts have been procured for the equipment in 
caches.  Caches are prepackaged for rapid deployment and are also 
strategically stored around the country so that they are readily available 
when an incident response is required.39  
HHS also has procured contracts for services to ensure it is able to fulfill 
its ESF-8 responsibilities.  For example, in 2011, HHS contracted with a 
vendor to develop an 
Internet-based 
application to help track 
medical care personnel.  
The application makes 
public health and 
medical volunteer 
credential information 
available to health care 
facilities when incidents 
occur.  It allows States 
credential information to 
Photo provided by ASPR  be linked, creating a 
A member of a DMAT sets up an NDMS cache with 
equipment and supplies needed to provide medical care.  single network for use 
nationwide. 
Further, HHS contracted with a vendor to conduct a national survey of 
medical equipment and supplies.  This survey determined the number of 
ventilators in acute care hospitals that could be used in mass casualty 
scenarios, such as a pandemic.   
 
39
 HHS has purchased equipment for caches in the following areas:  Basic IT/Telecom Kit, 
Critical Care, Disaster Medical Assistance Team, Disaster Portable Morgue Unit, Electronic 
Medical Record Kit, Family Assistance Center Team, Federal Medical Station, Incident 
Response Coordination Team, International Surgical Response Team, Mobile Medical Kit, 
National Medical Response Team, National Special Security Event, National Veterinary 
Response Team, and Personnel Support Kit. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  13 
  HHS has coordinated its incident response efforts internally 
and externally  
During 2010 and 2011, HHS provided internal and external coordination 
to fulfill its responsibilities in all 17 core functional areas of ESF-8.  HHS 
regularly coordinates internally with its Staff Divisions and Operating 
Divisions to ensure it is ready to respond when incidents occur.  For 
example, the Office of the Surgeon Generals Office of Force and 
Readiness and Deployment coordinates with USPHS teams regarding 
ESF-8 response.  USPHS has seven types of teams and the Office of the 
Surgeon Generals Office of Force and Readiness and Deployment 
frequently conducts meetings to update written incident response plans, 
training, and exercises regarding ESF-8 response responsibilities.40   
HHS also coordinates externally with other Federal, State, tribal, and local 
governments and organizations and participates in preparedness activities 
with them to 
ensure resources 
are provided 
through a 
coordinated 
response.  For 
example, in 2011, 
HHS coordinated 
with other Federal 
agencies, State, 
Photo provided by FEMA  and local 
Ambulances departed from Stewart Air Force Base to evacuate 
governments, and 
patients from New York hospitals after Hurricane Irene in August 
2011 under the Federal National Ambulance Contract.   organizations to 
 
establish procedures for joint delivery of veterinary services in preparation 
for an incident response through the Pets Multi-Agency Coordination 
System (Pets-MACS).  Through its participation in Pets-MACS, HHS 
coordinates with other agencies, governments, and organizations to deploy 
National Veterinary Response Teams to treat animals in need.   
In many instances, HHS must coordinate internally and externally to cover 
the same responsibility.  For example, in 2011, HHS coordinated with 
FEMA to develop the National Federal Ambulance Contract, which was 
developed to provide patient evacuation using private-sector ground and 
air ambulance services.  Coordination internally within HHS and with 
 
40
 The seven types of teams are Services Access, Rapid Deployment Force, Applied Public 
Health, Mental Health, Capitol Area Providers, National Incident Response, and Regional 
Incident Response. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  14 
  FEMA, and externally with private-sector ambulance service businesses, 
was necessary to develop this contract.   
HHS regularly conducts situational and readiness 
assessments to respond to an incident quickly 
The HHS Secretarys Operation Center (SOC) operates 24 hours a day, 
every day of the year, and maintains real-time situational and readiness 
assessments.  Through these assessments, HHS monitors potential and 
actual incidents requiring public health and medical resources within all 
17 core functional areas of ESF-8. 
 
 
To provide 
comprehensive 
assessments, the 
SOC conducts 
situational  
and readiness 
assessments 
before, during, 
and after an 
incident. 
Photo provided by 
ASPR 
HHSs Emergency Management Group staffs the SOC and maintains 
communication with Federal, State, territorial, tribal, and local 
governments, and other organizations.41  The Emergency Management 
Group provides real-time information to assist HHS Staff Divisions and 
Operating Divisions as they consider deploying resources before and 
during an incident.  Examples of regular SOC situational and readiness 
assessment activities include: 
  identifying emerging threats through public health data for special 
topics (e.g., West Nile virus, influenza activity).  When threats are 
identified, SOC personnel provide relevant information to HHS, other 
government agencies, and leaders of organizations; 
  tracking field reports received from Regional Emergency Coordinators 
(REC), HHS Operating Divisions, and other ESF-8 agencies that 
support State, territorial, tribal, and local incident response;   
 
41
 The Emergency Management Group consists of liaisons from HHS Staff Divisions and 
Operating Divisions and other Federal agencies. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  15 
    conducting conference and video calls to facilitate coordination and 
information sharing between HHS and deployed field personnel, such 
as the RECs, NDMS, and USPHS; and   
  preparing and coordinating situational assessments regarding HHS 
resources available for deployment in advance of and during 
prominent national events (e.g., Presidential inauguration, Super 
Bowl).  
HHS has participated in preparedness activities to fulfill its 
Support agency ESF responsibilities  
HHS has participated in preparedness activities for all nine of the 
additional ESFs it is required to support.42  Coordinator and Primary 
agencies from eight of the nine ESFs said that, as a Support agency, HHS 
is prepared to fulfill its responsibilities.  One ESF-3 agency, DOD-U.S. 
Army Corps of Engineers, said that it has not communicated with HHS 
regarding its Support agency role.   
Many of the preparedness activities in which HHS has participated as a 
Coordinator and Primary agency are the same as those HHS provides in its 
Support agency role.  For example, HHS participated in the 2011 National 
Level Exercise as an ESF-8 Coordinator and Primary agency and as a 
Support agency for nine additional ESFs.   
 
HHS also participated in exercises with Coordinator and Primary agencies 
for five of the nine ESFs for which it is a Support agency.43  For example, 
HHS participated as an ESF-7 Support agency in quarterly meetings of the 
Disaster Management Strategic working group with FEMA and the 
Government Services Administration.  HHS also provided public health 
and medical services resources requested by these agencies.  HHS 
provided many of the same core public health and medical services in each 
instance, with the distinction being who was responsible for leading the 
ESF response.  
Coordinator and Primary Agencies Did Not Always Report Having a 
Clear Understanding of HHSs Support Agency Role and HHSs Available 
Resources.   
Two of the eight ESF Coordinator and Primary agencies that reported 
HHS participation in preparedness activities as a Support agency indicated 
 
42
 Support agency preparedness activities include developing written incident response plans, 
conducting training and exercises, purchasing equipment and procuring contracts, and 
conducting situational and readiness assessments.  Internal and external coordination are not 
considered Support agency preparedness activities in this report.    
43
 ESF-5, -6, -7, -10, and -15 reported that HHS participated in exercises. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  16 
  that increased HHS communication regarding planning activities and 
available resources would improve its Support capabilities.  The ESF-9 
agency (FEMA-Urban Search and Rescue) stated that better 
communication of strategic information and preparedness planning and 
activities would improve HHSs performance as a Support agency.  The 
ESF-6 agency (FEMA-Individual Assistance Division) stated that 
improved communication about resources that HHS is able to provide 
could improve incident response.  For example, during an ESF-6 incident 
response, HHS can provide medical personnel as an ESF-6 Support 
agency.  FEMA stated that it would be helpful for HHS to communicate, 
as soon as possible during an incident response, the number of available 
HHS-authorized medical facilities and medical personnel.  Using this 
information, FEMA would be better able to determine whether additional 
facilities and medical personnel were needed.   
HHS deployed resources to 28 incidents in 2010 and 
2011 and demonstrated its ability to effectively fulfill 
its ESF responsibilities for 3 selected incidents we 
reviewed in 2010 and 2011  
HHS deployed resources to 15 incidents in 2010 and to 13 in 2011.  The 
incidents varied from mudslides in Kentucky to humanitarian missions in 
Hawaii after the 2011 earthquake and tsunami (see Appendix F).  HHS 
also provided resources for 20 prominent national events in 2010 and 
2011.44  These events ranged from the State of the Union address to the 
Cherry Blossom Festival.  In preparing to provide public health and 
medical services, HHS may position resources prior to incidents and 
events.     
Of the 28 incidents, we reviewed 3 that affected 17 States.  During these   
3 incidents, HHS demonstrated its ability to effectively fulfill all 17 core 
functional areas of its ESF-8 responsibilities.  The incidents were:   
  Red River flooding in North Dakota in March 2010; 
  Tornado in Joplin, Missouri, in May 2011; and 
  Hurricane Irene along the East Coast in August 2011.    
Public health emergencies were declared for all three incidents.  For each, 
ASPR conducted situational and readiness assessments to determine what 
public health and medical services States might need.  Through its 
Emergency Management Group, ASPR monitored the incident from the 
SOC.  ASPR disseminated relevant information to HHS Staff Divisions 
 
