Table of Contents 

1. INTRODUCTION .......................................................................................................... 1 

2. IMPLEMENTATION PLAN: VISION AND INITIAL ACTIVITIES FOR JANUARY 

2010 THROUGH SEPTEMBER 2010 ............................................................................... 4 

2.1. INVESTMENTS TO ENHANCE CAPABILITIES THAT SUPPORT 

NATIONAL HEALTH SECURITY .............................................................................. 5 

2.2. WORKFORCE ........................................................................................................ 7 

2.3. FEDERAL INTERAGENCY COORDINATION .................................................. 9 

2.4. RISK ASSESSMENT............................................................................................ 10 

2.5. EVALUATION FRAMEWORK .......................................................................... 12 

2.6. QUALITY IMPROVEMENT ............................................................................... 15 

2.7. RESEARCH AGENDA......................................................................................... 17 

2.8. COUNTERMEASURES ENTERPRISE .............................................................. 18 

3. OVERALL ROLES AND RESPONSIBILITIES ........................................................ 19 

4. IMPROVING THE RESOURCE BASE FOR NATIONAL HEALTH SECURITY .. 21 

5. CONCLUSION............................................................................................................. 23 

Table A.1 Elements of Preparedness within Hospital Preparedness Program, Fiscal 

Table A.2 Hospital and Awardees Preparedness Indicators and Capabilities, by States 

Table A.3 FY 2009 Public Health Emergency Preparedness Cooperative Agreement 

Table A.4 Public Health Emergency Preparedness Cooperative Agreement Awards, by 

Table A.5 Public Health Emergency Preparedness Public Health Emergency Response 

Table A.7 Hospital Preparedness Program Awards by Awardees, Year, and Major 

APPENDIX A. EVALUATION OF PROGRESS........................................................... 24 

Years 2002 and 2007 .................................................................................................... 38 

and Awardees, Fiscal Years 2006 and 2007 ................................................................. 40 

Awards, by Awardee, Year, and Major Category......................................................... 41 

Awardee and Year ........................................................................................................ 44 

Awards, by Year ........................................................................................................... 47 

Table A.6 FY 2007 Pandemic Flu Funding ................................................................ 49 

Category........................................................................................................................ 52 

Table A.8 FY 2009 H1N1 Supplemental Funding ...................................................... 55 

Table A.9 FY 2007 ASPR Healthcare Facilities Partnership Program ...................... 58 

Table A.10 FY 2007 ASPR Emergency Care Partnership Program ........................... 59 
Table A.11 Emergency System for Advance Registration of Volunteer Health 

Professionals Awards, by Awardee, Year, and Major Category .................................. 60 

Table A.12 United States–Canada and United States–Mexico Border States Original 

Early Warning Infectious Disease Surveillance (EWIDS) Allocations from HHSASPR-Office of Medicine, Science, and Public Health (OMSPH) .............................. 64 

APPENDIX B. GAP ASSESSMENT OF PERFORMANCE MEASURES .................. 66 

APPENDIX C. STATUS OF PERFORMANCE MEASURE DEVELOPMENT FOR 

CAPABILITIES................................................................................................................ 70 

Table C.1 Status of Performance Measures for Community Resilience and Recovery 70 

Table C.2 Status of Performance Measures for Infrastructure ..................................... 73 

Table C.3 Status of Performance Measures for Situational Awareness ....................... 75 

Table C.4 Status of Performance Measures for Incident Management ........................ 83 

Table C.5 Status of Performance Measures for Disease Containment and Mitigation 85 

Table C.6 Status of Performance Measures for Health Care Services ......................... 87 

Table C.7 Status of Performance Measures for Population Safety and Health ............ 90 

Table C.8 Status of Performance Measures for Quality Improvement and 

Accountability............................................................................................................... 91 

APPENDIX D. ACRONYMS ......................................................................................... 92 
1. INTRODUCTION 

The Pandemic and All-Hazards Preparedness Act (PAHPA) was enacted in 2006 to 

improve the Nation’s ability to detect, prepare for, and respond to a variety of public 

health emergencies. Among other things, PAHPA directs the Secretary of the 

Department of Health and Human Services (HHS) to develop a National Health Security 

Strategy (NHSS), to be initially presented to Congress in 2009 and subsequently revised 

every four years afterward. 

National Health Security Strategy Identifies Goals and Strategic Objectives for the 

Nation 

As noted in the National Health Security Strategy document, national health security is 

achieved when the Nation and its people are prepared for, protected from, ready to 

respond to, and able to recover from incidents with potentially catastrophic health 

consequences. 

The NHSS is designed to achieve two goals: 

	 Build community resilience 

	 Strengthen and sustain health and emergency response systems. 

These goals are supported by ten strategic objectives, which address areas that require 

urgent and focused attention and improvement. The strategic objectives describe what 

must be accomplished to address current gaps in national health security over the next 

four years and to maintain improvements in health security over the longer term. The ten 

strategic objectives are: 

1.	 Foster informed, empowered individuals and communities 

2.	 Develop and maintain the workforce needed for national health security 

3.	 Ensure situational awareness 

4.	 Foster integrated, scalable health care delivery systems 

5.	 Ensure timely and effective communications 

6.	 Promote an effective countermeasures enterprise 

7.	 Ensure prevention or mitigation of environmental and other emerging threats to 

health 

8.	 Incorporate post-incident health recovery into planning and response 

9.	 Work with cross-border and global partners to enhance national, continental, and 

global health security 

1 
10. Ensure that all systems that support national health security are based upon the 

best available science, evaluation, and quality improvement methods 

The strategic objectives, in turn, are supported by a set of 50 operational capabilities. 

The capabilities provide the means to accomplish the goals of the NHSS and are the 

“building blocks” of health security. These capabilities promote the ability of 

individuals, communities, and governments to prevent, protect against, respond to, and 

recover from threats to the Nation’s health and well-being. 

Interim Implementation Guide Identifies Initial Activities That Provide the 

Foundation for a More Complete Biennial Implementation Planning Process 

The Nation has already made considerable progress in achieving health security (see 

Appendix A). Yet fully realizing the NHSS’s goals and strategic objectives will require 

detailed planning to guide implementation. Such detailed guidance will come in an 

Implementation Plan, the first version of which is scheduled for September 2010 and 

which will be revised every two years. The Plan will outline federal-level activities and 

provide guidance to inform planning at the local, state, territorial, and tribal levels and in 

the non-governmental sector. It will also outline a comprehensive evaluation approach to 

ensure that activities undertaken to achieve the goals and strategic objectives of the 

NHSS are informed by performance monitoring and lessons learned over time. 

In the meantime, this Interim Implementation Guide describes initial implementation 

activities, most of which are already under way, that will take place during the ninemonth period from January 2010 through September 2010 and provides a foundation for 

developing a more comprehensive Biennial Implementation Plan. The initial nine-month 

planning period will allow for coordination with ongoing planning by the Department of 

Homeland Security (DHS), including completion of the next round of revisions to the 

Target Capabilities List (TCL), revision of Homeland Security Presidential Directive 

(HSPD) 8, and the development of workforce competencies for all sectors involved in 

national health security. 

Implementation Is a National, Not Merely a Federal, Responsibility 

As is noted in the NHSS, national health security is everyone’s responsibility. The 

Nation draws its strength from the combined efforts of local, state, territorial, tribal, and 

federal levels of government, private sector industry, nonprofit agencies, academia, 

communities, families, and individuals. Thus, implementation of the NHSS will require 

the dedicated efforts of all of these stakeholders. The process for developing the Biennial 

Implementation Plan will feature 

 Public forums conducted across the country 

 Solicitation of input and feedback from existing advisory committees and working 

groups on national health security 

 Use of technology to expand opportunities for public input and feedback 

2 
Organization of the Interim Implementation Guide 

Chapter 2 of this Interim Implementation Guide describes initial implementation 

activities for the first nine months of 2010. Chapter 3 then describes, in general terms, 

roles and responsibilities in implementation. Chapter 4 discusses how to improve and 

sustain resources for national health security. Finally, Chapter 5 provides a brief 

conclusion to the Guide. 

3 
2. IMPLEMENTATION PLAN: VISION AND INITIAL ACTIVITIES 

FOR JANUARY 2010 THROUGH SEPTEMBER 2010 

During the first nine months of 2010, HHS and its partners will focus on accomplishing 

eight initial activities that provide a foundation for further implementation of the NHSS: 

	 Identify and prioritize a list of investments to enhance the capabilities required to 

achieve national health security (2.1) 

	 Conduct a workforce gap analysis and develop workforce competencies for all 

sectors involved in national health security (2.2) 

	 Coordinate HHS’s efforts to improve national health security with those of DHS 

and all federal agencies involved in national health security (2.3) 

	 Begin to identify and develop methods for risk analysis appropriate to the broad 

range of risks to public health (2.4) 

	 Develop an evaluation framework, including plans for performance monitoring 

and evaluating the impact of investments (2.5) 

	 Promote and implement quality improvement (QI) methods for health security on 

a broader scale (2.6) 

	 Propose an agenda for research to enhance national health security (2.7) 

	 Conduct an assessment of the countermeasures enterprise with the aim of 

identifying how to develop, manufacture, and ensure availability and delivery of 

countermeasures faster and more efficiently (2.8) 

These cross-cutting activities are applicable to and support the two goals and ten strategic 

objectives of the NHSS. The remainder of this chapter describes underlying principles 

and recommended next steps for each of these initial implementation activities. 

4 
2.1. INVESTMENTS TO ENHANCE CAPABILITIES THAT SUPPORT 

NATIONAL HEALTH SECURITY 

HHS will develop a list of candidate investments and policies designed to address all 

stages of a health incident, including “prevent,” “protect,” “respond,” and “recover.” 

This development process will include consultation with a wide range of stakeholders and 

reviews of commission reports and after-action reports. The candidate investments will 

likely fall into the following broad categories: 

	 Developing and improving plans for emergencies, including communication, 

security, transportation, etc. 

	 Involving community organizations in emergency planning, including developing 

community resilience 

	 Developing partnerships between coordinating agencies and local communities 

	 Developing tools and approaches for training 

	 Training and exercising specific capabilities 

	 Increasing the quantity of material available for medical emergencies, including 

stockpiles of and the capacity for the manufacture of countermeasures and 

medical equipment and the capabilities required at all levels of government 

(local, state, territorial, tribal, and federal) to deliver these materials in a time of 

need 

	 Building a fully national biosurveillance system 

	 Increasing the number of personnel needed for biosurveillance, including skilled 

laboratory personnel and epidemiologists 

	 Increasing the number of pre-identified and trained volunteers for responding to 

medical emergencies 

	 Ensuring that legal protections and authorities are in place and legal barriers are 

removed for emergency medical care and resources 

	 Ensuring that laboratory information is available through an electronic laboratory 

information exchange. 

Given the broad range of stakeholders involved in national health security, these 

investments will be carried out at the local, state, territorial, tribal, and federal levels and 

in the public and private sectors. 

Next Steps 

During the first nine months of 2010, it will be important to undertake a process for 

developing and prioritizing the list of investments. In addition, it will be useful to 

develop planning templates that communities can use to tailor investments to local 

5 
conditions as well as tools for measuring progress. Communities, in turn, must analyze 

the list in the context of their own capabilities and requirements in order to best prepare 

themselves. 

6 
 

 

 

 

 

 

2.2. WORKFORCE 

An adequately sized, capable, and diverse workforce is a key ingredient of health security 

systems. The workforce for national health security includes but is not limited to 

employees in public health, health care, homeland security, pre-hospital emergency 

medical systems, volunteers, and others. Workforce shortages in sectors with key roles in 

national health security (e.g., public health1 and health care2) are projected to worsen over 

time. For instance, studies at the local3 and national4, 5, 6 levels have identified key 

shortages in the supply of public health nurses, epidemiologists, and laboratory 

personnel.7, 8 In addition, the workforces in public health departments are often less 

racially/ethnically diverse than the populations they serve.9 

Next Steps 

Planning for implementation of the NHSS must be based on a clear understanding of the 

needs and gaps in the entire workforce vital to health security. Thus, the HHS Assistant 

Secretary for Preparedness and Response (ASPR) will seek to synthesize existing 

research to generate a more complete picture of the size, competencies, and diversity of 

the entire health security workforce. This more comprehensive view will include not 

only public health employees in a wide range of settings, but also employees in other 

sectors relevant to health security for which workforce enumerations have been 

conducted (e.g., health care and emergency medical services). 

1 American Public Health Association, Shortage of U.S. Public Health Workers Projected to Worsen: 

About 250,000 New Workers Needed (May 2008) (accessed online 9/30/09 at 

http://www.apha.org/publications/tnh/archives/2008/May+2008/Nation/WorkforceNAT.htm).

2 Health Resources and Services Administration, The Physician Workforce: Projections and Research into 

Current Issues Affecting Supply and Demand (December 2008) (accessed online 10/09/09 at 

ftp://ftp.hrsa.gov/bhpr/workforce/physicianworkforce.pdf).

3 K.M. Gebbie, A. Raziano, and S. Elliott, “Public Health Workforce Enumeration,” American Journal of 

Public Health, 99, 786-787 (2009). doi:10.2105/AJPH.2008.137539. 

4 Association of State and Territorial Health Officials, 2007 State Public Health Workforce Survey Results 

(Arlington, VA, 2008).

5 National Association of County and City Health Officials (NACCHO), 2005 National Profile of Local 

Health Departments (Washington, D.C., July 2006) (Accessed online 10/05/09 at 

http://www.naccho.org/topics/infrastructure/profile/upload/NACCHO_report_final_000.pdf).

6 Another, more recent survey of local health departments across the nation was conducted by NACCHO, 

but data have not yet been analyzed.

7 Association of State and Territorial Health Officials, 2007 State Public Health Workforce Survey Results 

(Arlington, Va., 2008).

8 NACCHO, 2005 National Profile of Local Health Departments (Washington, D.C., July 2006) (accessed 

online 10/05/09 at 

http://www.naccho.org/topics/infrastructure/profile/upload/NACCHO_report_final_000.pdf).

9

 National Association of County & City Health Officials, 2005 National Profile of Local Health 

Departments (Washington, D.C., July 2006) (accessed online 10/05/09 at 

http://www.naccho.org/topics/infrastructure/profile/upload/NACCHO_report_final_000.pdf). 

7 
 

 

 

In addition, ASPR will begin planning for a more comprehensive study in the future. 

This study will include the broader range of workforces relevant to national health 

security and address limitations of past research. Specifically, this study should: 

	 Include the full range of employees that play a role in health security in the 

enumeration of the workforce, including not only public health but also health 

care, homeland security, first responders, and others 

 Ensure that workers who are employed in multiple settings are counted only once 

 Include volunteers in the workforce assessment 

 Facilitate streamlined and routine data collection to quantify the workforce10 

 Establish a standard taxonomy for classifying occupations relevant to health 

security 

	 Create a method for counting health security workers outside government 

agencies that does not place undue burdens on local community agencies and 

organizations 

	 Assess the racial/ethnic composition of the health security workforce to identify 

areas in which greater racial/ethnic diversity is needed. 

ASPR will also review opportunities to use existing efforts to identify core health 

security competencies to inform efforts to close gaps in the workforce.11 

10 K.M. Gebbie, A. Raziano, and S. Elliott, “Public Health Workforce Enumeration,” American Journal of 

Public Health, 99, 786–787 (2009). doi:10.2105/AJPH.2008.137539. 

11 The Centers for Disease Control and Prevention (CDC) /Council of State and Territorial Epidemiologists 

(CSTE) Applied Epidemiology Competencies Toolkit that describes these competencies and their 

evaluation can be accessed at the following website: 

http://www.cste.org/dnn/Home/CSTEFeatures/Competencies/tabid/174/Default.aspx (accessed online 

12/22/09) 

8 
2.3. FEDERAL INTERAGENCY COORDINATION 

Harmonization of efforts by HHS and DHS, as well as by other federal agencies involved 

in national health security (e.g., Department of Veterans Affairs, Department of Defense, 

Department of Labor, Department of Agriculture, and Department of Transportation), is 

necessary to ensure consistency of approaches to improving health security. 

Defining capabilities and developing appropriate measures is one particular area in which 

coordination is especially crucial. For instance, DHS is currently revising the TCL. This 

revision is scheduled for completion in September 2010, approximately nine months after 

the release of this Interim Implementation Guide. The timing of the release of the more 

detailed Biennial Implementation Plan has been deliberately set to coincide with the 

release of the revised TCL. Thus, in the coming months, HHS will need to work with 

DHS to ensure that the NHSS’s capability definitions and measures are consistent with 

the TCL. 

9 
 

2.4. RISK ASSESSMENT 

To help decide on priorities for investment in national health security, it is necessary to 

identify the key health security risks faced by the Nation. As in the NHSS, risk is defined 

as the multiplicative product of “threat,” “vulnerability,” and “consequences.” While 

risk-based resource allocation does not necessarily imply targeting the highest risks, it is 

clear that resource allocation and other policies should be made with knowledge of the 

health security risks faced by different planning jurisdictions (e.g., local, state, territorial, 

and tribal) and the Nation as a whole. Thus, risk assessment provides a cornerstone in 

implementing the NHSS. 

Traditional approaches to risk assessment are based on being able to identify threats, 

estimate vulnerabilities, and then estimate consequences if the threat were manifested. 

Differing approaches have been taken by DHS,12 the World Health Organization 

(WHO),13 and other large organizations14 to attempt to effectively assess health risks. 

Given the recent addition of health security as an explicit focus of national policy, more 

work is needed to determine the appropriateness and effectiveness of these approaches 

for the NHSS, including the availability and collection burdens of the necessary data and 

the practical utility of these approaches at the national to local levels. 

Principles 

The risk assessment approach should be based on exemplary practices from other sectors 

and other countries and should integrate effectively with risk assessment methods and 

risk management frameworks used by other federal organizations, particularly DHS. 

Three basic principles should guide the development of the NHSS’s risk assessment 

approach. The approach should be 

1. Analytic and data driven: Reliable, valid, and replicable 

2. Deliberative: Transparent and comprehensive 

3. Practical and timely: Provide actionable information. 

The National Planning Scenarios, 15 all-hazard scenarios developed by DHS for a 

capabilities-based approach to preparedness activities, are a starting point for the national 

health security risk assessment, since they provide an accepted, challenging set of 

hazards. Planning jurisdictions at all levels, from national to local, can use these 

scenarios. However, an assessment of other health-related hazards, or combinations of 

12 “National Strategy for Homeland Security,” Homeland Security Council, October 2007. 