44
 HHS provided resources for 13 events in 2010 and for 7 in 2011. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  17 
  and Operating Divisions and coordinated with them to provide requested 
HHS resources.   
HHS Operating Divisions outside of the Office of the Secretary also 
conducted situational and readiness assessments to ensure that resources 
were prepared for deployment in all three incidents.  For example, CDC 
monitored State health department reports regarding vector control (i.e., 
eradicating mammals, birds, or insects that transmit diseases such as West 
Nile virus) and prepared to provide resources, such as products to 
eradicate insects, if needed.  The Substance Abuse and Mental Health 
Services Administration (SAMHSA) assessed potential impact to 
behavioral health systems (i.e., networks of behavioral health services 
providers) and coordinated with stakeholders, assessed needs, and 
provided technical assistance to all three affected populations.  SAMHSA 
and support organizations also distributed behavioral health materials.  
SAMHSA deployed behavioral health specialists and provided grants to 
restore behavioral health facilities and support services. 
The Administration for Children and Families (ACF) and FDA also 
participated in HHSs response efforts.  ACF assessed the impact the 
incidents had on services such as access to food and emergency housing.  
FDA deployed food safety consultants to conduct risk assessments of food 
service and manufacturing facilities and of agricultural animals used for 
human consumption. 
For all three incidents, NDMS medical personnel were activated (i.e., 
instructed by the HHS Secretary to provide medical services) and hospital 
bed availability was continually assessed through the Hospital 
Preparedness Programs Hospital Available Beds for Emergencies and 
Disasters system.  This system reports available hospital beds in real time 
at the local and regional level.  HHS also provided reports detailing 
available blood resources and types to NDMS and other medical personnel 
for all three selected incidents. 
Finally, after each of the three incidents, ASPR coordinated with all 
affected States to determine whether supplementary HHS resources were 
needed.  Appendix E is a detailed list of ESF-8 resources provided to 
States by HHS during its response to three selected incidents in 2010 and 
2011.   
Red River flooding in North Dakota  
On March 21, 2010, the Red River crested at 36.99 feet19 feet above 
flood level.  Floodwaters destroyed homes, covered roadways, and closed 
bridges.  In an attempt to protect the city of Fargo from the floodwaters, 
Federal, State, and local governments and organizations coordinated 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  18 
  efforts to stack 700,000 sandbags around the city.  At least 10 people were 
reportedly rescued from floodwaters.45  
During the flood response, HHS provided North Dakota with resources in 
12 of the 17 core functional areas of ESF-8.46  (The State did not request 
resources for the other five core functional areas.)  Throughout the 
response, HHS RECs monitored North Dakotas requests for public health 
and medical equipment and technical assistance, and provided requested 
resources. 
HHS deployed ESF-8 personnel to the North Dakota Emergency 
Operations Center to provide technical support.  Specifically, an HHS 
Incident Response Coordination Team (IRCT) was deployed to assess 
flood damage.  The 
IRCT interacted 
with State and local 
emergency 
response personnel 
to determine what 
additional ESF-8 
resources HHS 
could provide to 
support the State 
response.   
In addition to the 
Photo provided by FEMA  IRCT, DMATs 
Burlington, North Dakota, was inundated during the Red River 
were identified to 
flood in March 2010. 
assist in shelter 
operations, as needed.  Health and medical caches containing mobile 
medical kits and prescription drugs were deployed to support response 
personnel.   
An HHS public affairs officer coordinated with State representatives to 
assess public health and medical communication needs.  To provide 
further support, CDC posted information on its Web site to keep the public 
informed about the flooding. 
 
45
 CNN, FEMA Chief to Survey Red River flooding.  Accessed at 
http://www.cnn.com/2010/US/weather/03/22/severe.weather/index.html?iref=allsearch on 
June 22, 2012. 
46
 Core functional area resources not needed during the Red River flooding response were 
Patient Evacuation; Agricultural Safety and Security; Vector Control; Mass Fatality 
Management, Victim Identification, and Decontaminating Remains; and Veterinary Medical 
Support.   
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  19 
  State representatives reported that HHSs response was efficient and 
effective, and that all resources provided by HHS were sufficient, 
helpful, and appropriate.  
Tornado in Joplin, Missouri  
On May 23, 2011, a monster tornado struck Joplin, killing 116 people 
and injuring another 400.47  Measuring over a half-mile wide, the tornado 
destroyed an estimated 2,000 homes, schools, and businesses.  One 
hundred eighty 
patients at St. 
Johns 
Regional 
Medical Center 
attempted to 
find shelter as 
the roof was 
ripped off by 
the tornado.  
Weather 
officials 
reported that 
the tornado was 
the single 
Photo provided by FEMA 
Damage to the front entrance of St. Johns Regional Medical Center in  deadliest 
Joplin, Mo.,  after a deadly F-5 tornado struck.  
twister in the 
 
United States since 1947 and one of the nine deadliest in recorded 
history.48     
HHS provided Missouri with resources in 16 of the 17 core functional 
areas of ESF-8.  (The State did not request resources for the other core 
functional area.49)  HHS ESF-8 personnel deployed to Joplin assessed 
damage to the medical infrastructure, including hospitals and long-term-
care facilities.  An HHS IRCT and the Emergency Management Group 
collaborated with FEMA and State and local officials to determine the 
States need for Federal resources to repair the health care infrastructure.   
DMATs also assisted with patient care and emergency services.  A 
Medical Strike Team was deployed to assess the impact on public health 
 
47
 Reuters, Tornado devastates Joplin, Missouri, 116 dead.  Accessed at 
http://www.reuters.com/article/2011/05/23/ususaweathertornadoes
idUSTRE74M08L20110523 on June 22, 2012. 
48
 Ibid. 
49
 Patient Evacuation core functional area resources were not needed during the Joplin 
tornado response. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  20 
  and respond to chemical, biological, and radiological dispersals.50  RECs 
collaborated with a hospital to set up a mobile medical unit.  Health and 
medical caches containing prescription drugs and mortuary equipment and 
supplies were also deployed to Joplin.  HHS personnel conducted family 
interviews to assist with victim identification. 
SAMHSA deployed behavioral health specialists who provided 
psychological first aid and crisis counseling training to responders in 
Joplin.  SAMHSA coordinated with the American Red Cross, which also 
provided mental health services to Joplin residents, as needed.  SAMHSA 
also managed the transport of patients, service providers, and drugs 
requiring additional security, such as methadone, during the response.   
ACF collaborated with ESF-6 personnel (e.g., DHS, FEMA), the Missouri 
State Division of Family Services, and the Child Care Development Fund 
to provide technical assistance and consultation to affected Joplin 
residents.  FDA inspected and provided surveillance of retail food 
establishments and food manufacturing facilities.  CDC assessed vaccine 
need and availability and animal control, and assessed needs for vector 
control resources.  CDC worked with EPA to provide vector control 
resources to eradicate mosquitoes in Joplin.  CDC also worked with 
Joplins health department to inform the affected population about the 
need to boil water before use. 
Public health emergency information was disseminated to the public 
through ASPRs Web site.  CMS published information regarding 
Medicare, Medicaid, and the Childrens Health Insurance Plan benefits 
during an incident response.  SAMHSA also provided stress management 
information on its Web site.   
State representatives reported that all requested resources were sufficient, 
helpful, and appropriate.  They stated that HHS provided technical support 
and guidance in some very challenging circumstances. 
Hurricane Irene along the East Coast 
On August 22, 2011, Hurricane Irene struck Puerto Rico.  The storm 
downed trees, flooded streets, and left over a million people without 
electricity.  Hurricane advisories were issued for most States along the 
 
50
 A Medical Strike Team is prepared to assist with medical management and respond to the 
public health consequences of chemical, biological, and radiological incidents that result from 
accidental or deliberate acts.  The team is designed to supplement the local hazardous 
materials and medical response to weapons of mass destruction by offering specialized 
equipment and knowledge, as well as additional fire and emergency personnel, physicians, 
and nurses. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  21 
  East Coast as Irene left Puerto Rico.51  On August 26, the hurricane struck 
the East Coast and left millions of people without electricity for several 
days and, in some cases, several weeks.  Homes, businesses, and crops 
were damaged or destroyed by high winds and heavy rains.  The storm 
killed 45 people.52 
Fifteen States on the East Coast were affected by Hurricane Irene.53  HHS 
reported that it provided affected States with resources in 16 of the 17 core 
functional areas 
of ESF-8.  (States 
did not request 
resources for the 
remaining core 
functional 
area.54)  HHS 
began its 
response by 
deploying IRCTs, 
DMATs, 
Logistical 
Photo provided by National Oceanic Atmospheric Administration  Response 
Hurricane Irene as it strikes the East Coast in August 2011. 
Assistance 
Teams, and Rapid Deployable Force teams to affected States.  
Communications equipment was deployed to assist IRCTs in assessing 
States needs and the resources HHS could provide.  Caches containing 
medical equipment had been strategically positioned along the East Coast 
to prepare them for rapid deployment during incident response.  The 
Federal National Ambulance Contract was activated in New York to assist 
with patient evacuation from hospitals and other health care facilities. 
CDC assessed the need for vector control resources and conducted 
epidemiology conference calls with affected States.  CDC provided the 
Virginia Department of Health with technical assistance regarding vector 
control.  The Health Resources and Services Administration assessed the 
 