13 “Integrated Risk Assessment,” Report Prepared for the World Health Organization, UNEP/ILO, 

International Programme on Chemical Safety, WHO/IPCS/IRA/01/12, December 2001.

14 “Applying Risk Management Principles to Guide Federal Investments,” Testimony Before the 

Subcommittee on Homeland Security, Committee on Appropriations, House of Representatives. United 

States Government Accountability Office (GAO), GAO-07-386T, February 7, 2007. 

10 
 

 

hazards (to include geographic and temporal clustering), might be needed to inform the 

development of the NHSS’s risk assessment methods. 

One starting point for the effort should be to leverage existing, established practices of 

community health assessment (CHA), which involves collecting data on the 

demographics and health status indicators of a specific community to identify the primary 

health problems faced by that community.15 Specifically, ASPR should identify, 

develop, and refine user-friendly CHA tools and templates that can be disseminated and 

adapted to the specific needs of local communities, states, territories, and tribes. 

Next Steps 

To begin this process, during the first nine months of 2010, the following steps will be 

required in selecting and developing an appropriate risk assessment approach for health 

security: 

	 Review and compare state-of-the-art, health-related risk assessment methods and 

tools. This review of recommended best practices should inform the NHSS’s risk 

assessment approach. 

	 Rigorously field-test one or more approaches to risk assessment in communities. 

Field testing of risk assessment tools and templates will help improve their 

effectiveness, generality, and feasibility of implementation. 

	 Develop a plan for broader implementation of the risk assessment tools/approach. 

The plan should include key steps, responsibilities, and timelines. 

15 “Finding Information for a Community Health Assessment,” University of North Carolina at Chapel Hill 

Health Sciences Library (accessed online 11/18/09 at 

http://www.hsl.unc.edu/services/guides/communityHealth.cfm). 

11 
2.5. EVALUATION FRAMEWORK 

Concerted efforts to develop and sustain national health security have begun only 

recently in the Nation’s history, and the evidence base for health security remains weak. 

Thus, implementation will need to be characterized by continuous learning and 

improvement. Evaluation and measurement provide the ongoing performance feedback 

needed to guide such learning and will be a part of the inaugural Biennial Implementation 

Plan. 

Principles 

The evaluation framework should provide information that decisionmakers and other 

stakeholders need to assess system functioning and return on investment. Specifically, 

the framework will provide concrete plans designed to support performance monitoring 

and evaluations of the impact of investments: 

	 Performance monitoring. Decisionmakers and other stakeholders need data that 

represent the health security system’s ability to execute the capabilities outlined in the 

NHSS. Performance measures should focus on aspects of health security that are 

mission critical, likely to fail, and applicable to a broad range of the Nation’s 

communities (ranging from large metropolitan areas to rural communities). Having 

such data will allow all stakeholders to track changes over time and identify strengths 

and weaknesses. 

	 Evaluations of the impact of investments. Decisionmakers and other stakeholders also 

need to know whether the investments the Nation is making in national health 

security are actually improving the ability of stakeholders at all levels to execute the 

capabilities outlined in the NHSS and ultimately to meet the goals and strategic 

objectives of the NHSS. These evaluations must be able to distinguish the impact of 

investments from other factors. This will help judgments about return on investment. 

They should also help support all phases in the development of new tools for and 

approaches to national health security, including design, implementation, and scaleup. 

Next Steps 

The inaugural Biennial Implementation Plan will provide a fully elaborated evaluation 

strategy. To help lay the foundation for that more complete plan, during the nine months 

between January 2010 and September 2010, it will be important to continue efforts to 

assess current performance measures of health security and begin to develop new ones 

where critical gaps exist. These provide the basis for performance monitoring and the 

essential building blocks for evaluations of the impact of the Nation’s health security 

investments. The evaluation strategy outlined in the Biennial Implementation Plan will 

emphasize that evaluation is the shared responsibility of local, state, territorial, tribal, 

12 
federal, and non-governmental entities and will provide mechanisms for coordinating 

evaluation efforts and sharing findings. 

Along with the evaluation strategy, this nine-month effort will culminate in a public 

evaluation report on progress in meeting NHSS goals and strategic objectives, thereby 

providing a snapshot of the state of health security in the United States. The report will 

include as many capabilities as possible and will establish a baseline against which future 

performance can be judged. It will also provide the foundation for development of more 

comprehensive reports in coming years. 

To develop the report, HHS will consult with other federal agencies and stakeholders in 

local, state, territorial, and tribal health departments; other government agencies; 

community groups; and other organizations to identify 

 Specific measures for the report 

 A reporting format useful to a broad spectrum of end users and audiences 

 A roll-out and messaging strategy that will effectively communicate key findings 

from the reported performance measures. 

To inform future efforts to develop measures, HHS has already authorized a high-level 

gap assessment of performance measures already in use or under development within its 

agencies and offices as of spring 2009 (see Appendix B). A more comprehensive 

account of the state of performance measurement for each of the capabilities identified in 

the NHSS is contained in Appendix C. Additional efforts are needed to identify gaps in 

performance measurement in all levels of government and sectors relevant to national 

health security. 

The initial report will emphasize measures for which data are already being collected. 

Given the short timeline, the inaugural report will emphasize previously developed and 

field tested measures for which data are already—or will soon be—collected. Thus, the 

initial report will include the following: 

	 State and territorial health department capabilities. Data collected as part of 

CDC’s Public Health and Emergency Preparedness (PHEP) Cooperative 

Agreement assess state and territorial health departments on incident 

management, crisis and emergency risk communication with the public, and 

public health laboratories. If possible, the first report might also include 

assessments of other biosurveillance capabilities (e.g., epidemiologic 

investigation and surveillance) in state and territorial health departments. 

	 Local, state, territorial, and tribal countermeasure delivery capabilities. Data 

collected by the CDC’s Division of Strategic National Stockpile assess the Cities 

Readiness Initiative metropolitan areas (including local, state, territorial, and 

tribal health departments and their partners) on staff and facility call-down, 

facility set-up, inventory management, and dispensing of medications. 

13 
 

	 Hospital and health care facilities’ capabilities. Data collected by ASPR’s 

Hospital Preparedness Program (HPP) assess communities on communications, 

resource tracking, patient transport, fatality management, and other capabilities. 

Additional measures may be developed but without data reported in the first report. 

Measures that have been developed but for which data are not yet available will be 

presented (without numbers) in the report in order to communicate to users and 

stakeholders what future versions of the report will look like. These might include new 

measures on various aspects of community resilience developed by ASPR, new PHEP 

Cooperative Agreement measures developed by CDC, and measures used by nongovernmental efforts such as Project Public Health Ready, the Joint Commission 

(formerly known as the Joint Commission on the Accreditation of Healthcare 

Organizations or JCAHO), and nonprofits involved in community preparedness efforts. 

Development of remaining measures will be described in the first Biennial 

Implementation Plan. The development of any additional measures will be described in 

the first Biennial Implementation Plan, to be released in fall 2010. 

14 
 

2.6. QUALITY IMPROVEMENT 

Ensuring national health security requires the Nation to be able to address any 

performance gaps revealed through evaluation and measurement. Quality improvement 

(QI) provides a set of tools for doing so. 

Principles 

QI methods share a common set of principles and strategies, including: (1) an 

organizational systems framework in which operational performance is the result of a 

series of interrelated processes, (2) data to define performance goals and measure 

performance, (3) various statistical and group process methods and tools to decide how to 

improve performance, and (4) the deliberate spread and implementation of process 

changes that have shown promise at improving performance. 

Although QI models have proven effective in such varying contexts as manufacturing and 

clinical health care provision, they have not yet been widely used in national health 

security. Recent work in the public health sector indicates that QI methods are generally 

well received by public health personnel and have the potential to enhance performance 

in pursuing national health security.16 Early efforts to adapt QI methods to public health 

practice generally have also been promising. 

Next Steps 

As a foundation for future development of QI tools for health security, it would be 

desirable to identify existing tools that incorporate QI and have demonstrated success. 

This review should focus where possible on tools currently used in disciplines involved 

in health security but might also include other fields such as industrial manufacturing. 

In addition, given the successes of pilot QI learning collaboratives in public health, 

further efforts to promote and implement QI methods for health security on a broader 

scale are recommended. Specifically, ASPR will develop a plan for scaling up QI in 

health security. Such a plan could involve some of the following elements and occur 

within existing programs: 

	 Fund efforts to develop and refine QI tools to address gaps or deficiencies in 

existing QI tools. To motivate the improvement of existing health security tools 

informed by QI principles, funding could be made available for efforts to 

accomplish these goals. For example, based on the gaps identified above, 

Requests for Applications (RFAs) could be released to encourage development 

and pilot testing of new health security tools based on QI principles. 

16 See, for example, D. Lotstein, M. Seid, K. Ricci, K. Leuschner, P Margolis, and N. Lurie, “Using 

Quality Improvement Methods to Improve Public Health Emergency Preparedness: PREPARE for 

Pandemic Influenza,” Health Affairs, 27 (July 2008), w328-w339. 

15 
	 Incorporate QI into relevant grant guidance and support. One way to incentivize 

the use of health security tools based on QI principles on a large scale is to require 

or encourage it as a condition of receiving grant funds. Specifically, grantees 

might be required or encouraged to demonstrate the use of a QI process in general 

or the use of a particular QI tool that has evidenced utility for a particular health 

security capability. 

	 Embed QI in the technical assistance provided through grant and accreditation 

programs. To facilitate dissemination of QI methods in health security, technical 

assistance offered by grant and accreditation programs, whose goals are to 

improve and strengthen health security performance, could provide training for QI 

methods. QI could also be offered in technical assistance for grantees receiving 

funds to improve health security across various relevant sectors of activity. 

	 Embed instruction in QI in education programs. To institutionalize the use of QI 

in health security, it must be integrated into the curriculum for degree programs 

and continuing education programs for public health, health care, and other 

relevant professional areas. That is, efforts to teach QI methods must reach both 

practitioners in training and those who are already in the field. 

	 Create recognition programs for agencies with high levels of performance and 

evidence of robust QI programs. The use of QI may be further encouraged by 

publicly commending high-performing agencies that demonstrate robust QI 

programs. These agencies could be recognized through an award given at the state 

level on an annual basis. These recognition programs could follow the models of 

awards for organizational excellence, such as the Malcolm Baldrige National 

Quality Award (www.quality.nist.gov), given by the U.S. National Institute of 

Standards and Technology, and the Governor’s Sterling Award 

(www.floridasterling.com) in Florida. 

16 
2.7. RESEARCH AGENDA 

Research to document the current status of national health security risks and capabilities 

and evaluate the comparative effectiveness of various practices is vital to establishing an 

evidence base for national health security, identifying relevant exemplary practices, and 

spurring innovation in strategies for promoting the Nation’s health security. 

Next Steps 

During the first nine months of 2010, HHS will work with other federal agencies and 

stakeholders to propose a research agenda and identify areas for future research on 

national health security. In the future, it will be necessary to revise the research agenda as 

the evidence base for health security grows and security threats change over time. 

17 
 

2.8. COUNTERMEASURES ENTERPRISE 

At the direction of the Secretary, the Office of the ASPR will lead a review of the 

medical countermeasures enterprise, to be completed in the first quarter of 2010. ASPR 

will analyze how its policies affect every step of countermeasure development, 

production, distribution, dispensing, and utility with a singular goal of improving the 

system. 

Additionally, as part of the research agenda setting process described earlier, during the 

first nine months of 2010, HHS will work with other federal agencies and stakeholders to 

propose a research agenda and identify areas for future research on countermeasures. In 

the future, it will be necessary to revise the research agenda as the evidence base for 

countermeasures grows and security threats change over time. 

18 
 

 

3. OVERALL ROLES AND RESPONSIBILITIES 

The NHSS specifies that national health security requires robust efforts by multiple 

stakeholders across all sectors. In government this includes, but is not limited to, public 

health, health care, emergency management, and law enforcement. Public health and 

other government agencies occupy a distinctive role as the lead sector in ensuring 

national health security—and consistent with the lead role assigned to the HHS Secretary 

in PAHPA.17 National health security also requires the development and maintenance of 

resilient communities, including health care providers, non-governmental organizations, 

academia, and private businesses. Thus, a broad range of actors share responsibility for 

national health security. 

During the coming year, it will be necessary to develop an Implementation Plan that 

provides a detailed understanding of who must be involved in each aspect of national 

health security and ensures that all participants are adequately prepared, exercised, and 

aware of each other’s roles in preventing, protecting against, responding to, and 

recovering from health emergencies. Plans must also recognize that roles, 

responsibilities, and mechanisms for coordinating implementation partners will vary 

somewhat from community to community, reflecting differences in governmental 

structure, community resources, culture, and risk profiles. However, all such planning 

should be guided by the principles articulated in the National Response Framework and 

other key sources of national homeland security doctrine. In general terms, key partners 

in ensuring national health security and their roles and responsibilities are 

	 Local, state, territorial, and tribal governments. Primary authority for health 

security lies with local, state, territorial, and tribal governments. 

	 Federal government. The federal government has a significant role in supporting 

local, state, territorial, and tribal governments before, during, and after incidents. 

It seeks to reduce unwarranted variations in capacity and capability through such 

activities as providing funding and guidance, developing and promulgating 

performance measures and standards, sponsoring research, supporting 

disseminating evidence-based tools and practices, and providing technical 

assistance. 

	 Communities (individuals, families, and non-governmental organizations). As 

noted in the National Response Framework (NRF), “resilient communities begin 

with prepared individuals and depend on the leadership and engagement of local 

government, non-governmental organizations, and the private sector” (NRF, 5). 

In an emergency, individual citizens are often first responders and provide search 

and rescue and medical aid before professional responders arrive. Additionally, 

17 Public Health Service Act (42 U.S.C. 300hh-1), as amended by section 103 of the Pandemic and All 

Hazards Preparedness Act, Public Law No. 109-417. 

19 
 

during major disease outbreaks, volunteers have assisted with mass vaccination 

clinics, supporting the sick and their caregivers, and have participated in policy 

decisions related to health security.18 

	 Academia. Academia can contribute to national health security by conducting 

basic to applied research (to develop new technologies and identify best practices 

for national health security) and providing education and training in activities 

necessary to ensure health security. Academia may also play a key role in helping 

to institute cultural change by conducting research on interventions designed to 

promote attitudes and behaviors that enhance preparedness and resilience. 

	 Private sector. The private sector is a critical part of society, as it provides 

essential goods and services and touches the majority of our population on a daily 

basis, through an employer-employee or vendor-customer relationship. 

Businesses should develop and practice plans for protecting their employees and 

ensuring business continuity. Critical infrastructure entities, such as power 

companies and other utility services, must also be engaged in planning for public 

health emergencies because of our society’s dependence upon their services. 

	 International community. Increasingly, health security also requires collaboration 

among international organizations and governments, as many risks and threats do 

not respect borders and are heightened due to globalization and technology; 

moreover, experience outside the United States offers a fertile and heretofore 

largely untapped avenue to help inform national health security policy and 

practices. 

18 M. Schoch-Spana, B. Courtney, A. Norwood, "Expanding the Public’s Role in Health Emergency 

Policy. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science Vol. 7, No. 1 (March 

2009): 39-41. 

20 
 

4. IMPROVING THE RESOURCE BASE FOR NATIONAL 

HEALTH SECURITY 

Improving and sustaining the Nation’s health security will require a clear strategy for 

providing required resources and overcoming a number of current resource challenges. 

First, government-wide funding for health security is spread across many different 

agencies and programs at the national to local levels and would benefit from stronger 

coordination. Moreover, governmental funding has been inconsistent over time; ebbs and 

flows in funding priorities and levels have often left local, state, territorial, and tribal 

agencies reluctant to make long-term commitments to the staff and activities required to 

develop and maintain robust national health security capabilities. Finally, health security 

requires partnerships among governmental agencies, non-governmental organizations, 

academia, private businesses, and communities; and there is currently little activity to 

promote this type of partnership. One way to promote this type of partnership would be 

to require or encourage the formation of such partnerships in grant guidances. 

Principles 

Thus, implementation of the National Health Security Strategy will require 

	 Improving the coordination of and streamlining federal funding sources for 

national health security 

	 Developing incentives and supports for non-governmental investments in health 

security 

	 Identifying and disseminating promising practices for governmental and nongovernmental resource coordination 

	 Developing workable funding sources for non-governmental partners 

	 Employing sound fiscal management, accounting, and budgeting principles. 

Next Steps 

Further implementation planning during the nine-month interim period from January 

2010 through September 2010 should include the following activities: 

	 Analyze existing funding streams across governments for health security in order 

to identify overlaps and opportunities for partnerships across programs to 

streamline and coordinate funding streams, application and reporting processes, 

and performance measurement. This analysis should lead to concrete 

recommendations for budget development 

	 Conduct an initial scan of opportunities and promising practices for building 

health security capacities and capabilities into routine public health systems and 

processes (e.g., concept of dual use) 

21 
	 Review and identify opportunities to create incentives (e.g., through grant 

programs and the tax code) for non-governmental organizations to make or seek 

investments and engage in activities that contribute to the health security of their 

communities 

	 Identify promising approaches for coordinating governmental and nongovernmental resources for health security (e.g., through mechanisms including 

regional consortia and public-private partnerships) 

	 Identify an appropriate mechanism for continuing to identify, collect, disseminate, 

and implement promising practices related to the topics listed above that does not 

place undue burdens on community governmental and non-governmental agencies 

and entities 

	 Review and evaluate policy and program design options for directly catalyzing 

non-governmental health security efforts in targeted areas through challenge 

grants aimed directly at non-governmental entities. 

22 
5. CONCLUSION 

The National Health Security Strategy is a document of long-range vision and enormous 

potential not only to make our nation more secure, but to increase the quality of life for 

each individual citizen. In order to ensure the best chance of reaching its full potential, 

several preparatory activities must occur before the first Biennial Implementation Plan is 

published in September 2010. This Interim Implementation Guide outlines principles and 

next steps to guide efforts to implement the NHSS and develop a more detailed 

implementation plan during the first nine months of 2010. To this end, the Interim 

Implementation Guide covers eight initial activities to support the NHSS’s 

implementation and describes relevant resource allocation. It also provides an overview 

of HHS’s role in the NHSS’s implementation and describes opportunities to solicit input 

from and involve other stakeholders in this process. After the nine-month interim period, 

a more detailed Implementation Plan that defines more fully the roles and responsibilities 

of the full range of stakeholders will be released concurrent with the revised TCL to 

continue efforts to achieve national health security. 