51
 CBS News, Hurricane Irene Slams Puerto Rico, Eyes U.S.  Accessed at 
http://www.cbsnews.com/2100201_16220095323.html on June 22, 2012. 
52
 Associated Press, Hurricane Irenes Impact, State by State.  Accessed at 
http://www.nj.com/news/index.ssf/2011/08/hurricane_irenes_impact_state.html on June 22, 
2012. 
53 
The 15 States were Connecticut, the District of Columbia, Delaware, Massachusetts, 
Maryland, North Carolina, New Jersey, New York, Pennsylvania, Puerto Rico, Rhode Island, 
South Carolina, Vermont, Virginia, and the U.S. Virgin Islands. 
54 
Safety and Security of Drugs, Biologics, and Medical Devices core functional area 
resources were not needed during the Hurricane Irene response. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  22 
  impact of Hurricane Irene on service providers and their ability to deliver 
community-based services to patients.  HHS provided critical 
infrastructure support to the American Red Cross in Baltimore to ensure 
that blood supplies were secure.    
Public health information regarding well water contamination was 
disseminated to the public through ASPRs Web site.  CDC also updated 
hurricane information on its Web site.   
Representatives from 10 of the 15 States reported that they received HHS 
resources, and that the resources provided were appropriate, based on their 
requests.  Of the 10 States that reported receiving resources, 9 indicated 
that HHS resources were helpful.  One State reported a neutral response 
about the resources it received.55 
States Reported That Multiple Requests From HHS for the Same 
Information Were Burdensome During Incident Response. 
Five of the fifteen respondents reported that the same information was 
requested multiple times by different HHS Staff Divisions and Operating 
Divisions.56  States reported that it appeared HHS personnel did not 
communicate information among Staff Divisions and Operating Divisions 
and that each division made separate requests.  States indicated that these 
multiple requests were burdensome. 
One State said that although it had established a regular, recurring 
reporting system during the Hurricane Irene response, HHS requested 
information that the State had already provided or intended to provide in 
the next reporting cycle.57   
 
55
 The 10 States that received resources were Connecticut, Maryland, New Jersey, New York, 
North Carolina, Pennsylvania, Puerto Rico, Rhode Island, Vermont, and Virginia.  The five 
States that did not receive resources were the District of Columbia, Delaware, Massachusetts, 
South Carolina, and the U.S. Virgin Islands.  The only State that reported a neutral response 
about HHS resources received was Maryland. 
56
 The five States that reported receiving multiple requests for the same information were 
Maryland, New York, North Carolina, Rhode Island, and Virginia.  
57
 Virginia. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  23 
  CONCLUSION AND RECOMMENDATIONS 
In 2010, CIGIE published the IGs Guide, which recommended that IGs 
assess their Federal agencys emergency preparedness capabilities.  Recent 
incidents such as the Sandy super storm emphasize the need for Federal 
agencies to assess their emergency response capabilities.  HHS is charged 
with serving as the Coordinator and Primary agency for ESF-8 Public 
Health and Medical Services.  Within HHS, ASPR organizes HHS 
resources and response as the Coordinator and Primary agency for ESF-8.  
HHS also serves as the Support agency for nine additional ESFs.   
HHS has taken action in all five preparedness activities we reviewed to 
fulfill its ESF responsibilities as a Coordinator, Primary, and Support 
agency.  However, HHS can improve communication of its Support 
agency role, responsibilities, and the resources it can provide during 
incident response.   
Further, HHS responded to 28 incidents in 2010 and 2011 and 
demonstrated its ability to respond to 3 incidents we reviewed that 
affected 17 States.  Twelve of the seventeen States affected by these three 
incidents reported requesting HHS resources and stated that the resources 
they received were appropriate, based on their requests.  However, internal 
communication with Staff Divisions and Operating Divisions could be 
increased to reduce duplicative information requests to States. 
We recommend that HHS: 
Continue to Increase Communication with ESF Coordinator 
and Primary Agencies It Serves as a Support Agency 
The NRF states that ESF Support agencies must be prepared to provide 
resources and participate in preparedness activities to support the ESF 
Coordinator and Primary agencys mission.  HHS should continue to work 
toward increasing its communication with the Coordinator and Primary 
agencies for the nine additional ESFs for which HHS serves as a Support 
agency.  Specifically, HHS should increase communication regarding its 
Support agency role and the resources it can provide during incident 
response.   
Coordinate Requests for Information From HHS Staff Divisions 
and Operating Divisions To Reduce the Burden on States 
During an Incident Response   
Five of the fifteen States affected by Hurricane Irene indicated that HHS 
Staff Divisions and Operating Divisions made several requests for the 
same information.  States found this burdensome and reported that the 
repeated requests slowed their incident response.  HHS should coordinate 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  24 
  all requests for information during an incident response to ensure that 
States are not being unnecessarily burdened.  For example, HHS could 
establish one point of contact per response area to communicate with State 
and local governments during the incident response.  This point of contact 
could, in turn, disseminate information to HHS Staff Divisions and 
Operating Divisions.  
   
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  25 
  AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
ASPR concurred with our recommendations and provided information 
regarding its efforts to fulfill its emergency support responsibilities.  
Specifically, ASPR will continue to include all appropriate Coordinator 
and Primary agencies in any planning endeavors as well as routine 
collaboration with partner agencies.   
Regarding our second recommendation, ASPR will continue to improve 
information collection from States concerning multiple agency requests 
during incident response.  Although ASPR makes every effort to ensure 
that requests to States are well-coordinated and minimally burdensome, it 
recognizes that during a response communication breakdowns may occur 
at the Federal and State levels.  ASPR acknowledges this challenge and 
places a high priority on building and enhancing communications with all 
of its partners and stakeholders.  
We support ASPRs efforts to address and continue to make progress in 
these areas.  For the full text of ASPRs comments, see Appendix G. 
   
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  26 
  APPENDIX A 
Emergency Support Functions  
 The National Response Framework assigns 15 Emergency Support Functions (ESF) to various Federal agencies.  Each 
ESF divides Federal responsibilities among Coordinator (C), Primary (P), and Support (S) agencies and organizations.  
The chart below indicates which Federal agencies and organizations are assigned responsibilities within each ESF.  The 
highlighted column and row indicate the Department of Health and Human Services ESF-8 responsibilities. 
Table A-1  Selected Federal Agencies With Coordinator, Primary, and Support Roles for Emergency Support Functions 
#1  #2  #3  #4  #5  #6  #7  #8  #9  #10  #11  #12  #13  #14  #15 
OAgrgeannciizeast iaonnds   Transportation  Communications  Public Works and Engineering  Firefighting  Emergency Management  Mass Care, Emer. Assist., Housing, and Human Svs.  Logistics Management and Resource Support  Public Health and Medical Services  Search and Rescue  Oil and Hazardous Materials Response  Agriculture and Natural Resources  Energy  Public Safety and Security  Long-Term Community Recovery  External Affairs 
American 
Council on 
                    S         
Historic 
Preservation 
American Red 
    S    S  S    S      S      S   
Cross 
Corporation for 
National & 
    S    S                  S   
Community 
Service 
Department of 
Homeland  S  C/P/S  P/S  S  C/P/S  C/P/S  C/P/S  S  C/P/S  P/S  S  S  S  C/P  C/P 
Security (DHS) 
Department of 
S  S  S  S  S    S  S  S  S  S  S  S  S  S 
Commerce 
Department of 
S  S  C/P/S  S  S  S  S  S  P/S  S  S  S  S  S  S 
Defense 
Department of 
S    S    S    S  S    S  S  C/P  S  S  S 
Energy 
continued on next page 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  27  Table A-1  Selected Federal Agencies With Coordinator, Primary, and Support Roles for Emergency Support Functions, Continued 
#1  #2  #3  #4  #5  #6  #7  #8  #9  #10  #11  #12  #13  #14  #15 
OAgrgeannciizeast iaonnds   Transportation  Communications  Public Works and Engineering  Firefighting  Emergency Management  Mass Care, Emer. Assist., Housing, and Human Svs.  Logistics Management and Resource Support  Public Health and Medical Services  Search and Rescue  Oil and Hazardous Materials Response  Agriculture and Natural Resources  Energy  Public Safety and Security  Long-Term Community Recovery  External Affairs 
Department of the 
S  S  S  S  S  S  S  S  P  S  P/S  S  S  S  S 
Interior 
Department of 
S        S  S    S  S  S  S    C/P    S 
Justice 
Department of 
    S    S  S  S  S  S  S  S  S    S  S 
Labor 
Department of 
S    S  S  S      S    S  S  S      S 
State 
Department of 
C/P    S    S  S  S  S    S  S  S    S  S 
Transportation 
Delta Regional 
                          S   
Authority 
Department of 
        S                    S 
Education 
Environmental 
    S  S  S      S    C/P  S  S  S  S  S 
Protection Agency 
Federal 
Communications    S      S                    S 
Commission 
General Services 
S  S  S    S  S  C/P  S    S  S        S 
Administration 
Heritage 
Emergency 
                    S         
National Task 
Force 
Department of 
Health and      S    S  S  S  C/P  S  S  S      S  S 
Human Services 
continued on next page 
 
 
 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  28  Table A-1  Selected Federal Agencies With Coordinator, Primary, and Support Roles for Emergency Support Functions, Continued 
#1  #2  #3  #4  #5  #6  #7  #8  #9  #10  #11  #12  #13  #14  #15 
OAgrgeannciizeast iaonnds   Transportation  Communications  Public Works and Engineering  Firefighting  Emergency Management  Mass Care, Emer. Assist., Housing, and Human Svs.  Logistics Management and Resource Support  Public Health and Medical Services  Search and Rescue  Oil and Hazardous Materials Response  Agriculture and Natural Resources  Energy  Public Safety and Security  Long-Term Community Recovery  External Affairs 
Department of 
Housing and 
        S  S                P  S 
Urban 
Development 
National 
Archives and 
                    S         
Records 
Administration 
National 
Aeronautics and 
        S    S    S        S    S 
Space 
Administration 
Nuclear 
Regulatory      S    S          S    S      S 
Commission 
National 
Voluntary 
Organizations            S                S   
Active in 
Disaster 
Office of 
Personnel          S    S                S 
Management 
Small Business 
        S  S                P  S 
Administration 
Social Security 
          S              S    S 
Administration 
continued on next page 
 
 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  29  Table A-1  Selected Federal Agencies With Coordinator, Primary, and Support Roles for Emergency Support Functions, Continued 
#1  #2  #3  #4  #5  #6  #7  #8  #9  #10  #11  #12  #13  #14  #15 
OAgrgeannciizeast iaonnds   Transportation  Communications  Public Works and Engineering  Firefighting  Emergency Management  Mass Care, Emer. Assist., Housing, and Human Svs.  Logistics Management and Resource Support  Public Health and Medical Services  Search and Rescue  Oil and Hazardous Materials Response  Agriculture and Natural Resources  Energy  Public Safety and Security  Long-Term Community Recovery  External Affairs 
Department of 
        S  S              S  S  S 
the Treasury 
Tennessee 
    S    S              S      S 
Valley Authority 
Agency for 
International                S  S            S 
Development 
Department of 
S  S  S  C/P  S  S  S  S    S  C/P/S  S    P  S 
Agriculture 
Postal Service  S        S  S    S      S    S    S 
Veterans 
    S    S  S  S  S          S    S 
Administration 
Source:  DHS, National Response Framework.  Accessed at http:// www.fema.gov/pdf/emergency/NRF/NRF-core.pdf on March 7, 2011.  DHS, ESF-8Public Health and Medical 
Services Annex.  Accessed at http://www.fema.gov/pdf/emergency/NRF/NRFesf08.pdf on May 13, 2011. 
 
 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  30  APPENDIX B   
Seventeen Core Functional Areas of Emergency Support 
Function-8 
Emergency Support Function-8 (ESF-8) describes Federal public health 
and medical services that can be provided to assist States, tribes, and 
localities when an incident occurs.  The Department of Health and Human 
Services (HHS), in conjunction with Federal Support agencies and 
organizations, fulfills the responsibilities within ESF-8.  The 17 core 
functional areas of ESF-8, as quoted in the National Response Framework 
are:58, 59 
1.  Assessment of Public Health/Medical Needs.  HHS, in collaboration with 
the Department of Homeland Security (DHS), mobilizes and deploys 
ESF-8 personnel to support national or regional teams to assess public 
health and medical needs, including the needs of at-risk population 
groups, such as language assistance services for limited English-
proficient individuals and accommodations and services for individuals 
with disabilities.  This function includes the assessment of the health care 
system/facility infrastructure.  
2.  Health Surveillance.  HHS, in coordination with supporting departments 
and agencies, enhances existing surveillance systems to monitor the 
health of the general and medical needs population; carries out field 
studies and investigations; monitors injury and disease patterns and 
potential disease outbreaks, blood and blood product bio-vigilance, and 
blood supply levels; and provides technical assistance and consultations 
on disease and injury prevention and precautions.  
3.  Medical Care Personnel.  Immediate medical response capabilities are 
provided by assets internal to HHS (e.g., U.S. Public Health Service 
Commissioned Corps (PHSCC), National Disaster Medical System 
(NDMS), and Federal Civil Service employees) and from ESF-8 
supporting organizations.  
ESF-8 may request Department of Defense (DOD) support for casualty 
clearing and staging, patient treatment, and support services such as 
surveillance and laboratory diagnostics.  
 
58
 DHS, ESF-8Public Health and Medical Services Annex.  Accessed at 
http://www.fema.gov/pdf/emergency/NRF/NRFesf08.pdf on May 13, 2011. 
59
 ESF-8 includes a core functional area entitled Worker Safety and Health.  The Department 
of Labor is the lead Federal agency for this core functional area, with HHS serving as a 
Support agency.  Therefore the Worker Safety and Health core functional area is not included 
in our list of HHSs 17 core functional areas of ESF-8. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  31  ESF-8 may seek individual clinical public health and medical care 
specialists from the Department of Veterans Affairs (VA) to assist State, 
tribal, and local public health and medical personnel.  
ESF-8 may engage civilian volunteers, such as Medical Reserve Corps 
(MRC), to assist State, tribal, and local public health and medical 
personnel.  
4.  Health/Medical/Veterinary Equipment and Supplies.  In addition to 
deploying assets from the Strategic National Stockpile (SNS), ESF-8 
may request DOD or the VA to provide medical equipment, durable 
medical equipment, and supplies, including medical, diagnostic, and 
radiation-detecting devices, pharmaceuticals, and biologic products in 
support of immediate medical response operations and for restocking 
health care facilities in an area affected by a major disaster or emergency.  
When a veterinary response is required, assets may be requested from the 
National Veterinary Stockpile (NVS), which is managed by the 
Department of Agriculture (USDA) Animal and Plant Health Inspection 
Service (APHIS).  
5.  Patient Evacuation.  ESF-8 is responsible for transporting seriously ill 
(i.e., seriously ill describes persons whose illness or injury is of such 
severity that there is cause for immediate concern, but there is not 
imminent danger to life) or injured patients, and medical needs 
populations from casualty collection points in the impacted area to 
designated reception facilities.  ESF-8 coordinates the Federal response 
in support of emergency triage and pre-hospital treatment, patient 
tracking, and distribution.  This effort is coordinated with Federal, State, 
tribal, and local emergency medical services officials.  
ESF-8 may request DOD, VA, and DHS/Federal Emergency 
Management Agency (FEMA), via the national ambulance contract, to 
provide support for evacuating seriously ill or injured patients. Support 
may include providing transportation assets, operating and staffing 
NDMS Federal Coordination Centers, and processing and tracking 
patient movements from collection points to their final destination 
reception facilities.  
DOD is the only recognized Federal partner responsible for regulating 
and tracking patients transported on DOD assets to appropriate treatment 
facilities (e.g., NDMS hospitals).  
6.  Patient Care.  ESF-8 may task HHS components to engage civil service 
personnel, the PHSCC, the regional offices, and States to engage civilian 
volunteers and request the VA and DOD to provide available personnel 
to support pre-hospital triage and treatment, inpatient hospital care, 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  32  outpatient services, pharmacy services, and dental care to victims who 
are seriously ill, injured, or suffer from chronic illnesses who need 
evacuation assistance, regardless of location.  
ESF-8 may assist with isolation and quarantine measures and with point 
of distribution operations (mass prophylaxis and vaccination). Health 
care providers and support staff will ensure appropriate patient 
confidentiality is maintained, including Health Insurance Portability and 
Accountability Act privacy and security standards, where applicable. 
7.  Safety and Security of Drugs, Biologics, and Medical Devices.  ESF-8 
may task HHS components to ensure the safety and efficacy of and 
advise industry on security measures for regulating human and 
veterinary drugs, biologics (including blood and vaccines), medical 
devices (including radiation emitting and screening devices), and other 
HHS-regulated products.  
8.  Blood, Organs, and Blood Tissues.  ESF-8 may task HHS components 
and request assistance from other ESF-8 partner organizations to monitor 
and ensure the safety, availability, and logistical requirements of blood, 
organs, and tissues.  This includes the ability of the existing supply chain 
resources to meet the manufacturing, testing, storage, and distribution of 
these products.  
9.  Food Safety and Security.  ESF-8, in cooperation with ESF-11, may task 
HHS components and request assistance from other ESF-8 partner 
organizations to ensure the safety and security of federally regulated 
foods.  (Note: HHS, through the Food and Drug Administration (FDA), 
has statutory authority for all domestic and imported food except meat, 
poultry, and egg products, which are under the authority of the USDA 
Food Safety and Inspection Service.  The Environmental Protection 
Agency (EPA) establishes tolerance levels for pesticide residues.)  
10. Agriculture Safety and Security.  ESF-8, in coordination with ESF-11, 
may task HHS components to ensure the health, safety, and security of 
food-producing animals, animal feed, and therapeutics.  (Note: HHS, 
through the FDA, has statutory authority for animal feed and for the 
approval of animal drugs intended for both therapeutic and non-
therapeutic use in food animals as well as companion animals.)  
11. All-Hazards Public Health and Medical Consultation, Technical 
Assistance, and Support.  ESF-8 may task HHS components and regional 
offices and request assistance from other ESF-8 partner organizations in 
assessing public health, medical, and veterinary medical effects resulting 
from all hazards.  Such tasks may include assessing exposures on the 
general population and on high-risk population groups; conducting field 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  33  investigations, including collection and analysis of relevant samples; 
providing advice on protective actions related to direct human and 
animal exposures, and on indirect exposure through contaminated food, 
drugs, water supply, and other media; and providing technical assistance 
and consultation on medical treatment, screening, and decontamination 
of injured or contaminated individuals.  While State, tribal, and local 
officials retain primary responsibility for victim screening and 
decontamination operations, ESF-8 can deploy the National Medical 
Response Teams (NMRT) to assist with victim decontamination. 
12. Behavioral Health Care.  ESF-8 may task HHS components and request 
assistance from other ESF-8 partner organizations in assessing mental 
health and substance abuse needs, including emotional, psychological, 
psychological first aid, behavioral, or cognitive limitations requiring 
assistance or supervision; providing disaster mental health training 
materials for workers; providing liaison with assessment, training, and 
program development activities undertaken by Federal, State, tribal, or 
local mental health and substance abuse officials; and providing 
additional consultation as needed.  
13. Public Health and Medical Information.  ESF-8 provides public health, 
disease, and injury prevention information that can be transmitted to 
members of the general public who are located in or near areas affected 
in languages and formats that are understandable to individuals with 
limited English proficiency and individuals with disabilities.  
14. Vector Control.  ESF-8 may task HHS components and request 
assistance from other ESF-8 partner organizations, as appropriate, in 
assessing the threat of vector-borne diseases; conducting field 
investigations, including the collection and laboratory analysis of 
relevant samples; providing vector control equipment and supplies; 
providing technical assistance and consultation on protective actions 
regarding vector-borne diseases; and providing technical assistance and 
consultation on medical treatment of victims of vector-borne diseases.  
15. Public Health Aspects of Potable Water/Wastewater and Solid Waste.  
ESF-8 may task HHS components and request assistance from other 
ESF-8 organizations to assist in assessing potable water, wastewater, 
solid waste disposal, and other environmental health issues related to 
public health in establishments holding, preparing, and/or serving food, 
drugs, or medical devices at retail and medical facilities, as well as 
examining and responding to public health effects from contaminated 
water; conducting field investigations, including collection and 
laboratory analysis of relevant samples; providing equipment and 
supplies as needed; and providing technical assistance and consultation.  
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  34  16. Mass Fatality Management.  ESF-8, when requested by State, tribal, or 
local officials, in coordination with its partner organizations, will assist 
the jurisdictional medico-legal authority and law enforcement agencies 
in the tracking and documenting of human remains and associated 
personal effects; reducing the hazard presented by chemically, 
biologically, or radiologically contaminated human remains (when 
indicated and possible); establishing temporary morgue facilities; 
determining the cause and manner of death; collecting ante mortem data 
in a compassionate and culturally competent fashion from authorized 
individuals; performing postmortem data collection and documentation; 
identifying human remains using scientific means (e.g., dental, 
pathology, anthropology, fingerprints, and, as indicated, DNA samples); 
and preparing, processing, and returning human remains and personal 
effects to the authorized person(s) when possible; and providing 
technical assistance and consultation on fatality management and 
mortuary affairs.  In the event that caskets are displaced, ESF-8 assists in 
identifying the human remains, recasketing, and reburial in public 
cemeteries.  
ESF-8 may task HHS components and request assistance from other 
ESF-8 partner organizations, as appropriate, to provide support to 
families of victims during the victim identification mortuary process.  
17. Veterinary Medical Support.  ESF-8 will provide veterinary assistance to 
ESF-11. Support will include the amelioration of zoonotic disease and 
caring for research animals where ESF-11 does not have the requisite 
expertise to render appropriate assistance.  
ESF-8 will assist ESF-11 as required to protect the health of livestock 
and companion and service animals by ensuring the safety of the 
manufacture and distribution of foods and drugs given to animals used 
for human food production.  ESF-8 supports DHS/FEMA together with 
ESF-6  Mass Care, Emergency Assistance, Housing, and Human 
Services, ESF-9  Search and Rescue, and ESF-11 to ensure an 
integrated response to provide for the safety and well-being of household 
pets and service and companion animals.  
   