23 
 

APPENDIX A. EVALUATION OF PROGRESS 

Evaluation of Progress—Assessment of Local, State, Territorial, Tribal, 

and Federal Progress As Measured Against Evidence-Based 

Benchmarks; Funding Charts from HPP and PHEP 

This appendix includes a short summary of reports assessing the local, state, territorial, 

tribal, and federal health security progress. Each report summary identifies the level of 

the evaluation (e.g., federal or state). Next, this appendix includes a summary of the 

Hospital Preparedness Program (HPP) from 2002 to 2007. This section includes both the 

preparedness elements and the indicators and capabilities reported by the awardees. 

Finally, this appendix includes funding charts from HPP and PHEP. 

Assessment of Local, State, Territorial, Tribal, and Federal Progress 

The Federal Response to Hurricane Katrina: Lessons Learned 

The White House 

February 2006 

Available at: http://165.189.80.115/docview.asp?docid=6457&locid=97 

The objective of this report was to review the response of the federal government to 

Hurricane Katrina; however, actions at the state and local levels that had bearing on 

federal decisions or operations were also included to provide full context. The scope of 

the review focuses on identifying systemic vulnerabilities and gaps in the federal 

government response and “fixing government.” The report includes a comprehensive 

description of what happened during the federal response to Hurricane Katrina, beginning 

with a discussion of the magnitude and complexity of the response challenge. A National 

Preparedness “Primer” on the current federal framework is then provided to give the 

reader an understanding of how the current system was supposed to function. The report 

also includes an analytical, narrative chronology providing a detailed account of 

Hurricane Katrina as well as “Lessons Learned,” which describes the 17 most critical 

challenges that were problematic before, during, and after Hurricane Katrina’s landfall. 

The conclusion describes the imperative and remedies for fixing the problems that 

Hurricane Katrina exposed. 

Public Health and Hospital Emergency Preparedness Programs: Evolution of 

Performance Measurement Systems to Measure Progress 

GAO Report to Congressional Requesters, GAO-07-485R 

March 2007 

24 
 

 

Available at: http://www.gao.gov/new.items/d07485r.pdf 

HHS has distributed funds annually to 62 recipients, including all 50 states and four large 

municipalities, through cooperative agreements under two programs—CDC’s Public 

Health Emergency Preparedness Program, and the Health Resources and Services 

Administration’s (HRSA) National Bioterrorism Hospital Preparedness Program (HPP) 

(now administered by ASPR and renamed the Hospital Preparedness Program (HPP)). 

The common goal of CDC’s and HRSA’s preparedness programs is to improve state and 

local preparedness to respond to bioterrorism and other large-scale public health 

emergencies, such as natural disasters or outbreaks of infectious disease. Annually, both 

CDC and HRSA develop and issue program guidance for recipients that describes 

activities necessary to improve their ability to respond to bioterrorism and other public 

health emergencies and sets out requirements for measuring their performance. Each 

recipient is required to submit periodic reports that track progress in improving their 

preparedness. As a result of the nation’s ineffective response to Hurricane Katrina and 

the need to prepare for a possible influenza pandemic, members of the Congress have 

raised questions about CDC’s and HRSA’s efforts to monitor the progress of their 

preparedness programs. 

This report addresses (1) how CDC’s and HRSA’s performance measurement systems 

have evolved and (2) how CDC and HRSA are using these systems to measure the 

progress of their preparedness programs. The review and analysis are specific to federal 

government documents related to national security and emergency preparedness as well 

as to reports obtained from federal agencies. Additionally, interviews were conducted 

with officials from federal agencies that had evaluated CDC’s and HRSA’s public health 

and hospital preparedness programs, professional associations involved in emergency 

preparedness, and policy research organizations that had published assessments or 

evaluations of public health and hospital preparedness programs. CDC and HRSA 

documents were analyzed and officials interviewed to determine how they have 

developed and implemented performance management systems for their cooperative 

agreement programs, including recipient reporting requirements, and systems for 

collecting data from recipients. Additionally, other CDC and HRSA documents were 

analyzed to identify procedures in place for management review of program progress and 

for providing feedback and suggestions for program improvements to recipients. This 

report did not include an evaluation of the actual performance measures adopted by CDC 

or HRSA or examine the accuracy or completeness of recipients’ self-reported data as 

contained in the progress reports they are required to submit to CDC or HRSA. 

Draft BARDA [Biomedical Advanced Research and Development Authority] 

Strategic Plan for Medical Countermeasure Research, Development, and 

Procurement (Draft BARDA Strategic Plan) 

Office of the Assistant Secretary for Preparedness and Response (ASPR) / Biomedical 

Advanced Research and Development Authority (BARDA) 

25 
 

July 2007 

Available at: http://www.hhs.gov/aspr/barda/documents/draftbardaplan.pdf 

ASPR/BARDA prepared a draft BARDA Strategic Plan for review by interested 

stakeholders in 2007; a final version of this document is being completed now for 

publication in early 2010. BARDA was developed to facilitate the research, 

development, and acquisition of medical countermeasures for chemical, biological, 

radiological, and nuclear (CBRN) agents and emerging infectious diseases, including 

pandemic influenza. BARDA establishes systems that encourage and facilitate the 

development and acquisition of medical countermeasures, such as vaccines, therapeutics, 

and diagnostics, as well as innovative approaches to meet the threat of CBRN agents and 

emerging infectious diseases, including pandemic influenza, in support of the mission 

and priorities of the HHS Public Health Emergency Medical Countermeasures Enterprise 

(HHS PHEMCE). 

The strategic plan has four goals: (1) BARDA will align with and coordinate the 

execution of the medical countermeasure goals articulated in the HHS Pandemic 

Influenza Plan; (2) BARDA will align with and coordinate the execution of the medical 

countermeasure goals articulated in the HHS Public Health Emergency Medical 

Countermeasures Enterprise Strategy for Chemical, Biological, Radiological, and 

Nuclear Threats; (3) BARDA, in concert with federal partners, will create a roadmap for 

execution of the HHS Public Health Emergency Medical Countermeasures Enterprise 

Implementation Plan for Chemical, Biological and Nuclear Threats; and (4) BARDA, in 

concert with federal partners, will establish programs that promote innovation in medical 

countermeasure development. 

NDMS Joint Review Phases 1–3 and Surge Capacity Concept Plan 

Phase 1: November 2007 

Phase 2: July 2009 

Phase 3: August 2009 

Available at: No Website Available 

This Joint Review of the National Disaster Medical System (NDMS) assessed NDMS 

using a three-phased approach. The first phase consisted of an “as-is” assessment of the 

current state of NDMS, including the three major components of medical response, 

patient evacuation, and definitive care. The second phase included a requirements 

analysis and corresponding gap analysis of NDMS that outlined recommendations. The 

third phase consisted of the development of an implementation plan for the Phase 2 

recommendations. This review was directed by the HHS Secretary, in coordination with 

the Secretary of Homeland Security, the Secretary of Defense, and the Secretary of 

Veterans Affairs. 

Phase 1: This report provides a picture of the current NDMS operating environment and 

describes the core components of NDMS: Medical Response, Patient Evacuation, and 

26 
 

Definitive Care. This assessment also includes descriptions of Telemedicine Capabilities 

and Initiatives, and a summary of state and local perspectives on the NDMS ability to 

meet the missions requested of them. 

Phase 2: This report includes a series of recommendations from stakeholders and partners 

for improvements in NDMS to close identified gaps. 

Phase 3: This report will include a roadmap (Action Plan) outlining the key strategic 

initiatives that should be considered to move forward and implement the enhancements 

outlined in the recommendations of the Joint Review. The NDMS roadmap highlights 

areas of emphasis and serves as guidance for action. 

Concept Plan: HSPD-21, Public Health and Medical Preparedness, required the 

development of a concept plan for identifying and coordinating federal, state, and local 

government and private-sector public health and medical disaster response resources. 

The Concept Plan is intended to build upon a thorough review of the NDMS and to 

develop strategies and collaborative relationships that extend beyond those more 

narrowly defined by the existing NDMS partnerships and capabilities. 

Public Health Preparedness: Mobilizing State by State 

A CDC Report on the Public Health Emergency Preparedness Cooperative Agreement 

February 2008 

Available at: 

http://www.emergency.cdc.gov/publications/feb08phprep/pdf/feb08phprep.pdf 

The events of September 11, 2001, and the subsequent anthrax attacks both highlighted 

the importance of public health departments during emergencies and showed weaknesses 

in public health’s ability to respond during a potential crisis. In 2002, Congress 

authorized funding for the Public Health Emergency Preparedness cooperative agreement 

to support preparedness nationwide in local, state, territorial, and tribal public health 

departments. As of 2007, the cooperative agreement has provided more than $5 billion to 

these public health departments. 

CDC administers the cooperative agreement and provides technical assistance to public 

health departments. This report outlines progress and challenges and also describes how 

CDC and its partners are working to address these challenges. 

Influenza Pandemic: Federal Agencies Should Continue to Assist States to Address 

Gaps in Pandemic Planning 

GAO Report to Congressional Requesters—GAO-08-539 

June 2008 

27 
 

 

 

Available at: http://www.gao.gov/new.items/d08539.pdf 

The Implementation Plan for the National Strategy for Pandemic Influenza states that in 

an influenza pandemic, the primary response will come from states and localities. To 

assist them with pandemic planning and exercising, Congress has provided $600 million 

to states and certain localities. The Department of Homeland Security established five 

federal influenza pandemic regions to work with states to coordinate planning and 

response efforts. 

In this report, GAO (1) describes how selected states and localities are planning for an 

influenza pandemic and who they have involved, (2) describes the extent to which 

selected states and localities have conducted exercises to test their influenza pandemic 

planning and incorporated lessons learned as a result, and (3) identifies how the federal 

government can facilitate or help improve state and local efforts to plan and exercise for 

an influenza pandemic. GAO conducted site visits to five states and ten localities. 

Emergency Preparedness: States Are Planning for Medical Surge, but Could 

Benefit from Shared Guidance for Allocating Scarce Medical Resources 

GAO Report to Congressional Requesters 

June 2008 

Available at: http://www.gao.gov/new.items/d08668.pdf 

Potential terrorist attacks and the possibility of naturally occurring disease outbreaks have 

raised concerns about the “surge capacity” of the nation’s health care systems to respond 

to mass casualty events. GAO identified four key components of preparing for medical 

surge: (1) increasing hospital capacity, (2) identifying alternative care sites, (3) 

registering medical volunteers, and (4) planning for altering established standards of care. 

HHS is the primary agency for hospital preparedness, including medical surge. In this 

report, GAO describes (1) what assistance the federal government has provided to help 

states prepare for medical surge, (2) what states have done to prepare for medical surge, 

and (3) what concerns states have identified related to medical surge. GAO reviewed 

documents from the 50 states and federal agencies. GAO also interviewed officials from 

a sample of 20 states and from federal agencies, as well as from emergency preparedness 

experts. 

Assessment of States’ Operating Plans to Combat Pandemic Influenza 

Report to Homeland Security Council 

January 2009 

Available at: http://www.pandemicflu.gov/plan/states/state_assessment.pdf 

28 
 

 

Pandemic influenza could produce a public health emergency that is more daunting than 

any other type of naturally occurring, accidental, or terrorist-instigated event that our 

nation has experienced or is likely to experience. Pandemic influenza preparedness is a 

shared responsibility among all levels of government (local, state, and federal), the 

private sector (for-profit and nonprofit entities), and individuals and their households. 

Each entity must (1) understand its unique role (i.e., the ones that only it can fulfill) in 

preparing for, responding to, and recovering from an influenza pandemic, and (2) address 

its respective challenges to the best of its abilities and resources. 

This report discusses the status of the Governments of the States’, the District of 

Columbia’s, and the U.S. Territories’ respective operating plans for performing critical 

state-level functions during and after an influenza pandemic. The report summarizes the 

status of states’ operating plans with respect to preparedness for, response to, and 

recovery from an influenza pandemic. This assessment fulfilled a requirement (Action 

#6.1.1.2) established by the Homeland Security Council, Executive Office of the 

President of the United States, in its National Strategy for Pandemic Influenza: 

Implementation Plan. 

Initial Evaluation of the Cities Readiness Initiative 

Technical Report, RAND Corporation 

January 2009 

Available at: http://www.rand.org/pubs/technical_reports/TR640/ 

The Cities Readiness Initiative (CRI) was created in 2004 to help the nation’s largest 

metropolitan areas develop the ability to provide life-saving medications in the event of a 

large-scale biological terrorist attack or naturally occurring disease outbreak. In 2007, 

CDC asked RAND to provide an initial evaluation of the impact of CRI on awardees’ 

readiness and capability to conduct mass countermeasure dispensing above and beyond 

what would be the case without the program. The subsequent study drew on available 

empirical evidence, including data from the Technical Assistance Review, a CDCadministered assessment of jurisdictions’ capabilities in 12 core functional areas 

associated with countermeasure distribution and dispensing, as well as qualitative data 

collected through discussions with personnel involved with countermeasure dispensing in 

nine metropolitan areas (both CRI awardees and non-CRI jurisdictions). The evaluation 

showed that, overall, CRI awardees had benefited from the program’s preparedness 

guidance and scenario focus and that the program had strengthened or encouraged the 

development of partnerships with other stakeholders. The program also encouraged a 

variety of changes to awardees’ training plans and had spillover effects on non-CRI sites. 

However, this evaluation did not address questions of how the documented benefits 

compare with the program costs. This report should be of interest to those seeking to 

understand the operations of public health preparedness and homeland security programs, 

as well as to those interested in developing feasible approaches to evaluating these 

programs’ effectiveness. 

29 
 

 

 

 

Hospitals Rising to the Challenge: The First Five Years of the U.S. Hospital 

Preparedness Program and Priorities Going Forward 

Center for Biosecurity of UPMC 

March 2009 

Available at: http://www.upmc-biosecurity.org/website/resources/ 

publications/2009/2009-04-16-hppreport.html 

Established by the HHS in 2002, HPPhas the goal of enhancing the ability of hospitals 

and healthcare systems to prepare for and respond both to bioterror attacks on civilians 

and to other public health emergencies, including pandemic influenza and natural 

disasters. Current HPP priorities include strengthening hospital capabilities in the areas of 

interoperable communication systems, bed tracking, personnel management, fatality 

management planning, and hospital evacuation planning. Past priorities include 

improving bed and personnel surge capacity, decontamination capabilities, isolation 

capacity, pharmaceutical supplies, training, education, drills, and exercises. 

In 2007, ASPR contracted with the Center for Biosecurity of the University of Pittsburgh 

Medical Center to conduct an assessment of U.S. hospital preparedness and to develop 

recommendations for evaluating and improving future hospital preparedness efforts. The 

first deliverable was the Center’s Descriptive Framework for Healthcare Preparedness 

for Mass Casualty Events, which provided a description of the most important 

components of preparedness for mass casualty response at the local and regional hospital 

and health care system levels. 

This report, Hospitals Rising to the Challenge: The First Five Years of the U.S. Hospital 

Preparedness Program and Priorities Going Forward, was the second deliverable under 

the contract. It is the Center’s assessment of the impact of the HPP on hospital 

preparedness from the time of the program’s establishment in 2002 through mid-2007, as 

well as the preliminary recommendations for improving the state of U.S. hospital 

preparedness going forward. This evaluation report involved extensive analyses of the 

published literature, government reports, and HPP program assessments, as well as 

detailed conversations with 133 health officials and hospital professionals representing 

every state, the largest cities, and major territories of the United States. 

Personal Preparedness in America: Findings from the Citizen Corps National 

Survey 

National Office of Citizen Corps—FEMA Community Preparedness Division 

June 2009 

Available at: http://www.citizencorps.gov/pdf/Personal_Preparedness_In_AmericaCitizen_Corps_National_Survey.pdf 

Disaster preparedness became a renewed priority for our nation as a direct response to the 

devastation of September 11, 2001. Following the tragedies of that day, government at 

all levels has imbedded stronger collaboration with non-governmental civic and private 

30 
 

 

 

sector organizations and the general public in policies and practices. The Citizen Corps 

grassroots model of community preparedness has spread across the country, and 

Americans have been asked to become fully aware, trained, and practiced on how to 

respond to potential threats and hazards. 

To evaluate the nation’s progress on personal preparedness, the Federal Emergency 

Management Agency’s (FEMA’s) Community Preparedness Division and Citizen Corps 

conducted national household surveys to measure the public’s knowledge, attitudes, and 

behaviors relative to preparing for a range of hazards. This report provides a summary of 

the findings from the 2007 Citizen Corps National Survey. 

Healthcare Facilities Partnership Program Evaluation Report 

Center for Biosecurity of UPMC 

August 2009 

Available at: No Website Available—Draft HFPP Report 

In 2006, the Pandemic and All-Hazards Preparedness Act authorized the Healthcare 

Facilities Partnership and Emergency Care Partnership Programs. These programs 

provide competitive grant opportunities to eligible entities to enhance community and 

hospital preparedness and to promote surge capacity for public health emergencies in 

specific geographic areas. In 2007, ASPR contracted with the Center for Biosecurity of 

UPMC to evaluate the Healthcare Facilities Partnership Program (HFPP) and Emergency 

Care Partnership Program (ECP). The purpose of this evaluation was to assess the 

effectiveness, impact, and efficiency of the HFPP and ECP and to review best practices 

and identify lessons learned. Additionally, it requested an evaluation of the feasibility, 

advisability, and policy implications of adopting the partnership grant program model on 

a national level. 

This report focuses only on the evaluation of HFPP, and a separate report on the ECP 

evaluation was scheduled to be available in October 2009. This report provides 

information useful for assessing the feasibility and effectiveness of the direct grant 

funding concept and for informing efforts to support the development and growth of 

health care partnerships. 

State and Local Pandemic Influenza Preparedness: Medical Surge 

Office of Inspector General, Department of Health and Human Services 

September 2009 

Available at: http://oig.hhs.gov/oei/reports/oei-02-08-00210.pdf 

The objective of the Office of Inspector General (OIG) report was to determine the extent 

to which selected states and localities have (a) prepared for a medical surge in response to 

31 
 

an influenza pandemic and (b) conducted and documented exercises that test their 

medical surge preparedness for an influenza pandemic. The study focused on five key 

components of medical surge identified in the HPP and PHEP guidance, which include 

(1) coordination among stakeholders; (2) recruitment and management of medical 

volunteers; (3) acquisition and management of medical equipment; (4) identification of 

alternate care sites; and (5) identification of guidelines for altering triage, admission, and 

patient care. Most of the selected localities were in the early stages of planning and had 

not identified guidelines for altering triage, admission, and patient care. All of the 

selected localities had established partnerships, had acquired limited medical equipment 

for a pandemic, and had conducted medical surge exercises. Finally, fewer than half of 

those selected had started to recruit medical volunteers. 