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  35  APPENDIX C 
National Planning Scenarios 
Fifteen National Planning Scenarios describe specific incidents that may 
occur, ranging from hurricanes and influenza pandemics to biological 
attacks.  Agencies with Emergency Support Function responsibilities can 
use the 15 National Planning Scenarios as a guide to developing 
preparedness plans and participating in activities for these specific 
incidents that may require unique plans and resources beyond all-hazards 
plans.  The 15 National Planning Scenarios are: 60  
1.  Biological AttackAerosolized Anthrax 
2.  Biological AttackBotulinum Food Contamination 
3.  Biological AttackPandemic Influenza 
4.  Biological AttackPneumonic Plague 
5.  Biological AttackForeign Animal Disease 
6.  Chemical AttackBlister Agent  
7.  Chemical AttackChlorine Tank Explosion 
8.  Chemical AttackToxic Industrial Chemicals 
9.  Chemical AttackNerve Agent 
10. Cyber AttackCyber Security  
11. Explosives AttackBombing Using Improvised Explosive 
Devices 
12. Explosives AttackImprovised Nuclear Device 
13. Natural DisasterMajor Earthquake 
14. Natural DisasterMajor Hurricane 
15. Radiological AttackRadiological Dispersal Devices and 
Radiological Explosive Devices  
 
60 
Federal Emergency Management Agency, National Preparedness Guidelines, pp. 45.  
Accessed at 
http://www.fema.gov/pdf/emergency/NRF/National_Preparedness_Guidelines.pdf on June 21, 
2011. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  36  APPENDIX D 
The National Planning Scenario Playbooks and Emergency Support Function-8 
The 15 National Planning Scenario (NPS) playbooks contain written guidance that addresses Federal agencies 
responsibilities when an incident (i.e., emergency or disaster) occurs.  The Department of Health and Human Services 
(HHS) is assigned public health and medical services responsibilities for Emergency Support Function #8 (ESF-8).  
Within ESF-8 are 17 core functional areas for which HHS is responsible when an incident occurs.  The chart below 
indicates which of the 17 core functional areas are addressed in the HHSs 14 NPS playbooks. 
 
Table D-1  The 17 Core Functional Areas of ESF-8 and the 15 NPS Playbooks 
#1  #2  #3  #4  #5  #6  #7  #8  #9  #10  #11  #12  #13  #14  #15 
Core Functional Areas  Aerosolized Anthrax  Botulinum Food Contamination  Pandemic Influenza  Pneumonic Plague  Foreign Animal Disease  Blister Agent  Chlorine Tank Explosion  Toxic Industrial Chemical  Nerve Agent  Cyber Security*  Improvised Explosive Device  Improvised Nuclear Device    Major Earthquake  Major Hurricane  Radiological Dispersal Device and Radiological Explosive Device 
Assessment of public 
x  x  x  x  x  x  x  x  x    x  x  x  x  x 
health and medical needs 
Health surveillance  x  x  x  x  x  x  x  x  x    x  x  x  x  x 
Medical care personnel  x  x  x  x  x  x  x  x  x    x  x  x  x  x 
Health/medical/veterinary 
x  x  x  x  x  x  x  x  x    x  x  x  x  x 
equipment and supplies 
Patient evacuation  x  x  x  x  x  x  x  x  x    x  x  x  x  x 
Patient care  x  x  x  x  x  x  x  x  x    x  x  x  x  x 
Safety and security of 
drugs, biologics, and  x  x  x  x  x  x  x  x  x    x  x  x  x  x 
medical devices 
Blood and blood products  x  x    x  x  x  x  x  x    x  x  x  x  x 
Food safety and security  x  x  x  x  x  x  x  x  x    x  x  x  x  x 
Agriculture safety and 
x  x  x  x  x  x  x  x  x    x  x  x  x  x 
security 
continued on next page 
   
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  37     
Table D-1  The 17 Core Functional Areas of ESF-8 and the 15 NPS Playbooks, Continued 
#1  #2  #3  #4  #5  #6  #7  #8  #9  #10  #11  #12  #13  #14  #15 
Core Functional Areas  Aerosolized Anthrax  Botulinum Food  Contamination  Pandemic Influenza  Pneumonic Plague  Foreign Animal Disease  Blister Agent  Chlorine Tank Explosion  Toxic Industrial Chemical  Nerve Agent  Cyber Security*  Improvised Explosive Device  Improvised Nuclear Device    Major Earthquake  Major Hurricane  Radiological  Dispersal Device and Radiological Explosive Device 
All-hazard public health 
and medical consultation, 
x  x  x  x  x  x  x  x  x    x  x  x  x  x 
technical assistance, and 
support 
Behavioral health care  x  x  x  x  x  x  x  x  x    x  x  x  x  x 
Public health and 
x  x  x  x  x  x  x  x  x    x  x  x  x  x 
medical information 
Vector control  x    x  x    x  x    x    x  x  x  x  x 
Potable 
water/wastewater and  x  x  x  x  x  x  x  x  x    x  x  x  x  x 
solid waste disposal 
Mass fatality 
management, victim 
identification, and  x  x  x  x  x  x  x  x  x    x  x  x  x  x 
decontamination of 
remains 
Veterinary medical 
x  x  x  x  x  x  x  x  x    x  x    x  x 
support 
* No NPS playbook has been written for cyber security.  Gray-shaded boxes indicate that planning for the listed core functional area was not found in the playbooks.  However, HHS has written incident response 
plans to address these areas.  Source:  Federal Emergency Medical Agency, ESF-8-Public Health and Medical Services Annex.  Accessed at  http://www.fema.gov/pdf/emergency/nrf/nrf-esf-08.pdf, on May 15, 
2011.  DHS, National Preparedness Guidelines, September 2007, p. 3.  Accessed at http://www.fema.gov/pdf/emergency/NRF/National_Preparedness_Guidelines.pdf on June 21, 2011. 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  38  APPENDIX E 
Department of Health and Human Services Response to Three Selected Incidents in 2010 and 2011  
The Department of Health and Human Services (HHS) provides resources to States when an incident (i.e., emergency or 
disaster) occurs.  HHS is assigned public health and medical services responsibilities as the lead for the Emergency 
Support Function 8 (ESF-8), Public Health and Medical Services.  Within ESF-8 are 17 core functional areas for which 
HHS is responsible.  The chart below describes three selected incidentsRed River flooding in North Dakota, March 
2010; a tornado in Joplin, Missouri, May 2011; and Hurricane Irene along the East Coast, August 2011and the resources 
HHS provided, or was prepared to provide, to these States during incident response. 
 