Study recommendations for ASPR in collaboration with CDC are to work with states and 

localities to improve their efforts within each of the five components of medical surge 

that were reviewed. Specifically, these include: (1) coordination of diverse stakeholders; 

(2) recruiting, registering, and training volunteers; (3) managing medical equipment 

stockpiles; (4) planning for alternative care sites; and (5) identifying and adopting 

guidelines for altering triage, admission, and patient care. Other recommendations 

include ensuring that states and localities consistently document the lessons learned from 

preparedness exercises for medical surge, address legal protections for medical 

professional and volunteers, facilitate the sharing of information and emerging practices 

among states and localities, and provide training and technical assistance to states and 

localities on key issues. 

Update on the Strategic Plan for Countermeasure Research, Development, and 

Procurement 

BARDA 

November 2009 

Available at: http://www.hhs.gov/aspr/barda/documents/draftbardaplan.pdf 

Background 

Section 401(b) of the Pandemic and All-Hazards Preparedness Act (PAHPA), Public Law 

109-417, requires the Secretary of HHS to: (1) develop and make public a strategic plan 

to guide and facilitate the research, development, innovation, and procurement of medical 

countermeasures19 for CBRN agents and emerging infectious diseases, including 

pandemic influenza; (2) carry out such activities as may be practicable to disseminate the 

information contained in such a strategic plan to stakeholders who may have the capacity 

to substantially contribute to the activities described in such a strategic plan; and (3) 

19 Medical countermeasures include qualified countermeasures as defined in section 319F–1(a) of the 

Public Health Service Act (42 U.S.C. section 247d–6a(a)); qualified pandemic or epidemic products as 

defined in section 319F–3 of the Public Health Service Act (42 U.S.C. section 247d–6d)), and security 

countermeasures as defined in section 319F-2(c)(1)(B) of the Public Health Service Act (42 U.S.C. section 

247d–6b). 

32 
 

 

update and incorporate such strategic plan as part of the National Health Security 

Strategy described in section 2802 of PAHPA.20 

The strategic plan for medical countermeasure research, development, and procurement 

was initially due not later than six months after the date of enactment of the PAHPA 

(enacted December 19, 2006). On July 5, 2007, BARDA released the Draft BARDA 

Strategic Plan for Medical Countermeasure Research, Development, and Procurement 

(Draft BARDA Strategic Plan) to fulfill this requirement.21 The Draft BARDA Strategic 

Plan notes that it represents “current thinking” within BARDA with respect to facilitating 

research, development, innovation, and procurement of medical countermeasures, in 

fulfillment of Section 401(b) of PAHPA, and that a final BARDA Strategic Plan will be 

updated, finalized, and made public after the appointment of a BARDA Director.22 

Strategic Goals 

The Draft BARDA Strategic Plan is built upon the framework established the National 

Strategy for Pandemic Influenza23 and the National Strategy for Medical 

Countermeasures against Weapons of Mass Destruction (HSPD-18)24 and lays out four 

strategic goals for BARDA with respect to medical countermeasure research, 

development, and procurement: 

 Goal 1. BARDA will align with and coordinate the execution of the medical 

countermeasure goals articulated in the HHS Pandemic Influenza Plan.

25 

 Goal 2. BARDA will align with and coordinate the execution of the medical 

countermeasure goals articulated in the HHS Public Health Emergency Medical 

20 Pandemic and All-Hazards Preparedness Act, Public Law 109–417, 120 Stat. 2831 (2006). 

21 Draft BARDA Strategic Plan for Medical Countermeasure Research, Development, and Procurement, 

Washington, D.C.: U.S. Department of Health and Human Services, July 5, 2007 (accessed online 11/23/09 

at http://www.hhs.gov/aspr/barda/documents/draftbardaplan.pdf).

22 HHS announced its intentions to establish BARDA under ASPR in April 2007 (accessed online 12/23/09 

at http://www.hhs.gov/news/press/2007pres/04/pr20070426d.html); Robin Robinson, Ph.D., was selected 

as the first BARDA Director on April 14, 2008 (accessed online 12/23/09 at 

http://www.hhs.gov/news/press/2008pres/04/20080414a.html).

23 National Strategy for Pandemic Influenza, Washington, D.C.: White House, Homeland Security 

Council; December 2005 (accessed online 12/23/09 at http://www.flu.gov/professional/federal/pandemicinfluenza.pdf).

24 Homeland Security Presidential Directive 18: Medical Countermeasures against Weapons of Mass 

Destruction, Washington, D.C.: The White House; January 31, 2007 (accessed online 11/23/09 at 

http://www.dhs.gov/xabout/laws/gc_1219175362551.shtm).

25 HHS Pandemic Influenza Plan, Washington, D.C.: U.S. Department of Health and Human Services. 

November 2005 (accessed online 11/23/09 at 

http://www.hhs.gov/pandemicflu/plan/pdf/HHSPandemicInfluenzaPlan.pdf). 

33 
 

 

 

 

Countermeasures Enterprise26 Strategy for Chemical, Biological, Radiological 

and Nuclear Threats.

27 

	 Goal 3. BARDA, in concert with federal partners, will create a roadmap for 

execution of the HHS Public Health Emergency Medical Countermeasures 

Enterprise Implementation Plan for Chemical, Biological, Radiological and 

Nuclear Threats.

28 

	 Goal 4. BARDA, in concert with federal partners, will establish programs that 

promote innovation in medical countermeasure development. 

The Draft BARDA Strategic Plan notes that with respect to implementation, BARDA will 

employ proven and successful approaches for the advanced development of medical 

countermeasures, such as milestone-driven contracts and incremental funding, to support 

multiple medical countermeasure candidates in the advanced stages of product 

development in order to stimulate competitive product development, enable flexible and 

sound product acquisition decisions, and mitigate risk. 

Stakeholder Outreach 

The Draft BARDA Strategic Plan notes that BARDA is committed to stakeholder 

outreach as a way to enable effective collaboration with domestic and international 

stakeholders among academia; industry; and federal, state, and local governments in 

order to maximize the transparency of HHS priorities, solicit feedback, and discuss the 

implementation of future medical countermeasure advanced development and acquisition 

programs. BARDA stakeholder outreach activities include 

	 Annual HHS PHEMCE Stakeholders Workshop. The BARDA office 

convenes a meeting with interested persons to communicate HHS priorities for 

medical countermeasure development and acquisition and to receive feedback that 

can be appropriately incorporated into future efforts. Stakeholder workshops have 

been conducted annually since 2006.29 

	 Annual BARDA Industry Day. The BARDA office provides an opportunity for 

industry representatives and other interested parties to demonstrate in an open 

meeting the operation of biodefense technologies relevant to vaccines, 

26 The HHS PHEMCE is a coordinated, intra-agency effort that leads the mission to develop and acquire 

medical countermeasures that will improve public health emergency preparedness as well as prevent and
 

mitigate the adverse health consequences associated with CBRN threats and emerging infectious diseases, 

including pandemic influenza.

27 HHS Public Health Emergency Medical Countermeasure Enterprise Strategy for Chemical, Biological,
 

Radiological, and Nuclear Threats, Washington, D.C.: U.S. Department of Health and Human Services;
 

April 2007 (accessed online 11/23/09 at 

http://www.hhs.gov/aspr/barda/documents/federalreg_vol72no53_032007notices.pdf).

28 HHS Public Health Emergency Medical Countermeasure Enterprise Implementation Plan for Chemical, 

Biological, Radiological, and Nuclear Threats, Washington, D.C.: U.S. Department of Health and Human 

Services; April 2007 (accessed online 11/23/09 at 

http://www.hhs.gov/aspr/barda/documents/phemce_implplan_041607final.pdf).

29 See https://www.medicalcountermeasures.gov/BARDA/PHEMCE/phemce.aspx
 

34 
 

 

 

 

 

diagnostics, therapeutics, and non-pharmaceutical medical countermeasures. 

BARDA Industry Day has been held annually since 2007.30 

	 Stakeholders Portal. BARDA provides ongoing outreach to product developers 

through the stakeholders portal at www.MedicalCountermeasures.gov.

31 This web 

portal allows BARDA to centrally manage stakeholder requests for meetings with 

the U.S. government to discuss possible development of acquisition targets and to 

present medical countermeasure product information and provide interested 

persons with information on government-sponsored opportunities and events 

related to medical countermeasures. 

	 BARDA Dialogues. These dialogues represent an ongoing effort by BARDA 

staff to engage stakeholders regarding the implementation of the BARDA 

legislation. 

Current Status 

The final version of the BARDA Strategic Plan is expected to be published in early 2010. 

Update on Vaccine Tracking and Distribution as per Section 319A of the Public 

Health Service Act, as amended 

Secretary of HHS 

November 2009 

Available at: No Website Available 

Section 319A of the Public Health Service Act, as amended, requires that as part of the 

National Health Security Strategy, as described in section 2802, the Secretary of HHS 

shall provide an update on the implementation of subsections (a) through (d). 

a.	 Secretary may track initial distribution of federally purchased influenza vaccine in a 

pandemic 

To inform decision making regarding the 2009-H1N1 Flu vaccine campaign, the 

Centers for Disease Control and Prevention (CDC) receives daily updates from the 

contract vaccine distributor showing the number of doses available for ordering. 

When the CDC receives these updates, the CDC allocates the available doses to the 

62 CDC Public Health Emergency Response (PHER) grantees on a pro rata basis. 

CDC provides daily updates to the grantees on the number of doses allocated / 

available for them to order. The CDC receives orders from grantees and forwards 

those orders to the vaccine distributor. The vaccine distributor provides daily updates 

to the CDC showing the number of doses shipped to each grantee. The aggregate 

30 See https://www.medicalcountermeasures.gov/BARDA/PHEMCE/phemce.aspx 

31 See https://www.medicalcountermeasures.gov/Default.aspx 

35 
 

number of doses allocated / available is posted on the CDC’s web site daily 

(http://www.cdc.gov/h1n1flu/vaccination/vaccinesupply.htm). The number of doses 

shipped to each grantee is updated on the CDC web site each Friday. The CDC does 

not provide demographic data for high priority populations along with vaccine 

distribution data, rather, the CDC advises grantees to refer to census data for the most 

recent estimates of high priority populations. 

b.	 Secretary shall promote communication between State, local, and tribal public health 

officials and manufacturers, wholesalers, and distributors regarding effective 

distribution of seasonal influenza vaccine 

CDC’s FluFinder provides information to state and local health officials regarding 

distribution of seasonal influenza vaccine. FluFinder helps provide visibility about the 

vaccine supply / distribution for public health decision making and management of 

supply issues. 

In response to a shortfall of seasonal influenza vaccine, in October 2004 CDC began 

tracking seasonal influenza vaccine to provide distribution information to state and 

local public health officials. Tracking during the 2004–2005 season focused on 

inactivated (injectable) influenza vaccine produced and distributed by Sanofi Pasteur 

(formerly Aventis Pasteur), which represented approximately 95 percent of the doses 

available that season. CDC provided access to the secure system for a limited number 

of state and local health officials in each jurisdiction. 

In 2005, CDC reached out to Chiron’s major influenza vaccine distributors to enlist 

their participation. CDC updated the system as data were submitted during the season, 

and a key lesson learned during the 2005–2006 season was the need for public health 

officials to have access to vaccine distribution data as early in the distribution process 

as possible. 

Since the 2005–2006 season, FluFinder has evolved to include all U.S.-licensed 

vaccine products (intranasal vaccine and injectable vaccines), and distribution data 

are available to state and local health officials each week from mid-September 

through the end of January. Influenza vaccine distribution data in FluFinder is 

proprietary and is voluntarily submitted by the six U.S.-licensed influenza vaccine 

manufacturers and the major influenza vaccine distributors. The data support state 

and local health officials’ management of seasonal influenza vaccine supply. 

In addition, in the context of the current influenza season, communications with 

stakeholders have included guidance for high priority populations to receive the 

2009-H1N1 Flu vaccine as it becomes available. These guidelines can be found on 

CDC’s website at http://www.cdc.gov/h1n1flu/vaccination/acip.htm. 

c.	 The information submitted to the Secretary related to vaccine distribution information 

shall remain confidential 

36 
The Department adheres to all applicable law regarding confidentiality, including but 

not limited to, the Freedom of Information Act (FOIA), the Trade Secrets Act, and 

the Health Insurance Portability and Accountability Act (HIPAA). 

In addition, compliance with Section 319A of the Public Health Service Act, as 

amended by the Pandemic and All-Hazards Preparedness Act of 2006, and all other 

applicable law includes ensuring that no proprietary data is inappropriately disclosed. 

Information provided to the Secretary by a manufacturer, wholesaler, or distributor is 

not disclosed without consent to another manufacturer, wholesaler, or distributor, or 

used in any manner to give a manufacturer, wholesaler, or distributor a proprietary 

advantage. 

d. the Secretary shall develop guidelines for (a) and (b) 

As described above under subsections (a) and (b), CDC has established processes for 

collecting and disseminating both 2009-H1N1 Flu and seasonal influenza vaccine 

availability data. CDC as a matter of practice protects proprietary information, and 

therefore, the Department has not found the need to develop guidelines to protect 

proprietary information related to influenza vaccine. 

37 
Summary of the Hospital Preparedness Program from 2002 to 2007 According to the Preparedne

and the Indicators and Capabilities Reported by the Awardee

The relative progress of key elements of the decontaminate, personnel training, isolation of hospitals partic

HPP since its inception in 2002 was capacity, and the engagement in drills and surge capacity ab

compared to more recent markers as reported exercises (Table A.1). The elements reflect trained over 700,0

in the end-of-year (EOY) report for fiscal year broad categories that may not share exactly and engaged ove

(FY) 2007. Notable progress has been the same measures, but share a similar hospitals in the ex

demonstrated in the key areas of state emphasis. According to the EOY 2007 participation, surge capacity, the ability to reporting cycle, the states reported that 83% 

Table A.1 Elements of Preparedness within Hospital Preparedness Program, Fiscal Years 2002 and 2007 

Preparedness Element FY 2002* FY 2007*

Participation 

Limited infrastructure for integrated and coordinated hospital preparedness activities among hospitals in the U.S. 

In the U.S., 83% of all hospitals part

Surge Bed Capacity No known surge bed capacity among hospitals in the U.S. 

Hospitals participating in the HPP prto surge nearly 300,000 beds above bed capacity within a 24-hour period 

Decontamination 

Two-thirds (66%) of hospitals reported the ability to handle less than nine patients an hour through a 5-minute decontamination shower per 100 staffed beds 

Nearly 400,000 persons could be deover a 3-hour period 

Personnel Training 

Seven out of ten hospitals trained their staff to diagnose biological-agent-related illnesses, with unknown 

extensiveness of the training 

Over 700,000 health care personnecompetency-based programs in FY 

Isolation Capacity Half of all hospitals reported having fewer than four isolation beds per 100 staffed beds Over 90% of hospitals (4,655) in the 

to maintain at least one suspected innegative pressure isolation 

Drills and Exercises 

About half of all hospitals had participated in drills or tabletop exercises focused on a biological attack during the past two years 

Of the participating hospitals, over 8of an incident and nearly 80% prepawithin 60 days of the drill or exercise 

*The data are based on HPP Fiscal Year 2002 final and 2007 EOY reports. ^The FY 2007 EOY reports were provided to ASPR in December 2008. 

To provide a snapshot, the FY 2006 and 2007 EOY reports were used. The Cooperative Agreement with the state for FY 2006 began on September 1, 2006, and ended on August 31, 2007. The performance measures and data elements were developed subsequent to the program guidance and were released with an Excel database template prior to reporting deadlines. The data elements requested in the spreadsheet were divided into three 

groups, including performance measurement data, program measurement data and sentinel indicators. For FY 2007, the reports were submitted at the end of December 2008 and the data included demographic capabilities, data elements, and performance measures. In determining the percentage of hospitals meeting the requirements of the element, the total number of hospitals was used as the denominator. Either the total 

number of states (of awardees (N=6The total number HPP awardees wa2006 and 2007, repercentage of parand 83% (Table Aand 2007 data poslight changes whthan 5% differenc

38 
percentage of hospitals that have reported 

available beds (according to HAvBED definitions) to State Emergency Operating Centers, within 60 minutes of a request by the state, was, respectively, 84% and 94%. The percentage of hospitals that have participated in a preparedness exercise or incident was 84% and 89%. Some elements remained unchanged or changed just slightly. For example, hospitals’ ability to demonstrate dedicated, redundant, interoperable 

communication during an exercise or incident, was reported as 91% for both years; if the hospitals developed improvement plans based on after action reports with HPP funds, ability was 70% for both years; and hospitals that have adopted the national incident command structure reached 89% and 91%, respectively. Elements that measure the performance of the awardees to demonstrate the ability to report an electronically verified list of available 

volunteer health pof request were 73FY 2007. Awardeeability to report av(according to HAvhours of a request ability to demonstbeds data was unFY 2007. 

39 
Table A.2 Hospital and Awardees Preparedness Indicators and Capabilities, by States and Awardees, Fiscal Y

Indicators and Capabilities 2006 

States Awardees* States 

Hospital Sum n Percent % Sum N Percent % Sum n Perc

% 

Total number of hospitals statewide 5,550 - 5,832 - 5,825 - 

Total number of participating hospitals statewide 4,846 87 5,067 87 4,840 83 

Total number of hospitals that have adopted incident command structure for handling emergency events 4,276 88 4,485 89 4,400 91 Total number of hospitals that have reported available beds, according to HAvBED definitions, to the State Department Health Emergency Operating Center, within 60 minutes of a request, during an event 

4,043 83 4,233 84 4,457 92 

Total number of hospitals that have demonstrated dedicated, redundant communication during an exercise or incident 4,454 92 4,633 91 4,431 92 

Total number of hospitals that have fatality management plans - - - - 3,058 63 

Total number of hospitals that have evacuation plans - - - - 3,820 79 

Total number of hospitals that have participated in an exercise or incident during the reporting period 4,248 88 4,246 84 4,277 88 

Total number of hospitals that have developed improvement plans based on after-action reports 3,564 74 4,001 79 3,806 79 

Awardees* 

Awardees that demonstrated ability to report a verified list of available volunteer health professionals within 24 hours of a request issued by a requesting body or the HHS Secretary Operations Center (SOC). 

37 74 45 73 46 92 

Awardees that reported the number of hospital beds, defined as staffed and available on a day-to-day basis. 49 98 60 97 50 10

Awardees that can report available beds, according to HAvBED definitions, to the HHS SOC or other federal partners within four hours of a request, during an exercise or incident. 

41 82 50 81 50 10

Source: 2006 and 2007 EOY Reports, Hospital Preparedness Program, Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Service. *Awardees include all of the 50 states, four metropolitan areas, and eight territories.

40 
FUNDING CHARTS FROM HPP AND PHEP 

PAHPA specifies that the NHSS shall include an evaluation of progress toward evidence-based benchmarks of pshould include state-specific breakdowns of obligated funding spent by major category (as defined by the Secreta

under HPP and PHEP. The Interim Implementation Guide includes the following state-specific breakdowns of ob

program area. Subsequent submissions of the NHSS will provide breakdowns by the major strategic objectives (oNHSS. Table A.3 FY 2009 Public Health Emergency Preparedness Cooperative Agreement Awards, by Awardee, Category 

STATE / CITY / 

TERRITORY 

GRANTEE 

Total Base Plus 

Population 

Funding 

FY 2009 Cities 

Readiness 

Funding 

FY 2009 Level 1 

Chemical Lab 

Supplement 

FY 2009 

EWIDS 

Funding 

FY 

Publi

STATE Alabama $9,634,114 $350,817 $0 $0 

Alaska $4,800,000 $200,000 $0 $15,000 

Arizona $11,894,931 $1,288,173 $0 $475,290 Arkansas $7,054,691 $224,812 $0 $0 California $41,239,981 $6,026,193 $939,845 $1,135,736 

Colorado $9,856,760 $780,643 $0 $0 Connecticut $8,055,697 $648,709 $0 $0 Delaware $4,632,380 $367,620 $0 $0 

District of Columbia $5,838,859 $622,500 $0 $0 

Florida $29,094,714 $3,235,898 $576,000 $0 

Georgia $16,507,511 $1,638,679 $0 $0 

Hawaii $4,854,334 $290,173 $0 $0 Idaho $5,115,380 $200,000 $0 $15,000 

Illinois $17,423,079 $2,547,840 $0 $15,000 Indiana $12,107,270 $856,931 $0 $15,000 

Iowa $7,301,666 $238,767 $0 $0 Kansas $6,987,186 $459,359 $0 $0 

41 
STATE (cont’d) 

Total Base Plus 

Population 

Funding 

FY 2009 Cities 

Readiness 

Funding 

FY 2009 Level 1 

Chemical Lab 

Supplement 

FY 2009 

EWIDS 

Funding 

FY 

Publi

Kentucky $9,067,274 $443,231 $0 $0 

Louisiana $9,185,117 $571,246 $0 $0 

Maine $4,906,374 $200,000 $0 $76,963 

Maryland $11,100,702 $1,589,340 $0 $0 Massachusetts $12,285,669 $1,462,035 $576,000 $0 

Michigan $17,562,993 $1,425,240 $896,397 $238,912 

Minnesota $10,453,558 $991,880 $576,000 $33,842 

Mississippi $7,198,462 $269,429 $0 $0 

Missouri $11,428,130 $1,047,684 $0 $0 

Montana $4,800,000 $200,000 $0 $19,036 

Nebraska $5,550,822 $223,560 $0 $0 Nevada $6,599,808 $693,153 $0 $0 

New Hampshire $4,896,740 $332,752 $0 $15,000 

New Jersey $15,585,202 $2,662,654 $0 $0 

New Mexico $5,819,515 $260,497 $683,461 $89,668 

New York $18,999,891 $1,954,586 $886,334 $330,193 

North Carolina $15,775,533 $448,959 $0 $0 North Dakota $4,800,000 $200,000 $0 $23,393 

Ohio $19,557,056 $1,740,124 $0 $15,000 Oklahoma $8,163,023 $373,882 $0 $0 

Oregon $8,338,354 $546,562 $0 $0 Pennsylvania $20,945,631 $2,014,731 $0 $15,000 

Rhode Island $4,659,518 $340,482 $0 $0 

South Carolina $9,233,414 $287,922 $576,000 $0 

South Dakota $4,800,000 $200,000 $0 $0 

Tennessee $11,710,990 $784,547 $0 $0 

Texas $36,910,043 $4,300,989 $0 $1,605,920 

Utah $6,678,473 $340,517 $0 $0 

Vermont $4,800,000 $200,000 $0 $42,969 

Virginia $14,024,882 $1,675,130 $913,961 $0 Washington $12,225,957 $1,175,941 $0 $160,078 

West Virginia $5,623,148 $216,087 $0 $0 Wisconsin $11,015,276 $571,303 $576,000 $15,000 

42 
STATE (cont’d) 

Total Base plus 

Population 

Funding 

FY 2009 Cities 

Readiness 

Funding 

FY 2009 Level 1 

Chemical Lab 

Supplement 

FY 2009 

EWIDS 

Funding 

FY 

Publi

Wyoming $4,800,000 $200,000 $0 $0 

STATE SUBTOTAL $561,900,108 $49,921,577 $7,199,998 $4,352,000 

CITY Chicago $9,087,074 $1,612,500 $0 $0 

Los Angeles $19,350,135 $3,172,636 $0 $0 

New York City $16,849,333 $3,825,000 $0 $0 

CITY SUBTOTAL $45,286,542 $8,610,136 $0 $0 

TERRITORY American Samoa $383,368 $0 $0 $0 

Guam $546,695 $0 $0 $0 

Marshall Islands $387,201 $0 $0 $0 

Micronesia $455,796 $0 $0 $0 

Northern Mariana Islands $418,947 $0 $0 $0 

Palau $329,686 $0 $0 $0 

Puerto Rico $8,665,828 $0 $0 $0 

Virgin Islands (U.S.) $456,664 $0 $0 $0 

TERRITORY SUBTOTAL $11,644,185 $0 $0 $0 

TOTAL FY 2009 PHEP FUNDING $618,830,835 $58,531,713 $7,199,998 $4,352,000 

* Allocation is based on the FY 2009 Omnibus enact numbers * Funding aligns with a 12-month budget cycle * EWIDS = Early Warning Infectious Disease Surveillance 

43 
Table A.4 Public Health Emergency Preparedness Cooperative Agreement Awards, by Awardee and Year 

STATE / CITY 

/ TERRITORY 

AWARDEE 

FY 2006 PHEP 

SUPPLEMENT 

FY 2007 PHEP 

TOTAL 

AWARD 

FY 2008 

PHEP 

TOTAL 

AWARD 

FY 2009 

PHEP 

TOTAL 

AWARD 

FY 2009 

PHER 

PHASE I 

FY 2009 

PHER 

PHASE II 

FY 

PH

PHA

STATE Alabama $1,595,205 $12,951,862 $10,241,093 $9,984,931 $3,934,220 $3,981,585 $13

Alaska $657,647 $5,838,752 $5,015,000 $5,015,000 $573,193 $1,861,553 $3

Arizona $1,856,742 $17,681,799 $14,227,671 $13,658,394 $5,274,949 $4,827,276 $16

Arkansas $1,163,333 $9,389,730 $7,435,489 $7,279,503 $2,404,548 $3,016,715 $8

California $6,723,207 $65,303,030 $50,161,370 $49,341,755 $22,677,408 $15,804,211 $66

Colorado $1,605,882 $14,009,943 $11,141,885 $10,637,403 $4,066,256 $4,064,869 $13

Connecticut $1,347,950 $11,324,491 $8,927,705 $8,704,406 $2,998,173 $3,391,156 $10

Delaware $698,960 $5,911,494 $5,000,000 $5,000,000 $730,103 $1,960,526 $4

District of Columbia $635,601 $9,898,127 $6,698,743 $6,461,359 $497,467 $1,313,787 $2

Florida $4,633,819 $42,467,775 $32,940,501 $32,906,612 $15,474,914 $11,261,100 $45

Georgia $2,609,920 $23,156,267 $18,689,009 $18,146,190 $8,010,341 $6,552,677 $24

Hawaii $803,669 $6,418,428 $5,228,184 $5,144,507 $1,099,673 $2,193,640 $5

Idaho $832,432 $6,637,005 $5,405,739 $5,330,380 $1,254,481 $2,291,288 $5

Illinois $2,878,268 $24,575,584 $19,912,211 $19,985,919 $8,553,300 $6,895,159 $26

Indiana $2,007,596 $16,965,990 $13,335,867 $12,979,201 $5,400,873 $4,906,704 $17Iowa $1,215,422 $9,779,223 $7,702,063 $7,540,433 $2,551,012 $3,109,100 $9Kansas $1,162,607 $9,548,746 $7,598,339 $7,446,545 $2,364,516 $2,991,464 $8Kentucky $1,501,451 $12,441,275 $9,750,535 $9,510,505 $3,598,068 $3,769,550 $12Louisiana $1,592,758 $13,243,221 $9,998,186 $9,756,363 $3,667,952 $3,813,631 $12Maine $818,369 $6,526,615 $5,271,144 $5,183,337 $1,130,535 $2,213,106 $5

Maryland $1,840,470 $16,047,435 $13,038,391 $12,690,042 $4,803,949 $4,530,183 $15Massachusetts $2,061,287 $18,039,564 $14,805,770 $14,323,704 $5,506,668 $4,973,437 $17Michigan $2,951,805 $26,992,552 $20,453,241 $20,123,542 $8,636,273 $6,947,495 $26Minnesota $1,731,493 $15,591,573 $12,616,406 $12,055,280 $4,420,173 $4,288,110 $14

44 
STATE (cont’d) 

FY 2006 PHEP 

SUPPLEMENT 

FY 2007 PHEP 

TOTAL 

AWARD 

FY 2008 

PHEP 

TOTAL 

AWARD 

FY 2009 

PHEP 

TOTAL 

AWARD 

FY 2009 

PHER 

PHASE I 

FY 2009 

PHER 

PHASE II 

FY 

PH

PHA

Mississippi $1,200,982 $9,722,247 $7,629,747 $7,467,891 $2,489,808 $3,070,495 $9

Missouri $1,890,782 $16,566,343 $13,029,088 $12,475,814 $4,998,123 $4,652,662 $16

Montana $723,275 $5,982,934 $5,022,876 $5,019,036 $808,081 $2,009,713 $4

Nebraska $922,515 $7,324,391 $5,877,064 $5,774,382 $1,512,711 $2,454,172 $6

Nevada $1,045,254 $9,340,451 $7,652,253 $7,292,961 $2,134,789 $2,846,559 $8

New Hampshire $813,384 $6,447,504 $5,317,054 $5,244,492 $1,124,821 $2,209,503 $5

New Jersey $2,601,641 $22,337,727 $18,788,803 $18,247,856 $7,463,387 $6,207,674 $23

New Mexico $956,824 $8,690,645 $7,054,780 $6,853,141 $1,672,053 $2,554,680 $6

New York $3,205,759 $28,874,621 $22,518,790 $22,171,004 $9,488,395 $7,484,987 $28

North Carolina $2,547,844 $21,306,097 $16,696,497 $16,224,492 $7,576,259 $6,278,870 $23

North Dakota $654,029 $5,839,561 $5,023,132 $5,023,393 $543,949 $1,843,107 $3

Ohio $3,281,387 $28,837,726 $21,838,104 $21,312,180 $9,818,808 $7,693,403 $29

Oklahoma $1,352,695 $11,101,950 $8,740,269 $8,536,905 $3,061,821 $3,431,303 $10

Oregon $1,366,765 $11,468,821 $9,100,217 $8,884,916 $3,165,797 $3,496,887 $10

Pennsylvania $3,508,291 $31,306,870 $23,758,643 $22,975,362 $10,642,275 $8,212,819 $32

Rhode Island $761,679 $6,073,926 $5,012,619 $5,000,000 $913,283 $2,076,070 $4

South Carolina $1,508,881 $12,548,500 $9,968,869 $10,097,336 $3,696,593 $3,831,697 $12

South Dakota $686,008 $5,878,521 $5,000,000 $5,000,000 $668,889 $1,921,915 $3

Tennessee $1,921,423 $16,418,187 $12,844,807 $12,495,537 $5,165,868 $4,758,470 $16

Texas $5,875,044 $56,222,601 $43,355,376 $42,816,952 $20,109,629 $14,184,535 $58

Utah $1,071,983 $8,878,797 $7,162,839 $7,018,990 $2,181,440 $2,875,985 $8

Vermont $650,611 $5,843,658 $5,041,316 $5,042,969 $533,720 $1,836,654 $3

Virginia $2,291,072 $21,300,739 $17,222,047 $16,613,973 $6,538,072 $5,624,014 $20

Washington $1,990,994 $17,735,543 $14,012,182 $13,561,976 $5,471,257 $4,951,101 $17

West Virginia $940,502 $7,412,363 $5,933,288 $5,839,235 $1,555,603 $2,481,226 $6

Wisconsin $1,831,224 $15,868,645 $12,188,297 $12,177,579 $4,753,288 $4,498,228 $15

Wyoming $622,102 $5,748,448 $5,000,000 $5,000,000 $440,557 $1,777,890 $3

STATE SUBTOTAL $91,148,843 $805,818,297 $636,383,499 $623,373,683 $238,158,321 $226,222,941 $775

45 
CITY 

FY 2006 PHEP 

SUPPLEMENT 

FY 2007 PHEP 

TOTAL 

AWARD 

FY 2008 

PHEP 

TOTAL 

AWARD 

FY 2009 

PHEP 

TOTAL 

AWARD 

FY 2009 

PHER 

PHASE I 

FY 2009 

PHER 

PHASE II 

FY 

PH

PHA

Chicago $1,197,706 $15,703,041 $11,382,673 $10,699,574 $2,423,752 $2,528,828 $7

Los Angeles $2,900,529 $30,712,150 $22,852,470 $22,522,771 $8,510,041 $6,367,873 $25

New York City $2,466,271 $28,822,589 $22,371,459 $20,674,333 $7,026,995 $5,432,412 $20

CITY SUBTOTAL $6,564,506 $75,237,780 $56,606,602 $53,896,678 $17,960,788 $14,329,113 $53

TERRITORY / FREELY ASSOCIATED STATE American Samoa $114,066 $547,830 $386,338 $383,368 $49,441 $531,185 $

Guam $139,782 $771,759 $555,484 $546,695 $146,297 $592,280 $

Marshall Islands $113,722 $550,237 $390,307 $387,201 $51,713 $532,619 $

Micronesia $126,298 $649,441 $461,346 $455,796 $92,392 $558,278 $

Northern Mariana Islands $118,513 $593,312 $423,185 $418,947 $70,539 $544,494 $

Palau $104,795 $471,804 $330,743 $329,686 $17,605 $511,104 $

Puerto Rico $1,443,014 $11,445,404 $8,867,670 $8,665,828 $3,359,999 $3,619,384 $11

Virgin Islands $126,461 $650,661 $462,244 $456,664 $92,905 $558,602 $

TERRITORY SUBTOTAL $2,286,651 $15,680,448 $11,877,317 $11,644,185 $3,880,891 $7,447,946 $15

TOTAL OF STATES, CITIES, AND TERRITORIES $100,000,000 $896,736,525 $704,867,418 $688,914,546 $260,000,000 $248,000,000 $846

46 
Table A.5 Public Health Emergency Preparedness Public Health Emergency Response Awards, by Year 

STATE / CITY / 

TERRITORY 

AWARDEE 

STATE Alabama 

FY 1999 

$1,026,768

FY 2000 

 $932,464 

FY 2001 and 

2002 

$16,277,122 

FY 2003 

$15,598,792 

FY 2004 

$12,910,651

FY 2005 

 $12,809,991 

FY 2006 

$16,408,481 

FY 2007 

$12,951,862

F

 $1

Alaska $807,530 $780,443 $7,751,884 $6,502,762 $5,205,459 $5,210,372 $6,768,343 $5,838,752 $

Arizona $601,905 $797,905 $1,780,8361 $17,586,381 $16,470,314 $17,067,370 $21,709,926 $17,681,799 $1

Arkansas $799,671 $637,469 $12,121,927 $11,390,938 $9,339,265 $9,302,434 $11,994,849 $9,389,730 $California $2,812,432 $2,505,947 $65,936,982 $64,203,968 $59,319,441 $61,339,288 $78,752,328 $65,303,030 $5

Colorado $1,261,720 $1,284,487 $16,583,399 $15,508,850 $13,654,314 $13,937,566 $17,500,375 $14,009,943 $1

Connecticut $717,099 $838,010 $14,097,316 $13,145,748 $10,828,647 $10,801,849 $14,016,230 $11,324,491 $

Delaware $360,816 $445,969 $7,779,467 $6,889,271 $5,518,506 $5,596,144 $7,262,546 $5,911,494 $

District of Columbia 

$135,000 $235,651 $12,136,423 $11,360,917 $11,985,069 $11,931,316 $8,198,017 $9,898,127 $

Florida $1,062,096 $1,201,152 $42,649,178 $43,832,162 $37,583,527 $39,221,056 $51,713,925 $42,467,775 $3

Georgia $1,006,194 $1,015,034 $25,161,441 $24,935,506 $21,575,121 $22,321,610 $28,600,468 $23,156,267 $1

Hawaii $660,420 $614,377 $8,855,244 $7,910,098 $6,384,925 $6,381,328 $8,268,365 $6,418,428 $

Idaho $0 $0 $8,515,356 $8,131,994 $6,588,258 $6,629,932 $8,656,659 $6,637,005 $

Illinois $1,145,974 $987,216 $27,849,408 $28,315,621 $23,718,971 $24,044,099 $30,466,673 $24,575,584 $2Indiana $95,576 $184,840 $19,224,277 $19,530,623 $16,262,765 $16,461,162 $21,111,440 $16,965,990 $1

Iowa $280,725 $242,914 $12,225,235 $11,953,663 $9,816,873 $9,725,489 $12,465,966 $9,779,223 $Kansas $753,421 $719,799 $12,384,717 $11,408,553 $9,354,215 $9,296,532 $12,182,064 $9,548,746 $Kentucky $140,670 $148,148 $14,759,368 $14,649,896 $12,105,282 $12,048,544 $15,591,456 $12,441,275 $