Table E-1  HHS Resources Provided to Affected States in 2010 and 2011 
HHS Resource(s) Provided 
Core Functional Area  Incident  State(s) 
Objective  Strategy  Response 
  ESF-8 personnel deployed to North Dakota 
Emergency Operations Center (EOC) and 
assessed potential damage from flooding 
  National Disaster Medical System (NDMS) 
activated 
  Incident Response Coordination Team 
(IRCT)/Logistics Response Assessment Team 
(LRAT) deployed 
Assess public health 
To evaluate the    Administration for Children and Families (ACF) 
and medical 
1.  Assessment of Public  Red River  need for public  assessed impact to human services 
North Dakota  infrastructure 
Health/Medical Needs  flooding  health and    Centers for Disease Control (CDC) monitored 
threatened by 
medical support  reports from state health departments, assessed 
flooding 
need for technical assistance on vector control 
(i.e., eradicating mammals, birds, or insects that 
transmit diseases such as West Nile virus) 
  Food and Drug Administration (FDA) conducted 
risk assessments 
  Substance Abuse and Mental Health Services 
Administration (SAMHSA) assessed impact to 
behavioral health systems 
continued on next page 
   
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  39  Table E-1  HHS Resources Provided to Affected States in 2010 and 2011, Continued 
HHS Resource(s) Provided 
Core Functional Area  Incident  State(s) 
Objective  Strategy  Response 
  NDMS activated 
  ESF-8 Lead/Regional Emergency Coordinator 
(REC) to MOConducted assessments of 
Assess potential  medical infrastructure damage to hospitals and 
damage to health  long-term-care facilities 
Ensure the  care and long-term-    CDC monitored reports from State health 
integrity of the  care facilities and  departments, provided technical assistance on 
Joplin tornado  Missouri  public health  other infrastructure  vector control  
and medical  that may have    Regional Incident Support Team (RIST)/IRCT 
infrastructure  resulted from  deployed 
damage because of    ACF assessed impact to human services 
  winds, flooding, etc.    At-Risk Behavioral Health Coordination (ABC)/ 
ACF monitored child care support to ESF-6 
  SAMHSA assessed impact on behavioral health 
systems  
  NDMS activated  
Ensure the    ACF assessed impact to human services  
CT, DC, DE, 
integrity of the    CDC monitored reports from State health 
MA, MD, NC, 
public health  Support Local Public  departments, technical assistance on vector 
Hurricane Irene  NJ, NY, PA, 
and medical  Health Agency  control 
PR, RI, SC, VT, 
infrastructure    FDA conducted risk assessments 
VA, USVI 
    SAMHSA assessed impact on behavioral health 
systems  
Maintain  Monitor public health    Hospital Preparedness Program (HPP)/ Hospital 
Red River 
North Dakota  situational  surveillance reports  Available Beds for Emergencies and Disasters 
flooding 
awareness  and systems  (HAvBed) bed status reports reviewed 
Monitor public health    HPP/HAvBed bed status reports reviewed 
surveillance reports   
Maintain 
and systems; report 
Joplin tornado  Missouri  situational 
on anomalies 
awareness 
 
2. Health Surveillance 
 
CDC Epidemiology    HPP/HAvBED bed status reports reviewed 
CT, DC, DE,  Evaluate the  team (CDC EPI) 
MA, MD, NC,  need to provide  responds under its 
Hurricane Irene  NJ, NY, PA,  public health  own authorities, 
PR, RI, SC, VT,  and medical  conducts interviews, 
VA, USVI  support  and records abstract 
reviews 
continued on next page 
 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  40  Table E-1  HHS Resources Provided to Affected States in 2010 and 2011, Continued 
HHS Resource(s) Provided 
Core Functional Area  Incident  State(s) 
Objective  Strategy  Response 
Evaluate the need    Six on-call Disaster Medical Assistance Team 
Evaluate the 
for NDMS support  (DMAT) identified to support potential emergency 
need to provide 
and identify Medical  decompression and shelter operations; plus 2  
public health 
Strike Team (MST)  24-person teams identified, if needed 
and medical 
and IRCT on the    One IRCT deployed 
support 
basis of capability 
Evaluate the    Health and Safety Plan (HASP) used 
Red River  need to provide  Prepare safety 
North Dakota 
flooding  public health  briefing for alerted 
and medical  teams 
support 
Evaluate the  Be prepared to    ABC coordinated behavioral health stakeholders to 
need to provide  provide mental  identify needs/materials and provide technical 
public health  health and stress  assistance 
and medical  management   
support  technical assistance 
  Two standard DMATs determined whether the 
Monitor public health 
Provide life- State was unable to handle health care 
surveillance reports 
saving medical  infrastructure damage; each team had capability to 
3.  Medical Care  and systems; report 
capability  perform emergency decompression, as required 
Personnel  on anomalies 
 
Provide necessary    MST deployed for force protection 
Joplin tornado  Missouri  communication    Behavioral health specialist deployed to support 
Provide force  equipment, training,  responders 
protection for  Personnel Protective    HASP used 
deployed  Equipment, and 
personnel  medical 
countermeasures, if 
required 
Evaluate the    Three IRCT deployed 
need to provide     Five DMAT deployed to support States 
public health    One LRAT deployed  
CT, DC, DE, 
and medical  Evaluate the need    One Rapid Deployable Force (RDF) deployed 
MA, MD, NC, 
support and  for public health and 
Hurricane Irene  NJ, NY, PA,    HASP used 
ensure the  medical resources in 
PR, RI, SC, VT, 
integrity of the  support of the State 
VA, USVI 
health and 
medical 
infrastructure 
continued on next page 
 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  41  Table E-1  HHS Resources Provided to Affected States in 2010 and 2011, Continued 
HHS Resource(s) Provided 
Core Functional Area  Incident  State(s) 
Objective  Strategy  Response 
  One IRCT cache deployed 
  One DMAT cache deployed 
Augment local health    Two Federal Medical Station caches deployed 
Provide life- care with medical    Seven MST team kits deployed 
Red River 
North Dakota  saving medical  personnel or logistical    Three Lab caches deployed 
flooding 
capability  support to minimize    Seven Pharmacy caches deployed 
patient care shortfalls    Seven Electronic Medical Record kits deployed 
  Seventeen IT/Telecom kits deployed 
  Three Medical Mobile Kits (MMK) deployed 
  Two IRCT caches deployed 
  One Deployable Portable Morgue Unit (DPMU) 
4. Health/Medical/  Augment local health 
deployed 
Veterinary Equipment  Provide life- care with medical 
  One DMPU Family Assistance Center Team 
and Supplies  Joplin tornado  Missouri  saving medical  personnel or logistical 
(FACT) cache deployed 
capability  support to minimize 
  Two Electronic Medical Record kits deployed 
patient care shortfalls 
  Three MMKs deployed 
  Two IT/Telecom kits deployed  
  One IRCT cache deployed 
CT, DC, DE,  Augment local health    Two DMAT caches deployed  
MA, MD, NC,  Provide life- care with medical    Two Pharmacy caches deployed 
Hurricane Irene  NJ, NY, PA, PR,  saving medical  personnel or logistical    Two Lab caches deployed 
RI, SC, VT, VA,  capability  support to minimize    Five MMKs deployed 
USVI  patient care shortfalls    Twelve Electronic Medical Record kits deployed 
  Thirteen IT/Telecom kits deployed 
Evaluate the    No State requests or HHS actions 
need to provide 
Red River  Assess the need for 
North Dakota  public health 
flooding  patient movement 
and medical 
support 
Support patient    No State requests or HHS actions 
movement either by 
Provide life- Federal Emergency 
5.  Patient Evacuation  Joplin tornado  Missouri  saving medical  Medical Agency 
capability  (FEMA) ambulance 
contract or NDMS 
evacuation 
CT, DC, DE,    National Ambulance Contract activated in NY 
MA, MD, NC, 
Hurricane Irene  NJ, NY, PA, PR,  None noted  None noted 
RI, SC, VT, VA, 
USVI 
continued on next page 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  42  Table E-1  HHS Resources Provided to Affected States in 2010 and 2011, Continued 
HHS Resource(s) Provided 
Core Functional Area  Incident  State(s) 
Objective  Strategy  Response 
Evaluate the    Public Health Emergency (PHE) declared by the 
need to provide  Secretary of HHS 
Red River 
North Dakota  public health  None noted    CMS 1135 waiver requests61 
flooding 
and medical 
support 
Provide medical    PHE declared by the Secretary of HHS 
Provide life-
support teams with    CMS 1135 waiver requests 
saving medical 
strike team kits and    Four DMAT alerted for emergency 
capability 
logistic support  decompression/augmentation 
Augment local health    No State requests or HHS actions 
6.  Patient Care  Joplin tornado  Missouri 
care with medical 
Provide life-
personnel or logistic 
saving medical 
support to minimize 
capability 
patient care 
shortfalls 
CT, DC, DE,    PHE declared by the Secretary of HHS 
MA, MD, NC,    CMS 1135 waiver requests 
Hurricane Irene  NJ, NY, PA,  None noted  None noted    Five DMAT shelter support teams deployed 
PR, RI, SC, VT,    Three  IRCT deployed to affected regions 
VA, USVI 
Initiate actions to    REC monitored potential Durable Medical 
deploy and deliver  Equipment (DME) requests 
Evaluate the  appropriate Strategic   
7.  Safety and Security of  need to provide  National Stockpile 
Red River 
Drugs, Biologics, and  North Dakota  public health  (SNS) material to a 
flooding 
Medical Devices  and medical  Federal Mobilization 
support  Center or other 
designated reception 
location, if requested 
continued on next page 
 