Louisiana $853,767 $819,785 $16,485,507 $15,602,245 $12,913,581 $12,790,121 $16,529,518 $13,243,221 $1

Maine $142,753 $187,650 $8,529,114 $8,046,341 $6,600,682 $6,606,543 $8,504,047 $6,526,615 $

Maryland $413,529 $673,363 $17,800,960 $17,774,011 $14,756,853 $15,290,917 $19,973,979 $16,047,435 $1

Massachusetts $1,348,777 $1,587,191 $21,559,185 $20,181,459 $17,640,158 $17,872,452 $22,258,559 $18,039,564 $1

Michigan $1,542,617 $1,156,125 $30,392,446 $28,731,577 $26,896,854 $27,105,748 $33,291,873 $26,992,552 $2

Minnesota $1,274,462 $1,161,437 $17,893,590 $16,821,680 $14,701,780 $15,003,826 $18,722,401 $15,591,573 $1

Mississippi $360,299 $315,786 $12,155,146 $11,782,347 $9,671,470 $9,608,208 $12,350,237 $9,722,247 $Missouri $630,236 $758,709 $19,060,349 $18,369,845 $15,952,563 $16,321,799 $20,586,280 $16,566,343 $1

Montana $407,841 $454,346 $8,108,083 $7,147,269 $5,775,627 $5,751,801 $7,451,738 $5,982,934 $

Nebraska $299,325 $250,182 $9,526,033 $9,079,368 $7,377,335 $7,346,564 $9,469,800 $7,324,391 $

Nevada $391,350 $493,105 $10,556,508 $9,975,108 $8,927,588 $9,267,629 $11,785,334 $9,340,451 $

New Hampshire $423,981 $458,192 $8,526,428 $7,986,786 $6,465,014 $6,526,889 $8,422,433 $6,447,504 $

New Jersey $1,008,444 $1,028,078 $25,412,080 $25,185,572 $21,047,364 $21,953,336 $27,697,226 $22,337,727 $1

New Mexico $919,774 $1,918,091 $12,432,222 $9,342,376 $8,803,295 $8,810,432 $11,069,717 $8,690,645 $

47 
STATE (cont’d) 

FY 1999 FY 2000 

FY 2001 and 

2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 F

New York $2,603,650 $2,244,882 $34,087,623 $31,675,790 $28,493,781 $28,293,465 $35,407,116 $28,874,621 $2

North Carolina $286,435 $685,804 $24,102,003 $24,462,186 $20,433,395 $20,547,098 $26,604,327 $21,306,097 $1

North Dakota $316,138 $193,439 $6,747,355 $6,509,688 $5,223,458 $5,193,519 $6,717,516 $5,839,561 $

Ohio $1,116,275 $977,275 $31,889,797 $32,012,830 $27,626,951 $27,902,321 $35,468,721 $28,837,726 $2

Oklahoma $184,490 $149,614 $13,322,159 $13,228,697 $10,899,049 $10,840,379 $13,905,118 $11,101,950 $

Oregon $1,052,593 $1,054,779 $14,439,021 $13,237,862 $10,906,827 $11,154,657 $14,499,454 $11,468,821 $1

Pennsylvania $167,844 $225,065 $33,129,300 $34,178,922 $30,735,407 $30,976,767 $38,372,836 $3,130,6870 $2Rhode Island $773,102 $697,911 $8,634,169 $7,513,164 $6,048,030 $6,240,298 $7,946,779 $6,073,926 $

South Carolina $267,738 $466,960 $14,801,624 $14,634,027 $12,091,813 $12,108,891 $15,644,466 $12,548,500 $

South Dakota $118,238 $71,174 $7,134,856 $6,798,496 $5,441,461 $5,425,710 $7,033,040 $5,878,521 $

Tennessee $200,683 $207,763 $18,274,229 $18,635,684 $15,488,192 $15,459,458 $20,080,322 $16,418,187 $1

Texas $1,164,964 $1,207,634 $53,077,169 $55,684,954 $51,803,533 $53,589,709 $67,920,482 $56,222,601 $4

Utah $1,048,781 $107,2011 $11,852,383 $10,404,357 $8,501,910 $8,560,504 $11,210,487 $8,878,797 $

Vermont $479,748 $564,632 $7,601,406 $6,453,782 $5,198,685 $5,186,880 $6,702,951 $5,843,658 $

Virginia $1,698,682 $1,133,948 $23,848,999 $22,068,328 $19,924,893 $20,475,283 $26,206,694 $21,300,739 $1

Washington $1,088,064 $1,190,761 $20,048,260 $19,214,353 $16,978,969 $17,350,613 $21,956,597 $17,735,543 $1

West Virginia $582,816 $666,121 $10,128,728 $9,271,321 $7,540,254 $7,498,508 $9,623,643 $7,412,363 $

Wisconsin $1,120,743 $1,098,810 $18,846,878 $17,821,131 $14,811,846 $14,975,480 $19,198,714 $15,868,645 $1

Wyoming $352,493 $507,610 $7,030,885 $6,171,022 $4,908,897 $4,906,684 $637,2226 $5,748,448 $

STATE SUBTOTAL 

$38,308,649 $39,250,058 $919,551,600 $888,858,321 $769,209,118 $781,068,571 $990,652,742 $805,818,297 $65

CITY Chicago $365,456 $649,714 $12,520,307 $11,378,246 $12,563,491 $12,816,598 $15,255,231 $15,703,041 $1

Los Angeles $784,958 $786,172 $25,791,036 $27,856,971 $27,069,695 $27,933,032 $34,078,965 $30,712,150 $2

New York City $1,258,177 $1,112,456 $24,555,453 $23,586,022 $25,874,757 $26,069,578 $31,208,359 $28,822,589 $2

CITY SUBTOTAL 

$2,408,591 $2,548,342 $62,866,796 $62,821,239 $65,507,943 $66,819,208 $80,542,555 $75,237,780 $5

TERRITORY Amer. Samoa $0 $0 $544,481 $576,463 $444,499 $447,789 $735,140 $547,830 Guam $0 $92,614 $1,515,909 $679,585 $515,976 $550,696 $1,008,636 $771,759 Marshall Islands $0 $0 $306,025 $561,544 $434,158 $446,412 $737,460 $550,237 Micronesia $0 $0 $446,522 $653,415 $497,837 $496,736 $859,806 $649,441 N. Marianas $0 $0 $314,371 $585,043 $450,446 $465,583 $789,914 $593,312 Palau $0 $0 $192,061 $521,761 $406,583 $410,687 $641,746 $471,804 Puerto Rico $0 $0 $13,478,509 $14,103,332 $11,641,389 $11,573,929 $14,610,682 $11,445,404 $Virgin Islands $0 $0 $419,235 $639,297 $488,051 $497,389 $861,319 $650,661 TERRITORY SUBTOTAL 

$0 $92,614 $17,217,113 $18,320,440 $14,878,939 $14,889,221 $20,244,703 $15,680,448 $1

TOTAL $40,717,240 $41,891,014 $999,635,509 $970,000,000 $849,596,000 $862,777,000 $1,091,440,000 $896,736,525 $72

48 
Table A.6 FY 2007 Pandemic Flu Funding 

STATE / TERRITORY / 

CITY 

Total Pandemic Flu 

Funding 

STATE Alabama $1,170,933 Alaska $382,562 Arizona $1,390,853 Arkansas $807,782 California $5,482,954 Colorado $1,179,911 Connecticut $963,022 Delaware $417,301 District of Columbia $364,024 

Florida $3,726,035 Georgia $2,024,184 Hawaii $505,349 Idaho $529,535 Illinois $2,249,832 Indiana $1,517,704 Iowa $851,583 Kansas $807,171 Kentucky $1,092,098 Louisiana $1,168,876 Maine $517,710 Maryland $1,377,171 Massachusetts $1,562,851 Michigan $2,311,667 Minnesota $1,285,535 Mississippi $839,440 Missouri $1,419,477 Montana $437,747 

49 
STATE (cont’d) 

Total Pandemic Flu 

Funding 

Nebraska $605,283 Nevada $708,492 New Hampshire $513,518 New Jersey $2,017,222 New Mexico $634,133 New York $2,525,212 North Carolina $1,971,986 North Dakota $379,519 Ohio $2,588,806 Oklahoma $967,012 Oregon $978,843 Pennsylvania $2,779,604 Rhode Island $470,040 South Carolina $1,098,346 South Dakota $406,410 Tennessee $1,445,243 Texas $4,769,753 Utah $730,967 Vermont $376,645 Virginia $1,756,072 Washington $1,503,743 West Virginia $620,408 Wisconsin $1,369,397 Wyoming $352,673 STATE SUBTOTAL $67,952,634 CITY Los Angeles (County) $2,268,550 Chicago $836,685 New York City $1,903,393 

50 
CITY (cont’d) 

Total Pandemic Flu 

Funding 

CITY SUBTOTAL $5,008,628 TERRITORY / FREELY ASSOCIATED STATE Puerto Rico $1,042,959 Guam $158,452 Virgin Islands (U.S.) $147,251 Federated States of Micronesia $147,113 Northern Mariana Islands $140,567 American Samoa $136,828 Marshall Islands $136,539 Palau $129,032 TERRITORY SUBTOTAL $2,038,741 TOTAL OF STATES, CITIES, AND TERRITORIES $75,000,000 

51 
Table A.7 Hospital Preparedness Program Awards by Awardees, Year, and Major Category 

STATE / CITY / 

TERRITORY 

AWARDEE FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 

STATE Alabama $1,972,883 $7,762,315 $7,762,315 $7,326,068 $7,154,927 $6,330,2

Alaska $492,877 $1,958,803 $1,958,803 $1,484,009 $1,458,182 $1,349,4Arizona $2,237,637 $9,030,450 $9,030,450 $8,964,023 $8,753,827 $8,317,1

Arkansas $1,285,691 $5,077,591 $5,077,591 $4,633,962 $4,531,309 $4,063,4

California $9,962,905 $38,773,727 $38,773,727 $39,203,268 $38,325,286 $34,106,6

Colorado $1,916,334 $7,704,930 $7,704,930 $7,401,669 $7,221,888 $6,525,9Connecticut $1,569,336 $6,197,207 $6,197,207 $5,783,087 $5,651,890 $4,943,1Delaware $553,571 $2,205,406 $2,205,406 $1,739,851 $1,709,476 $1,581,9

Florida $6,441,669 $25,775,967 $25,775,967 $26,311,287 $25,638,227 $23,432,9Dist. of Columbia $721,619 $2,868,302 $2,868,302 $1,854,320 $1,823,510 $1,737,2

Georgia $3,421,481 $13,719,390 $13,719,390 $13,671,367 $13,330,420 $12,370,8

Hawaii $719,356 $2,856,721 $2,856,721 $2,407,137 $2,345,600 $2,129,6Idaho $751,285 $2,998,297 $2,998,297 $2,572,244 $2,521,506 $2,359,0

Illinois $3,939,374 $15,875,995 $15,875,995 $15,578,388 $14,951,481 $13,163,8

Indiana $2,605,616 $10,270,929 $10,270,929 $9,896,622 $9,660,723 $8,503,7

Iowa $1,383,675 $5,436,624 $5,436,624 $4,965,024 $4,846,845 $4,280,4Kansas $1,291,509 $5,088,830 $5,088,830 $4,630,597 $4,525,854 $4,004,0

Kentucky $1,815,805 $7,156,894 $7,156,894 $6,745,252 $6,585,429 $5,832,1Louisiana $1,981,308 $7,764,518 $7,764,518 $7,319,242 $7,139,266 $5,935,6

Maine $743,913 $2,943,648 $2,943,648 $2,480,391 $2,434,432 $2,175,3Maryland $2,301,890 $9,150,163 $9,150,163 $8,855,085 $8,645,984 $7,619,1

Massachusetts $2,709,678 $10,686,180 $10,686,180 $10,256,868 $9,983,770 $8,660,5

Michigan $4,100,212 $16,141,386 $16,141,386 $15,787,720 $15,395,465 $13,298,4

Minnesota $2,155,835 $8,542,551 $8,542,551 $8,173,336 $7,983,328 $7,050,4Mississippi $1,352,037 $5,327,321 $5,327,321 $4,869,883 $4,759,591 $4,189,7

52 
STATE (cont’d) FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 

Missouri $2,417,618 $9,530,322 $9,530,322 $9,151,953 $8,951,388 $7,906,9Montana $599,516 $2,370,015 $2,370,015 $1,891,709 $1,856,928 $1,697,5Nebraska $912,954 $3,602,747 $3,602,747 $3,137,831 $3,067,393 $2,741,7Nevada $1,024,136 $4,174,253 $4,174,253 $3,899,038 $3,818,014 $3,663,6

New Hampshire $728,751 $2,905,650 $2,905,650 $2,452,975 $2,404,444 $2,166,9New Jersey $3,509,769 $13,878,940 $13,878,940 $13,601,391 $13,269,518 $11,560,3

New Mexico $954,709 $3,770,553 $3,770,553 $3,343,195 $3,276,757 $2,977,8New York $4,499,138 $18,019,873 $18,019,873 $17,747,875 $16,937,704 $14,561,2North Carolina $3,368,351 $13,417,400 $13,417,400 $13,251,044 $12,948,887 $11,727,5

North Dakota $498,792 $1,963,221 $1,963,221 $1,461,290 $1,435,800 $1,306,1

Ohio $4,648,274 $18,234,914 $18,234,914 $17,843,984 $17,397,207 $15,050,9

Oklahoma $1,586,804 $6,250,131 $6,250,131 $5,825,603 $5,681,308 $5,037,4Oregon $1,575,470 $6,255,978 $6,255,978 $5,898,716 $5,767,951 $5,191,5

Pennsylvania $5,007,754 $19,616,940 $19,616,940 $19,254,011 $18,776,677 $16,271,2

Rhode Island $656,125 $2,603,466 $2,603,466 $2,132,147 $2,089,651 $1,853,4South Carolina $1,804,277 $7,146,769 $7,146,769 $6,789,755 $6,632,258 $5,978,1South Dakota $542,431 $2,147,489 $2,147,489 $1,659,192 $1,630,322 $1,491,2

Tennessee $2,454,062 $9,699,934 $9,699,934 $9,359,882 $9,138,740 $8,155,5

Texas $8,328,119 $33,338,368 $33,338,368 $34,045,388 $33,177,278 $30,301,3

Utah $1,115,143 $4,448,125 $4,448,125 $4,066,334 $3,978,558 $3,732,7

Vermont $485,864 $1,927,552 $1,927,552 $1,438,965 $1,415,048 $1,290,9Virginia $2,992,259 $11,890,053 $11,890,053 $11,701,905 $11,387,068 $10,189,0

Washington $2,533,418 $10,069,141 $10,069,141 $9,799,166 $9,562,647 $8,608,0West Virginia $950,564 $3,725,218 $3,725,218 $3,245,672 $3,176,132 $2,805,3Wisconsin $2,327,920 $9,180,227 $9,180,227 $8,799,529 $8,588,953 $7,544,1Wyoming $441,296 $1,747,144 $1,747,144 $1,260,221 $1,241,982 $1,152,8

STATE SUBTOTAL $114,391,010 $453,228,568 $453,228,568 $435,969,471 $424,986,829 $378,925,3

CITY Chicago $1,371,934 $5,069,493 $5,069,493 $4,596,335 $4,738,187 $4,103,5

Los Angeles (County) $3,659,172 $15,583,364 $15,583,364 $15,582,102 $15,084,217 $13,111,3

New York City $3,352,455 $12,858,383 $12,858,383 $12,349,690 $12,445,285 $10,913,6

53 
CITY (cont’d) FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 

CITY SUB TOTAL $8,383,561 $33,511,240 $33,511,240 $32,528,127 $32,267,689 $28,128,5

TERRITORY / FREELY ASSOCIATED STATE American Samoa $150,000 $601,511 $601,511 $350,097 $335,451 $323,3

Guam $150,000 $738,414 $738,414 $485,709 $491,833 $457,3N. Mariana Islands $150,000 $612,902 $612,902 $361,591 $362,602 $346,5Virgin Islands (U.S.) $150,000 $684,929 $684,929 $0 $250,000 $387,9

Federated States of Micronesia $0 $703,671 $703,671 $450,658 $409,753 $387,0

Marshall Islands $0 $581,705 $581,705 $330,787 $333,447 $321,5

Palau $0 $528,890 $528,890 $278,560 $279,146 $274,9

Puerto Rico $1,725,479 $6,808,171 $6,808,171 $0 $500,000 $5,479,3

TERRITORY SUBTOTAL $2,325,479 $11,260,193 $11,260,193 $2,257,402 $2,962,232 $7,978,1

TOTAL OF STATES, CITIES, AND TERRITORIES $125,100,000 $498,000,000 $498,000,000 $470,755,000 $460,216,752 $415,032,0

54 
Table A.8 FY 2009 H1N1 Supplemental Funding 

STATE / TERRITORY / CITY 

AWARDEE 

H1N1 

Supplemental 

Funding FY 2009 

STATE Alabama $1,359,073 Alaska $197,157 Arizona $1,822,566 Arkansas $830,261 California $7,838,642 Colorado $1,404,718 Connecticut $1,035,479 Delaware $251,401 District of Columbia $293,688 

Florida $5,348,721 Georgia $2,768,199 Hawaii $379,162 Idaho $432,680 Illinois $2,953,181 Indiana $1,866,098 Iowa $880,894 Kansas $816,422 Kentucky $1,242,864 Louisiana $1,267,023 Maine $389,831 Maryland $1,659,740 Massachusetts $1,902,672 Michigan $2,984,585 Minnesota $1,527,068 

55 
STATE (cont’d) 

H1N1 

Supplemental 

Funding FY 09 

Mississippi $859,736 Missouri $1,726,867 Montana $278,358 Nebraska $521,951 Nevada $737,005 New Hampshire $387,856 New Jersey $2,579,115 New Mexico $577,036 New York $3,279,165 North Carolina $2,618,135 North Dakota $187,047 Ohio $3,393,391 Oklahoma $1,057,482 Oregon $1,093,427 Pennsylvania $3,678,065 Puerto Rico $1,160,563 Rhode Island $314,726 South Carolina $1,276,924 South Dakota $230,239 Tennessee $1,784,856 Texas $6,950,954 Utah $753,132 Vermont $183,511 Virginia $2,259,231 Washington $1,890,430 West Virginia $536,778 Wisconsin $1,642,227 Wyoming $151,304 STATE SUBTOTAL $83,561,636 

56 
CITY 

Chicago $839,620 Los Angeles (County) $2,940,946 New York City $2,428,253 CITY SUB TOTAL $62,08,819 TERRITORY / FREELY ASSOCIATED STATE Guam (U.S.) $47,382 Virgin Islands (U.S.) $31,182 Federated States of Micronesia $30,983 Northern Mariana Islands (U.S.) $30,000 American Samoa (U.S.) $30,000 Marshall Islands $30,000 Palau $30,000 TERRITORY SUBTOTAL $229,547 TOTAL OF STATES, CITIES, AND TERRITORIES $90,000,000 

57 
Table A.9 FY 2007 ASPR Healthcare Facilities Partnership Program 

Entity Scope of Work Funding 

Massachusetts Emergency Preparedness Regions 4 A,B,C with the Boston University School of Public Health 

Medical response exercise planning and implementation $2,4

King County Healthcare Coalition, Washington Medical surge planning $1,9San Francisco City and County Community Hub Plan Medical surge planning $7Roper St. Francis Foundation, Charleston, SC Regional health care coordinating center development $2,5

North Broward Hospital District, Ft. Lauderdale, FL Critical incident management system software installation and training $4Pennsylvania State University, Hershey Medical Center Evaluation, planning, and exercising of health care facility partnership in the South Central region of PA $2,5

Wake Med Health Care System, Raleigh, NC 

Development, implementation, and evaluation of a comprehensive multi-health care facility disaster exercise 

$1,0

Elkhorn Logan Valley Public Health Department, NE Rural NE medical response system development $8Hennepin Healthcare System, Minneapolis, MN Expansion and further development of the hospital compact and related programs $2,5

Alaska Department of Health and Social Services Pediatric medical surge capacity $7New York State Department of Health Burn care integration system development and testing for mass casualty incidents $2,5

 TOTAL $18,1

58 
 Table A.10 FY 2007 ASPR Emergency Care Partnership Program 

Entity Scope of Work 

Health and Hospital Corp of Marion Co., Indianapolis, IN 

Main activities: Standardized hospital and health care facility preparedness plan; replicable policy outlining burden; establish community-wide standards of care; inter-facility communications plan; coordinate and un

tracking and capabilities software; implement resource tracking; develop training materials for staff at hospcare centers, etc.; enhance regional coroner capabilities with scalable mortuary services. 

Rhode Island Hospital, Providence, RI 

Main activities: National Incident Management System (NIMS) compliance, Patient Tracking System, Em

Communications Mobile Pallets (mobile communication platform that can be deployed at hospitals to suppcommunication tasks). Pallet is self-contained and can be made operational in 20 minutes to support hundrand data users. This effort will also improve communication capability in the event of the loss of land-basethrough an innovative mobile communication system. 

Children’s Hospital of Los Angeles, Los Angeles, CA 

Main activities: Pediatric disaster preparedness plans and strategies for including children and pediatric-reldrills and training activities; regional strategy and plan for pediatric evacuation and reunification; telecommeducation strategy and plan including telemedicine robots; pediatric disaster drill training and assessments DRCs; and software, documentation, and user manuals for PEDSS (Pediatric Emergency Decision Support hospital disaster plan preparation advisor and PREP (Pediatric Response Exercise Planner), a multicenter dtraining exercise planning tool. 

The Regents of the University of California, Davis, CA 

Main activities: Implement uniform standards and protocols; electronically track location and movement of expand the reach and effectiveness of telemedicine; provide seamless exchange of health care data across p

through standardized informatics; test the ability to meet the needs of children, burn patients, and non-nativspeaking patients; coordinate activities listed above through facilitation and training within the partnershipcomputer models of disaster-management processes to identify strengths and weaknesses. 

MedStar Health, Inc., DBA Washington Hospital Center, Washington, D.C. 

Main activities: Installation of a real-time connection between hospital emergency departments and the D.C

of Health, and management of surge equipment and supplies using a “Ready Room” model (Ready Room ctreating a wide range of patient severities and also hold the surge equipment for the hospital). Funds will bsupport deployment of ER One at WHC, and to fund other facilities with the initial ER One process at their NIMS compliance and additional partnership development activities are also included. 

TOTAL 

59 
Table A.11 Emergency System for Advance Registration of Volunteer Health Professionals Awards, by Aw

Major Category 

STATE / TERRITORY / CITY Phase*** FY 2004 

STATE Alabama Phase 2 $200,000 Alaska* Phase 3 Arizona Phase 3 Arkansas Phase 3 

California Phase 2 $200,000 Colorado Phase 3 Connecticut Phase 1 $200,000 Delaware Phase 3 

District of Columbia Phase 1 $200,000 Florida Phase 2 $200,000 Georgia Phase 2 $200,000 

Hawaii Phase 2 $200,000 

Idaho* Phase 3 

Illinois Phase 1 $200,000 

Indiana Phase 3 Iowa Phase 3 

Kansas Phase 2 $200,000 

Kentucky Phase 3 Louisiana Phase 3 Maine Phase 3 Maryland Phase 2 $200,000 

60 
STATE (cont’d) Phase FY 2004 

Massachusetts Phase 1 $200,000 

Michigan Phase 2 $200,000 Minnesota Phase 1 $200,000 Mississippi Phase 3 Missouri Phase 1 $200,000 Montana Phase 3 

Nebraska Phase 2 $200,000 

Nevada Phase 2 $200,000 

New Hampshire Phase 2 $200,000 New Jersey Phase 2 $200,000 

New Mexico Phase 2 $200,000 New York Phase 2 $200,000 

North Carolina Phase 2 $200,000 

North Dakota Phase 3 

Ohio Phase 1 $200,000 Oklahoma Phase 2 $200,000 

Oregon Phase 2 $200,000 Pennsylvania Phase 2 $200,000 

Rhode Island Phase 3 

South Carolina Phase 3 

South Dakota Phase 3 

Tennessee Phase 3 Texas Phase 1 $200,000 Utah Phase 2 $200,000 Vermont Phase 3 

61 
STATE (cont’d) Phase FY 2004 

Virginia Phase 2 $200,000 Washington Phase 2 $200,000 

West Virginia Phase 1 $200,000 Wisconsin Phase 1 $200,000 Wyoming Phase 3 

STATE SUBTOTAL $6,200,000 

CITY Los Angeles (County) Phase 3 

Chicago Phase 3 New York City Phase 3 

CITY SUBTOTAL TERRITORY / FREELY ASSOCIATED STATE American Samoa** Phase 3 Guam** Phase 3 Northern Mariana Islands** Phase 3 Virgin Islands (U.S.) Phase 3 

Federated States of Micronesia** Phase 3 Marshall Islands** Phase 3 Palau Phase 3 

Puerto Rico Phase 3 

TERRITORY SUBTOTAL TOTAL OF STATES, CITIES, AND TERRITORIES $6,200,000 

*Alaska and Idaho declined the ESAR-VHP supplemental funds.

**American Samoa, Federated States of Micronesia, Guam, Marshall Islands, and Northern Mariana Islands did not receive ESAR-VH

***Phase 1 consisted of the development of guidelines, standards, and definitions and pilot testing of ten National Bioterrorism Hospi

62 
Program (NBHPP) grantees from September 2004 through June 2005. Phase 2 consisted of the implementation of guidelines, standard

for 20 NBHPP grantees from June 2005 through December 2005. Phase 3 consisted of the implementation of guidelines, standards an

the 32 remaining NBHPP grantees from January 2006 through December 2006. 

63 
Table A.12 United States–Canada and United States–Mexico Border States Original Early Warning Infect

Surveillance (EWIDS) Allocations from HHS-ASPR-Office of Medicine, Science, and Public Health (OMS

STATE FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2008 

Supplement 

Alaska $10,000 $15,000 $15,000 $15,000 $15,000 $15,000 $29,411 

Idaho $10,000 $15,000 $15,000 $15,000 $15,000 $15,000 $0 

Maine $74,220 $100,121 $105,825 $117,309 $122,283 $96,856 $29,411 

Michigan $234,139 $315,848 $301,285 $296,641 $308,096 $239,552 $29,411 Minnesota $32,033 $43,211 $47,429 $50,928 $50,512 $38,195 $29,411 

Montana $28,279 $38,148 $23,414 $23,837 $26,487 $22,876 $0 

North Dakota $341,493 $460,667 $401,281 $427,665 $28,972 $23,132 $29,411 

New York $20,105 $27,121 $27,535 $28,198 $399,589 $322,137 $29,411 

Vermont $36,910 $49,797 $48,659 $47,557 $39,717 $41,316 $29,411 

Washington $125,752 $169,636 $170,252 $182,822 $186,959 $160,783 $29,411 

Illinois $10,000 $15,000 $15,000 $15,000 $15,000 $15,000 $29,411 

Indiana $10,000 $15,000 $15,000 $15,000 $15,000 $15,000 $29,411 

New Hampshire $10,000 $15,000 $15,000 $15,000 $15,000 $15,000 $0 

Ohio $10,000 $15,000 $15,000 $15,000 $15,000 $15,000 $29,411 

Pennsylvania $10,000 $15,000 $15,000 $15,000 $15,000 $15,000 $29,411 

Wisconsin $10,000 $15,000 $15,000 $15,000 $15,000 $15,000 $29,411 TOTAL U.S. – Canada Border 

$972,935 $1,324,550 $1,245,681 $1,294,958 $1,282,612 $1,064,847 $382,343 

Arizona $439,378 $592,711 $573,948 $587,973 $575,691 $456,569 $29,411 

California $1,059,378 $1,429,078 $1,537,683 $1,463,654 $1,476,742 $1,170,732 $29,411 

New Mexico $23,442 $63,630 $46,114 $46,838 $75,922 $66,150 $29,411 

Texas $1,504,867 $2,030,032 $2,036,574 $2,046,577 $2,029,033 $1,593,702 $29,411 

64 
STATE FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2008 

Supplement 

TOTAL U.S. — Mexico Border 

$3,027,065 $4,115,450 $4,194,319 $4,145,042 $4,157,388 $3,287,153 $117,644 

Total for Both U.S. Borders 

$4,000,000 $5,440,000 $5,440,000 $5,440,000 $5,440,000 $4,352,000 $499,987 

65 
APPENDIX B. GAP ASSESSMENT OF PERFORMANCE 

MEASURES 

This appendix contains a gap assessment of performance measures of health security 

conducted in spring 2009. The assessment is based on an HHS-wide survey of 

performance measures currently in use or under development. The performance 

measures collected through the survey were categorized into capability areas. It should 

be noted that the capabilities included in this analysis (seen in Table B.1 below), have 

been revised extensively since the gap assessment was conducted; the up-to-date list of 

capabilities can be found in Appendix A of the National Health Security Strategy. 

Introduction 

The NHSS outlines a set of goals and objectives and the capabilities needed to achieve 

them. A strong performance measurement system is needed to effectively monitor 

progress toward those goals and hold stakeholders accountable. To inform the 

development of the performance measures for the NHSS and the associated 

Implementation Plan, it is important to know what performance measures currently exist 

or are under development within HHS and to understand the quality of these measures. 

Having a clear picture of existing measures and their quality allows ASPR to take 

advantage of measure development efforts that have already taken place and to more 

effectively target future measure development efforts. 

Toward that end, ASPR led an effort to survey HHS Staff Divisions (e.g., ASPR, 

Assistant Secretary for Planning and Evaluation, and Office of Civil Rights) and 

Operating Division (e.g., Food and Drug Administration, Centers for Disease Control and 

Prevention, and Health Resources and Services Administration) regarding their efforts to 

develop and utilize evidence-based performance measures, benchmarks, and objective 

standards to assess federal, state, and local progress toward the preparedness goals. The 

results from the survey identify both strengths and areas for improvement in performance 

measure development. 

Approach 

The objective of the survey of HHS Staff and Operating Divisions was to collect 

information on performance measures that are currently used or under development and 

to use that information to understand whether and how such measures can support the 

NHSS and associated Implementation Plan. 

The performance measures collected through the survey were classified according to the 

capability area that it addressed. While the survey was the primary method of data 

collection, the survey results were supplemented with information on HHS measures that 

were collected through web searches. Based on these data, a gap analysis was conducted 

to identify areas where measure development is needed. 

66 
Results 

In total, 49 representatives of 26 different divisions within HHS were invited to 

participate in the survey, and 30 individuals responded. Thirteen respondents, 

representing nine divisions, indicated that they had measures in development or already 

in use and reported them; the remaining 17 respondents reported that there were no 

measures in development or in use. A total of 948 measures were identified from the 

survey responses and web searches. Only measures collected from HHS agencies (i.e., 

through the survey or the related web searches of HHS sites) were included in the 

database. 

As used here, the term “measures” is broadly defined. Some of the agencies surveyed 

submitted goals or standards, which may inform measure development but would not 

generally be considered measures by a more stringent definition. To accommodate the 

range of survey responses, we include goals and standards in our tabulation of measures. 

The number of measures identified for each capability area is displayed in Table B.1 

below. It should be noted that measures were assigned to all relevant capability areas. 

Therefore, the capability area counts are not mutually exclusive and the total in Table B.1 

exceeds the total number of unique measures. It is evident from the table that more 

attention has been devoted to the measurement of the countermeasures and medical 

response capabilities than to other capabilities. In contrast, little attention has been paid to 

the measurement of community involvement, long-term recovery, and ensuring 

population safety and health. 

As PHEP capacities and capabilities are more often executed at the state, local, and tribal 

levels, it is not surprising that most measures were designed to assess performance at the 

state, local, or tribal level rather than at the federal level: Across capability areas, the 

percentage of measures at the state, local, or tribal level ranged from 56% to 100%. The 

percentage of measures at the state, local, or tribal level is listed in Table B.1 below by 

capability area. 

The measures collected represent a wide range of quality. At the low end are measures 

that consist of vaguely worded goals for the agency without any attempt to quantify 

attainment of, or progress toward, the goal. At the high end are more precisely worded 

measures that include quantitative assessments, which can be aggregated to derive a 

composite score of overall performance. 

Reporting of targets or benchmarks for measures was rare, and when targets were cited, 

the basis for determining the target was not clear. To our knowledge, none of the 

measures is evidence-based. Aggregation of scores to generate a composite score that 

could be used for comparative purposes was the exception, not the rule. With regard to 

content, measures tended to focus more on capacity (i.e., resources) than on capability 

(execution of activities). Thus, measures are currently more focused on the availability 

of sufficient resources than on their implementation in an emergency event, thereby 

67 
leaving considerable ambiguity regarding the extent to which resources can be effectively 

mobilized. Below is a synopsis of the measures within each capability area. 

Table B.1: Number of Performance Measures, by Capability Area 

Capability Number of Measures Percentage of 

Measures at the State 

and Local Levels 

Situational awareness 79 63 

Community involvement 9 56 

Incident management 124 99 

Disease containment and 

mitigation 

95 97 

Countermeasures 359 91 

Medical response 208 91 

Ensuring population safety and 

health 

20 90 

Long-term recovery 11 100 

Crosscutting issues 76 91 

Discussion 

The evaluation of the measures collected through the survey of HHS Staff and Operating 

Divisions revealed several strengths and weaknesses. For instance, the set of 

performance measures for countermeasure delivery are relatively well developed and 

touch on both capacity and capability. In other capability areas, however, there were 

deficiencies in both the coverage (i.e., a set of measures that cover performance in all 

important elements of the capability area) and quality of the existing measures. A 

recurrent theme across these capability areas is the need for measures with a greater focus 

on the capability to execute key activities and mobilize resources in the face of an 

emergency. Moreover, there is a need for more measures that include sufficiently welldefined criteria to allow for greater quantification of performance. 

Given the nascent stage of measure development for public health and medical 

preparedness, it is not surprising there is a lack of evidence-based measures and that the 

reliability and validity of existing measures have not yet been evaluated. Well-defined 

criteria and quantifiable indicators of performance are measure characteristics that would 

facilitate the achievement of adequate reliability and validity. In addition, although some 

measures were accompanied by targets or benchmarks for determining an optimal level 

of performance, most were not. The identification of targets or benchmarks for 

performance is important, as the presence of a clearly articulated goal will help agencies 

to chart a path forward to improve their preparedness for emergency response. 

Finally, there was a noteworthy lack of attention to outcomes, namely morbidity and 

mortality. This omission is surely attributable to the difficulty of assessing outcomes 

outside real-world emergency events or functional exercises designed to simulate 

emergency events, all of which are fairly infrequent. However, as this field progresses, it 

68 
is expected that computer-based models that simulate emergency events will aid in the 

assessment of outcomes in relation to measures of structure and process. 

69 
APPENDIX C. STATUS OF PERFORMANCE MEASURE DEVELOPM

CAPABILITIES

This appendix displays the status of performance measure development for each NHSS capability, grouped inareas: Community Resilience and Recovery, Infrastructure, Situational Awareness, Incident Management, DiContainment and Mitigation, Health Care Services, Population Safety and Health, and Quality Improvement Accountability. Information in the table (as it is ordered in columns from left to right) includes the NHSS cameasure development efforts for that capability (e.g., whether measures have already been developed and datcollected, measures have been developed but data have not yet been collected, or no measures exist), what thsource of the measure (e.g., grant guidance), who collects the data, who reports the data, and the frequency w

reported to the overseeing agency or data collector. Only those existing measures that are considered viable widespread use are listed here as having been developed; thus, the existing measures listed here constitute a s

measures that are worthy of consideration for data collection and reporting in the NHSS public report, althouhere does not indicate that they necessarily should be included. This appendix differs from the gap assessme

Appendix B in that it indicates at a more granular level what the status of measures is for each capability; by 

assessment was conducted at a higher level of analysis. Table C.1 Status of Performance Measures for Community Resilience and Recovery 

Capability Measure 

Development Status 

Measure Source Collected 

By 

Reported By 

Public education to inform and prepare individuals and communities 

Included in community resilience measures to be developed by ASPR in 2010 

70 
Capability Measure 

Development Status 

Measure Source Collected 

By 

Reported By 

Citizen Included in engagement community resilience in local measures to be decision- developed by ASPR making in 2010 Local social Included in networks for community resilience preparedness measures to be and resilience developed by ASPR 

in 2010 

Integrated Included in support from community resilience non- measures to be governmental developed by ASPR organizations in 2010 Emergency public information and warning 

Measure already developed and data being collected 

Crisis and Emergency Risk Communication (CERC) Public Message Dissemination: Time to issue a risk communication message for dissemination to the public 

PHEP Cooperative Agreement FY 2008-BP9 

CDC 

50 states, Puerto Rico, Virgin Islands, Pacific Island JurisdictionsChicago, Los Angeles County, New York City, and Washington, D.C. 