61
 When a public health emergency is declared, the Centers for Medicare & Medicaid Services (CMS) is permitted to temporarily waive or modify 
Medicare, Medicaid, and the Childrens Health Insurance Program benefit requirements to assist in incident response efforts.  This is commonly referred 
to as the 1135 waiver request and is submitted by affected States.  ASPR, Public Health Emergency Declarations Q&A.  Accessed at 
http://www.phe.gov/Preparedness/legal/Pages/phe-qa.aspx on May 31, 2012. 
 
 
 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  43  Table E-1  HHS Resources Provided to Affected States in 2010 and 2011, Continued 
HHS Resource(s) Provided 
Core Functional Area  Incident  State(s) 
Objective  Strategy  Response 
Assess risk to the    SAMHSA monitored methadone movement and 
Ensure the  public health and  security  
integrity of the  medical assets, 
Joplin tornado  Missouri  public health  including safety of 
and medical  human, biologics,  
infrastructure  veterinary drugs, 
 
and medical devices 
CT, DC, DE,    No State requests or HHS actions 
MA, MD, NC, 
Hurricane Irene  NJ, NY, PA,  None noted  None noted 
PR, RI, SC, VT, 
VA, USVI 
  Blood supply reports for area provided to State 
Red River 
North Dakota  None noted  None noted 
flooding 
Assess blood and    Blood supply reports for area provided to State 
Provide life-
blood product 
Joplin tornado  Missouri  saving medical 
8.  Blood, Organs, and Blood  availability and 
capability 
Tissues  mitigate shortages 
CT, DC, DE,    Blood supply reports for area provided to States 
MA, MD, NC, 
Hurricane Irene  NJ, NY, PA,  None noted  None noted 
PR, RI, SC, VT, 
VA, USVI 
Perform    REC monitored State actions and requests 
assessments of 
needs for vector 
Assess integrity 
Red River  control, food and 
North Dakota  of public health 
flooding  water safety, and 
infrastructure 
sanitation.  Support 
State requests for 
assistance 
9.  Food Safety and Security  Assess blood and    Blood supply reports for area provided to State 
Provide life-
blood product 
Joplin tornado  Missouri  saving medical 
availability and 
capability 
mitigate shortages 
CT, DC, DE,    Blood supply reports for area provided to States 
MA, MD, NC, 
Hurricane Irene  NJ, NY, PA,  None noted  None noted 
PR, RI, SC, VT, 
VA, USVI 
continued on next page 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  44  Table E-1  HHS Resources Provided to Affected States in 2010 and 2011, Continued 
HHS Resource(s) Provided 
Core Functional Area  Incident  State(s) 
Objective  Strategy  Response 
Red River    No State requests or HHS actions 
North Dakota  None noted  None noted 
flooding 
Ensure the  Provide technical    CDC assessed vaccine and animal control efforts 
integrity of the  assistance for 
Joplin tornado  Missouri  public health and  protection of animal 
10.  Agriculture Safety and  medical  life in coordination 
Security  infrastructure  with ESF-11 
CT, DC, DE,    FDA food safety consultants deployed 
MA, MD, NC,    Technical assistance provided to ESF-11 
Hurricane Irene  NJ, NY, PA,  None noted  None noted 
PR, RI, SC, VT, 
VA, USVI 
Red River    REC monitored State actions and requests 
North Dakota  None noted  None noted 
flooding    PHS subject matter expert (SME) deployed 
  REC assisted hospital in setup of mobile medical 
unit 
Provide necessary 
  ACF collaborated with ESF-6 and MO Division of 
communication 
Provide force  Family Services, Child Care and Development 
equipment, training, 
protection for  Fund 
personnel protective 
Joplin tornado  Missouri  deployed    CDC vaccine and animal control efforts assessed 
equipment (PPE), 
personnel    DMORT needs assessed 
and medical 
    FACT engaged 
countermeasures, if 
  SAMHSA psychological first aid training provided 
11.  All-Hazards Public  required 
  SAMHSA  crisis counseling training provided 
Health and Medical 
 
Consultation, Technical 
  Monitored State health departments, water 
Assistance, and Support 
supplies, and technical assistance for vector 
control 
  CDC EPI conducted conference calls with States 
CT, DC, DE, 
  Health Resources and Services Administration 
MA, MD, NC, 
Provide technical  Technical  (HRSA) contacted grantees and partners to 
Hurricane Irene  NJ, NY, PA, 
assistance  assistance provided  determine impact to community-based services 
PR, RI, SC, VT, 
delivery 
VA, USVI 
  HHS Critical Infrastructure support to American 
Red Cross Blood HQ in Baltimore 
  SAMHSA provided behavioral health technical 
assistance  
continued on next page 
   
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  45  Table E-1  HHS Resources Provided to Affected States in 2010 and 2011, Continued 
HHS Resource(s) Provided 
Core Functional Area  Incident  State(s) 
Objective  Strategy  Response 
  REC monitored State actions and requests 
Be prepared to    ABC coordinated behavioral health stakeholders to 
Monitor  provide mental  identify needs/materials and provided technical 
transition to  health and stress  assistance 
recovery  management    SAMHSA provided technical assistance, crisis 
Red River 
North Dakota  technical assistance  counseling program grants, and monitored impact 
flooding 
on behavioral health systems  
Plan for recovery    ABC coordinated behavioral health stakeholders to 
Monitor 
operations,  ensure that behavioral health was included in 
transition to 
including mental  recovery efforts 
recovery 
health support 
  Deployed behavioral health specialist to DPMU 
Plan for recovery 
Monitor    ABC coordinated behavioral health stakeholders to 
operations 
transition to  ensure that behavioral health was included in 
including, mental 
recovery  recovery efforts 
health support 
 
  SAMHSA assessed and monitored the relocation 
of methadone, patients, and service providers 
  SAMHSA provided crisis counseling program and 
SAMHSA emergency response grants (SERG) 
12.  Behavioral Health Care 
  SAMHSA provided technical assistance and 
Ensure the 
Provide behavioral  consulted with State regarding behavioral health 
integrity of the 
health and stress  programs 
Joplin tornado  Missouri  public health and 
management    American Red Cross provided disaster mental 
medical 
technical assistance  health services  
infrastructure 
  SAMHSA administered crisis counseling program 
and SERG grants 
  SAMHSA provided communication materials for 
State and local dissemination and ABC technical 
assistance to HHS recovery personnel 
  ABC coordinated behavioral health stakeholders 
Monitor potential 
Maintain  and ensured recovery needs were addressed and 
behavioral health 
situational  emergent needs were identified 
concerns of affected 
awareness    SAMHSA communicated with local, regional, and 
populations 
State stakeholders  
CT, DC, DE,    SAMHSA and ABC monitored and coordinated 
MA, MD, NC,    SAMHSA grant funding info passed to VA DOH 
Hurricane Irene  NJ, NY, PA,  None noted  None noted    SAMHSA provided crisis counseling grants  
PR, RI, SC, VT,    SAMHSA provided communication materials for 
VA, USVI  statewide and local dissemination 
continued on next page 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  46  Table E1  HHS Resources Provided to Affected States in 2010 and 2011, Continued 
HHS Resource(s) Provided 
Core Functional Area  Incident  State(s) 
Objective  Strategy  Response 
Provide subject    REC monitored State actions and requests 
matter expertise on    CDC assisted in posting public messages on Web 
Assess the 
risk communication  site 
Red River  integrity of the 
North Dakota  for the public    Public affairs officer (PAO) contacted State officials 
flooding  public health 
regarding health    SAMHSA provided communication materials for 
infrastructure 
concerns after  State and local dissemination 
flooding 
  Public health emergency information published on 
the Assistant Secretary for Preparedness and 
Responses Web site  
Ensure the    SAMHSA published  stress management 
13.  Public Health and  integrity of the  Coordinate public  information on Web site 
Medical Information  Joplin tornado  Missouri  public health  messaging with local    CMS provided information to beneficiaries 
and medical  health officials  regarding  Childrens Health Insurance Program 
infrastructure  (CHIP) and other CMS services on Web site and 
printed materials 
  SAMHSA provided communication materials for 
State and local dissemination 
  PAO worked with States on public messaging 
CT, DC, DE, 
Assess the  regarding well water contamination 
MA, MD, NC,  Coordinate potential 
integrity of the    CDC updated information about hurricanes on 
Hurricane Irene  NJ, NY, PA,  requests or public 
public health  disaster Web sites 
PR, RI, SC, VT,  messaging 
infrastructure    SAMHSA provided communication materials for 
VA, USVI 
State and local dissemination 
continued on next page 
   