71 
Capability Measure 

Development Status 

Measure Source Collected 

By 

Reported By 

Post-incident social network reengagement 

Included in community resilience measures to be developed by ASPR in 2010 

Case management support or individual assistance 

No measures 

Reconstitution of the public health, medical and behavioral health infrastructure 

No measures 

Mitigated hazards to health and public health facilities and systems 

No measures 

Support services network for long-term recovery 

Included in community resilience measures to be developed by ASPR in 2010 

72 
Table C.2 Status of Performance Measures for Infrastructure 

Capability Measure 

Development 

Status 

Measure Source Collected 

By 

Reported By 

Sufficient, culturally competent and proficient public health, health care and emergency management workforce 

Measure developed and data being collected for health care facilities only 

Percentage of participating hospitals that have identified appropriate hospital personnel for training and have verified their completion of the following courses or their equivalent: IS 100, IS 200, IS 700, IS 800B 

Hospital Preparedness Program, FY 2008 

ASPR 

50 states, Puerto Rico, Virgin Islands, Pacific Island JurisdictionsChicago, Los Angeles County, New York City, and Washington, D.C. 

Volunteer Measures Generation of a list of recruitment developed and potential volunteer and data being health professionals management collected 50 states, Puerto 

Time to query ESAR- Rico, Virgin VHP system to Hospital Islands, Pacific generate list of volunteer health professionals 

Preparedness Program– 

ASPR 

Island JurisdictionsChicago, Los Angeles County, 

FY 2008 New York City, 

Time to compile an and Washington, initial list of willing D.C. volunteer health professionals 

73 
Time to report a 

verified list of available volunteer health professionals 

Inter- Measure Number of hospitals 50 states, Puerto 

operable and developed and that demonstrate Rico, Virgin 

resilient data being dedicated, redundant Hospital Islands, Pacific communicati ons systems 

collected for healthcare facilities only 

communications capability during an exercise or incident 

Preparedness Program - FY08 

ASPR 

Island JurisdictionsChicago, Los Angeles County, New York City, and Washington, D.C. 

Legal No measures protections and authorities 

74 
Table C.3 Status of Performance Measures for Situational Awareness 

Capability Measure 

Development Status 

Measure Source Collected 

By 

Reported By 

Risk assessment and risk management 

No measures 

Epidemiological Draft Percentage of state and 50 states, Puerto 

surveillance and measure local public health Rico, Virgin investigation developed 

and planned for data collection 

agencies in compliance with CDC recommendations for using standards-based, electronic disease surveillance systems for appropriate routine public health information collection, analysis, and reporting to appropriate public health authorities 

PHEP Cooperative Agreement 

CDC 

Islands, Pacific Island JurisdictionsChicago, Los Angeles County, New York City, and Washington, D.C. 

Draft 

Percentage of exposure 50 states, Puerto 

measure and outbreak Rico, Virgin 

developed investigation reports Islands, Pacific and planned generated PHEP Island Jurisdictionsfor pilot Cooperative CDC Chicago, Los testing Agreement Angeles County, 

New York City, and Washington, D.C. 

75 
Capability Measure 

Development Status 

Measure Source Collected 

By 

Reported By 

Draft 

Percentage of exposure 50 states, Puerto 

measure and outbreak Rico, Virgin 

developed investigation reports Islands, Pacific and planned containing the minimal PHEP Island Jurisdictionsfor pilot elements Cooperative CDC Chicago, Los testing Agreement Angeles County, 

New York City, and Washington, D.C. 

Draft 

Percentage of 50 states, Puerto 

measure recommendations Rico, Virgin 

developed and/or corrective Islands, Pacific and planned actions implemented PHEP Island Jurisdictionsfor pilot Cooperative CDC Chicago, Los testing Agreement Angeles County, 

New York City, and Washington, D.C. 

Draft 

Proportion of reports of 50 states, Puerto 

measure selected disease Rico, Virgin 

developed received by a public Islands, Pacific and planned health agency within PHEP Island Jurisdictionsfor pilot the awardee-required Cooperative CDC Chicago, Los testing timeframe Agreement Angeles County, 

New York City, and Washington, D.C. 

76 
Capability Measure 

Development Status 

Measure Source Collected 

By 

Reported By 

Draft 

Proportion of reports of 50 states, Puerto 

measure selected disease for Rico, Virgin 

developed which initial public Islands, Pacific and planned health control PHEP Island Jurisdictionsfor pilot measure(s) were Cooperative CDC Chicago, Los testing initiated within an 

appropriate timeframe 

Agreement Angeles County, 

New York City, and Washington, D.C. 

Animal disease surveillance and investigation 

No measures 

Agriculture surveillance and food safety 

No measures 

Chemical, Draft Time from when 50 states, Puerto biological, measure surveillance data Rico, Virgin radiological, developed suggests that a public Islands, Pacific nuclear, and and planned health outbreak may be Island Jurisdictionsexplosives for data underway to time of Chicago, Los (CBRNE) collection in management decision Angeles County, detection 2010 by Agency Director (or 

designee) to report CDC’s scientific determination that an event is naturally occurring or terrorism. Target = below established standard for each agent on the CDC 

PHEP Cooperative Agreement 

CDC 

New York City, and Washington, D.C. 

77 
Capability Measure 

Development Status 

Measure Source Collected 

By 

Reported By 

priority agent list (must establish standard for each agent on list) 

Monitoring of available health care resources 

No measures 

Laboratory testing 

Draft measure developed and planned for pilot testing 

Time for initial laboratorian to report for duty at the public health laboratory PHEP 

Cooperative Agreement 

CDC 

50 states, Puerto Rico, Virgin Islands, Pacific Island JurisdictionsChicago, Los Angeles County, New York City, and Washington, D.C. 

Draft Time for public health 50 states, Puerto 

measure laboratory to notify Rico, Virgin 

developed public health partners Islands, Pacific and planned of index test results PHEP Island Jurisdictionsfor pilot Cooperative CDC Chicago, Los testing Agreement Angeles County, 

New York City, and Washington, D.C. 

Draft Time for sentinel labs 50 states, Puerto 

measure to acknowledge receipt PHEP Rico, Virgin 

developed of communication from Cooperative CDC Islands, Pacific and planned public health laboratory Agreement Island Jurisdictionsfor pilot Chicago, Los 

78 
Capability Measure 

Development Status 

Measure Source Collected 

By 

Reported By 

testing Angeles County, 

New York City, and Washington, D.C. 

Draft Percentage of 50 states, Puerto 

measure Laboratory Response Rico, Virgin 

developed Network (LRN) Islands, Pacific and planned clinical specimens Island Jurisdictionsfor pilot received for PHEP Chicago, Los testing confirmation or ruleout testing from 

sentinel laboratories to public health laboratory without any quality assurance events 

Cooperative Agreement 

CDC Angeles County, 

New York City, and Washington, D.C. 

Draft Percentage of LRN 50 states, Puerto 

measure environmental samples Rico, Virgin 

developed received for Islands, Pacific and planned confirmation or rule- PHEP Island Jurisdictionsfor pilot out testing from first Cooperative CDC Chicago, Los testing responders to public 

health laboratory without any quality assurance events 

Agreement Angeles County, 

New York City, and Washington, D.C. 

Measure Percentage of pulsed PHEP CDC 50 states, Puerto 

developed field gel Cooperative Rico, Virgin 

and data electrophoresis (PFGE) Agreement - Islands, Pacific being subtyping data results FY08/BP9 Island Jurisdictionscollected for E. coli O157:H7 

submitted to the 

Chicago, Los Angeles County, 

79 
Capability Measure 

Development Status 

Measure Source Collected 

By 

Reported By 

PulseNet national database within four working days of receiving isolate at the PFGE laboratory 

New York City, and Washington, D.C. 

Measure Percentage of PFGE PHEP CDC 50 states, Puerto 

developed subtyping data results Cooperative Rico, Virgin 

and data for Listeria Agreement, Islands, Pacific being monocytogenes FY Island Jurisdictionscollected submitted to the 

PulseNet national database within four working days of receiving isolate at the PFGE laboratory 

2008/BP9 Chicago, Los 

Angeles County, New York City, and Washington, D.C. 

Draft Time from when 50 states, Puerto 

measure sample is received at Rico, Virgin 

developed CDC or a CDC Islands, Pacific and planned networked lab to time Island Jurisdictionsfor data Agency Director (or Chicago, Los collection in 2010 

designee) receives an identifying report. Target = below established standard for 

PHEP Cooperative Agreement 

CDC 

Angeles County, New York City, and Washington, D.C. 

each agent on the CDC priority agent list. (must establish standard for each agent on list) 

80 
Capability Measure 

Development Status 

Measure Source Collected 

By 

Reported By 

Draft measure developed and planned for data collection in 2010 

Percentage of LRN labs reporting routine public health testing results through standardsbased electronic disease surveillance systems and have protocols for immediate reporting by telephone for Category A agents (bacillus anthracis, yersina pestis, francisella tularensis, clostridium botulinum toxin, and variola major) for which they conduct testing 

PHEP Cooperative Agreement 

CDC 

50 states, Puerto Rico, Virgin Islands, Pacific Island JurisdictionsChicago, Los Angeles County, New York City, and Washington, D.C. 

Draft LRN labs with 50 states, Puerto 

measure cumulative proficiency Rico, Virgin 

developed testing scores of 90% Islands, Pacific and planned or better PHEP Island Jurisdictionsfor data Cooperative CDC Chicago, Los collection in Agreement Angeles County, 2010 New York City, 

and Washington, D.C. 

Near-real-time systems for data capture and 

No measures 

81 
Capability Measure 

Development Status 

Measure Source Collected 

By 

Reported By 

analysis Information gathering and recognition of indicators and warning (this is an intelligence community item) 

No measures 

Coordination with U.S. and international partners 

No measures 

82 
Table C.4 Status of Performance Measures for Incident Management 

Capability Measure 

Development 

Status 

Measure Source Collected 

By 

Reported By 

On-site incident Measures Time to notify PHEP CDC 50 states, Puerto management and developed and pre-identified staff Cooperative Rico, Virgin multiagency data being with public health Agreement, Islands, Pacific coordination collected agency incident FY Island Jurisdictio

management 2008/BP9 Chicago, Los functional Angeles County, responsibilities New York City, 

and Washington, 

Time for staff with D.C. public health agency incident management functional responsibilities to report for duty 

Communications Measures Number of hospitals among responders developed and that demonstrate 

data being collected 

sustained two-way communications capability with the local Emergency Operations Center (EOC) and Tier 2 partners during an exercise or incident, as evidenced by exercise evaluations 

Hospital Preparedness Program, FY 2008 

ASPR 

50 states, Puerto Rico, Virgin Islands, Pacific Island JurisdictioChicago, Los Angeles County, New York City, and Washington, D.C. 

or after action reports at least once during 

83 
Capability Measure 

Development 

Status 

Measure Source Collected 

By 

Reported By 

the current project period. 

Critical resource monitoring, logistics and distribution 

No measures 

84 
Table C.5 Status of Performance Measures for Disease Containment and Mitigation 

Capability Measure 

Development 

Status 

Measure Source Collected 

By 

Reported By 

Research, development, and procurement of No measures medical countermeasures Management and distribution of medical countermeasures 

Measures in use (data being collected). 

Time within which personnel can be contacted, in a drill 

PHEP Cooperative Agreement, FY 2008-BP9 

CDC 

72 CRI metropolitan statistical areas (MSA) 

Measures in use (data being collected). 

Percentage of personnel who can be reached, in a drill 

PHEP Cooperative Agreement, FY 2008-BP9 

CDC 

72 CRI metropolitan statistical areas (MSA) 

Measures in use (data being collected). 

Percentage of personnel who report being able to respond, in a drill 

PHEP Cooperative Agreement, FY 2008-BP9 

CDC 

72 CRI metropolitan statistical areas (MSA) 

Measures in use (data being collected). 

Set-up completion time 

PHEP Cooperative Agreement, FY 2008-BP9 

CDC 

72 CRI metropolitan statistical areas (MSA) 

85 
Capability Measure 

Development 

Status 

Measure Source Collected 

By 

Reported By 

Measures in use (data being collected) 

Completion rate 

PHEP Cooperative Agreement, FY 2008-BP9 

CDC 

72 CRI metropolitan statistical areas (MSA) 

Measures in use (data being collected) 

Pick list generation time (minutes) 

PHEP Cooperative Agreement, FY 2008-BP9 

CDC 

72 CRI metropolitan statistical areas (MSA) 

Measures in use (data being collected) 

Inventory data upload time (minutes) 

PHEP Cooperative Agreement, FY 2008-BP9 

CDC 

72 CRI metropolitan statistical areas (MSA) 

Administration of medical countermeasures 

Measures in use (data being collected) 

Expected rate at which patients can receive countermeasures at points of dispensing (PODs), in a drill 

PHEP Cooperative Agreement, FY 2008-BP9 

CDC 

72 CRI metropolitan statistical areas (MSA) 

No measures in PHEP 

Community interventions for 

Cooperative Agreement now, but a 

disease control candidate for 

development in PHEP metrics 

86 
Table C.6 Status of Performance Measures for Health Care Services 

Capability Measure Measure Source Collected Reported By 

Development By 

Status 

Access to health care and social No measures services Evidence-based mental/behavioral health prevention No measures and treatment services 

Measure According to 

Medical equipment and supplies monitoring, management, and distribution 

developed and data being collected 

HAvBED definitions, the number of participating hospitals that can report available beds to the state EOC within 60 minutes or less of a state request at least once during the current project period 

Hospital Preparedness Program, FY 2008 

ASPR 

50 states, Puerto Rico, Virgin Islands, Pacific Island JurisdictioChicago, Los Angeles County, New York City, and Washington, D.C. 

The state EOC can 50 states, Puerto 

Measure developed and data being collected 

report available beds for at least 75% of participating hospitals, according to HAvBED 

Hospital Preparedness Program, FY 2008 

ASPR 

Rico, Virgin Islands, Pacific Island JurisdictioChicago, Los Angeles County, 

definitions, to the New York City, 

87 
Capability Measure 

Development 

Status 

Measure Source Collected 

By 

Reported By 

HHS SOC within 4 hours or less of a request, during an incident or exercise at least once during the current project period 

and Washington, D.C. 

No measures, but is mentioned in JCAHO standards 

Hospital’s ability to track resources during an emergency JCAHO standards JCAHO Hospitals 

Use of remote medical care technology 

No measures 

Emergency triage and pre-hospital treatment 

No measures 

Patient transport Measures 

developed and data being collected. 

Number of hospitals that have plans to address medical evacuation 

Hospital Preparedness Program, FY 2008 

ASPR 

50 states, Puerto Rico, Virgin Islands, Pacific Island JurisdictioChicago, Los Angeles County, New York City, and Washington, D.C. 

Medical surge No measures Palliative care education for stakeholders 

No measures 

88 
Capability Measure 

Development 

Status 

Measure Source Collected 

By 

Reported By 

Fatality management 

Measures developed and data being collected 

Number of hospitals that have written plans to address mass fatality management 

Hospital Preparedness Program, FY 2008 

ASPR 

50 states, Puerto Rico, Virgin Islands, Pacific Island JurisdictioChicago, Los Angeles County, New York City, and Washington, D.C. 

Monitoring of physical and behavioral health outcomes 

No measures 

Application of clinical practice No measures guidelines 

89 
Table C.7 Status of Performance Measures for Population Safety and Health 

Capability Measure 

Development 

Status 

Measure Source Collected 

By 

Reported By 

Responder safety and health No measures Emergency public safety and security 

No measures 

Citizen evacuation and shelter-in-place 

No measures 

Mass care (sheltering, feeding, and related services) 

No measures 

Environmental health No measures Potable water/wastewater and solid waste disposal 

No measures 

90 
Table C.8 Status of Performance Measures for Quality Improvement and Accountability 

Capability Measure 

Development 

Status 

Measure Source Collected 

By 

Reported By 

Use of capabilitybased performance measures 

No measures 

Use of quality improvement methods 

No measures 

91 
APPENDIX D. ACRONYMS 

ASPR Assistant Secretary for Preparedness and Response 

BARDA Biomedical Advanced Research and Development Authority 

CBRN chemical, biological, radiological, and nuclear 

CBRNE chemical, biological, radiological, nuclear, and explosives 

CDC Centers for Disease Control and Prevention 

CERC Crisis and Emergency Risk Communication 

CHA community health assessment 

CRI Cities Readiness Initiative 

CSTE Council of State and Territorial Epidemiologists 

DHS Department of Homeland Security 

ECP Emergency Care Partnership Program 

EOC Emergency Operations Center 

EOY end of year 

ESAR-VHP Emergency System for Advance Registration of Volunteer Health 

Professionals 

EWIDS Early Warning Infectious Disease Surveillance 

FEMA Federal Emergency Management Agency 

FOIA Freedom of Information Act 

FY fiscal year 

GAO Government Accountability Office 

HAvBED National Hospital Available Beds for Emergencies and 

Disasters 

HFPP Healthcare Facilities Partnership Program 

HHS Department of Health and Human Services 

HIPAA Health Insurance Portability and Accountability Act 

HPP Hospital Preparedness Program 

HRSA Health Resources and Services Administration 

HSPD Homeland Security Presidential Directive 

92 
JCAHO Joint Commission on the Accreditation of Healthcare 

Organizations 

LRN Laboratory Response Network 

MSA metropolitan statistical area 

NACCHO National Association of County and City Health Officials 

NBHPP National Bioterrorism Hospital Preparedness Program 

NDMS	 National Disaster Medical System 

NHSS National Health Security Strategy 

NIMS National Incident Management System 

NRF National Response Framework 

OIG Office of Inspector General 

OMSPH Office of Medicine, Science, and Public Health 

PAHPA Pandemic and All Hazards Preparedness Act 

PEDSS Pediatric Emergency Decision Support System 

PFGE pulsed field gel electrophoresis 

PHEMCE Public Health Emergency Medical Countermeasures Enterprise 

PHEP Public Health and Emergency Preparedness 

PHER Public Health Emergency Response 

POD point of dispensing 

QI quality improvement 

RFA Request for Application 

SOC Secretary Operations Center 

TCL Target Capabilities List 

UPMC University of Pittsburgh Medical Center 

WHO World Health Organization 

93