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  47  Table E-1  HHS Resources Provided to Affected States in 2010 and 2011, Continued 
HHS Resource(s) Provided 
Core Functional Area  Incident  State(s) 
Objective  Strategy  Response 
Perform    No State requests or HHS actions 
assessments of 
Assess the  needs for vector 
Red River  integrity of the  control, food and 
North Dakota 
flooding  public health  water safety, and 
infrastructure  sanitation; support 
State requests for 
14.  Vector Control (i.e.,  assistance 
eradicating mammals,  Ensure the    CDC vector control efforts and fogging operations 
Provide vector 
birds, or insects that  integrity of the  assessed 
control and 
transmit diseases, such  Joplin tornado  Missouri  public health 
surveillance of food 
as West Nile virus)  and medical 
safety 
  infrastructure 
Conduct vector    REC monitored Virginia Department of Health 
CT, DC, DE,  Ensure the  control survey and  request for technical assistance for vector control 
MA, MD, NC,  integrity of the  provide 
Hurricane Irene  NJ, NY, PA,  public health  recommendations 
PR, RI, SC, VT,  and medical  for long-term control 
VA, USVI  infrastructure  and followup 
activities 
Perform    CDC/FDA monitored State and local requests  for 
assessments of  assistance 
Assess the  needs for vector 
Red River  integrity of the  control, food and 
North Dakota 
flooding  public health  water safety and 
infrastructure  sanitation. Support 
State requests for 
assistance 
15.  Public Health Aspects of 
  CDC/FDA  monitored State and local requests  for 
Potable  Ensure the  Provide technical 
assistance  
Water/Wastewater   integrity of the  assistance for 
  CDC worked with local health department advisory 
and Solid Waste  Joplin tornado  Missouri  public health  potable 
assistance regarding handwashing and boil-water 
and medical  water/wastewater 
order 
infrastructure  assessment 
  REC monitored needs regarding biowaste handling 
CT, DC, DE,    CDC/FDA  monitored State and local requests  for 
MA, MD, NC,  assistance  
Hurricane Irene  NJ, NY, PA,  None noted  None noted   
PR, RI, SC, VT, 
VA, USVI 
continued on next page 
   
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  48  Table E-1  HHS Resources Provided to Affected States in 2010 and 2011, Continued 
HHS Resource(s) Provided 
Core Functional Area  Incident  State(s) 
Objective  Strategy  Response 
Red River    No State requests or HHS actions 
North Dakota  None noted  None noted 
flooding 
Ensure the  Provide technical    Discussed potential for veterinary support on  
integrity of the  assistance for  ESF-8 national calls 
Joplin tornado  Missouri  public health  protection of animal 
16.  Veterinary Medical  and medical  life in coordination 
Support  infrastructure  with ESF-11 
CT, DC, DE,    Discussed potential for veterinary support on  
MA, MD, NC,  ESF-8 national calls  
Hurricane Irene  NJ, NY, PA,  None noted  None noted 
PR, RI, SC, VT, 
VA, USVI 
Red River    No State requests or HHS actions 
North Dakota  None noted  None noted 
flooding 
Ensure the    DMORT support requested and sent to MO; 
integrity of the  Provide fatality  processed over 120 remains 
public health  management 
and medical  capability 
infrastructure 
Joplin tornado  Missouri 
Ensure the    FACT conducted family interviews and collection of 
integrity of the  Provide victim  data to support victim identification 
public health  identification and 
and medical  mortuary services 
17.  Mass Fatality  infrastructure 
Management, Victim  Ensure the    Provided two fatality management SME to VT and 
Identification, and  integrity of the  Provide fatality  advised State on recovery of remains 
Decontaminating  public health  management 
Remains  and medical  capability 
infrastructure 
CT, DC, DE,  Ensure the    Provided two fatality management SME to VT and 
Support the local 
MA, MD, NC,  integrity of the  advised State on recovery of remains 
coroner, provide 
Hurricane Irene  NJ, NY, PA,  public health 
identification of 
PR, RI, SC, VT,  and medical 
human remains 
VA, USVI  infrastructure 
Ensure the    Provided two fatality management SME to VT  and 
integrity of the  Provide victim  advised State on recovery of remains 
public health  identification and 
and medical  mortuary services 
infrastructure 
Source:  The Office of the Assistant Secretary for Preparedness and Response (ASPR)
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  49  APPENDIX F 
Table F-1  2010 and 2011 Incidents to Which the Department of 
Health and Human Services Deployed Resources*  
 
2010 Incidents   2011 Incidents  
Biomedical Advanced Research and Development 
2011 Hawaii Humanitarian Mission 1  
Authority H1N1 Vaccine Support Mission  
H1N1 Outbreak (On-Call)   Earthquake and Tsunami Response  
Haiti Earthquake  Japan Earthquake/Tsunami Nuclear Accident  
Vaccination Team Support  Pennsylvania Severe Winter Storms 
Chile Earthquake  North Dakota Red River Flooding  
North Dakota Red River Flooding   South Dakota Flooding  
Alabama Severe Storms, Tornadoes, and 
New England Flooding  
Straight-Line Winds  
Tennessee Severe Storms, Flooding, and 
New York State Flooding  
Straight-Line Winds  
Federal Emergency Management Agency 
Tropical Storm and Hurricane Alex   (FEMA) Region II Flooding (Multiple States)62  
Hurricane Earl   Hurricane Irene/Tropical Storm Lee  
Louisiana BP Oil Spill   New England Severe Weather 
2010 Hawaii Humanitarian Mission 1   Tropical Storm Maria  
Missouri Severe Storms, Tornadoes, and 
Rocky Boy Indian Reservation Montana Flooding  
Flooding  
Kentucky Severe Storms, Flooding, and 
Mudslides    
2010 Hawaii Humanitarian Mission 2  
Total = 15   Total = 13  
* Incidents include  emergencies and disasters.  Resources may be provided for international incidents.   
Source:  The Office of the Assistant Secretary for Preparedness and Response. 
 
62
 FEMA provides resources to affected areas in States, territories, and tribes and divides its 
service area into regions.  Region II is composed of New York, New Jersey, Puerto Rico, and 
the U.S. Virgin Islands.  FEMA, Region II. Accessed at 
http://www.fema.gov/about/regions/regionii/ on June 22, 2012.  
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)   50  APPENDIX G 
Agency Comments  
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  51  HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  52  HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  53  HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  54  HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  55  Response to OEI-04-11-00260 
Page6 
the single point of contact with the states.  Further, we will add an item to the agenda for our 
incident coordination calls, reminding HHS Staff Divisions and Operating Divisions of the need 
tor a coordinated approach to information exchange with our state partners. Finally, we will 
stress to the StatTDivisions and Operating Divisions that questions can be forwarded to the SOC 
and the SOC can engage states, and then push summary reports out internally ASPR is 
identifying pre-existing federal reports and information sources to establish protected sharing 
capabilities with all our ESF partners prior to an incident response. These collaborations have 
improved situational awareness and planning efforts while similarly reducing the number of 
requests from the federal level to the states. These measures should alleviate multiple requests 
for information and help to ensure that states are not unnecessarily overburdened. 
Thank you for carrying out your study and providing us with a report highlighting how HHS has 
prepared to provide public health and medical services to fulfill its emergency support 
responsibilities, and has carried out those responsibilities in selected responses. We appreciate 
the opportunity to review your report and respond to your recommendations. Please direct any 
questions to Jessica Tytel by telephone at 202.205.4369, or by e-mail at Jessica.Tytel@hhs.gov. 
Nicole Lurie, MD, MSPH 
Assistant Secretary for Preparedness and Response 
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  56  ACKNOWLEDGMENTS 
This report was prepared under the direction of Dwayne Grant, Regional 
Inspector General for Evaluation and Inspections in the Atlanta regional 
office, and Jaime Durley, Deputy Regional Inspector General.   
Sarah McLaulin served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the Atlanta regional office who 
conducted the study include Hannah Spell.  Central office staff who 
provided support include Kevin Farber, Debra Roush, and Talisha Searcy.  
HHS Public Health and Medical Services Emergency Support Preparedness (OEI-04-11-00260)  57  Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.