Public health functions in the United States—such as disease detection, vaccinations, and emergency preparedness and response—are conducted by public health officials from 59 state and territorial health departments; approximately 3,000 county, city, and tribal health departments; about 180,000 public and private clinical laboratories; and multiple federal agencies. Since clinicians at the county, city, or tribal level are most likely to be the first ones to detect an incident, they and local public health officials are expected to report an incident or symptoms of diseases to the state health department and other designated parties. States provide supporting personnel, financial resources, laboratory capacity, and other assistance to local responders when needed. When an incident occurs that exceeds or is anticipated to exceed state, local, or tribal resources, state governors may request that the federal government provide resources to assist the state in its response efforts. For incidents involving primarily federal jurisdictions or authorities (e.g., military bases, federal facilities, or federal lands), federal departments and agencies may be the first responders and first line of defense in coordinating activities with state, local, and tribal partners. Along with HHS, several other federal agencies play a role in supporting public health functions, including the Departments of Agriculture, Homeland Security, Defense, and Veterans Affairs. Among these, HHS is the department with primary responsibility for supporting public health emergency preparedness and response: it serves as the federal focal point for coordinating response support for public health and medical services. Figure 1 provides an overview of the public entities having roles and responsibilities in sharing information to support nationwide public health situational awareness. Because of the many participants involved, the identification and management of a public health emergency call for effective communication and collaboration across all levels of government and the public health community. In this regard, efficient information sharing among these entities is essential to create and maintain the situational awareness needed to effectively prepare for, respond to, and manage a public health emergency. Congress recognized the importance of HHS’s role in supporting the nation’s ability to prepare for and respond to public health emergencies and, in 2006, through provisions of PAHPA, established the Office of ASPR. Among other things, the Assistant Secretary of this office serves as the principal advisor to the Secretary of HHS on all matters related to federal public health and medical preparedness and response. This official is also responsible for coordinating with state, local, tribal, and territorial officials to ensure effective integration of federal public health and medical assets during emergencies. The office was established in December 2006 and is made up of six subordinate offices. In addition, PAHPA established the National Biodefense Science Board in 2006, which HHS now refers to as the National Preparedness and Response Science Board. This board is to provide expert advice and guidance to the Secretary on scientific, technical, and other matters regarding current and future chemical, biological, nuclear, and radiological agents. PAHPA also mandated that the Secretary of HHS develop and submit to the appropriate committees of Congress by June 16, 2007, a strategic plan that described the steps the department would take to develop, implement, and evaluate an electronic public health situational awareness network. The network was to be made up of interoperable systems that would enable the simultaneous sharing of information needed to enhance awareness at the federal, state, local, tribal, and territorial levels of public health. The strategy was to identify measurable steps the Secretary would take to develop, implement, and evaluate the network. It was also to identify actions for improving information sharing, coordination, and communication among disparate biosurveillance systems supported by HHS. The law required the department to establish such a network by December 19, 2008. The Secretary designated ASPR to be responsible for developing the public health situational awareness strategy. However, we reported in December 2010 that the Secretary of HHS had not met the requirements enacted by PAHPA in 2006. In particular, we found that the department had not developed a strategic plan for establishing the network and had not integrated relevant but disparate strategies that existed throughout the department as a step toward establishing an electronic public health situational awareness network. Thus, we recommended that the Secretary of HHS develop and implement a strategic plan that defined goals, objectives, and priorities for establishing an electronic public health situational awareness network. We noted that such a plan should include performance measures for evaluating capabilities of existing and planned information systems, identify gaps in information-sharing capabilities and needed areas of improvement, and integrate related strategies within HHS for sharing information among federal, state, local, and tribal entities. The department neither agreed nor disagreed with the recommendation, but stated that a complete strategy would be developed. Subsequently, Congress reauthorized the act in 2013 and reiterated the mandate for HHS to develop a strategy and implementation plan for establishing an electronic public health situational awareness network, and to establish the network. The reauthorization, or PAHPRA, required the Secretary of HHS to submit to the appropriate committees of Congress a coordinated strategy and an accompanying implementation plan no later than 180 days after March 13, 2013—that is, by September 9, 2013. The network was to be established by March 13, 2015. PAHPRA authorized $138,300,000 for each of fiscal years 2014 through 2018 to support HHS’s efforts to implement the network and other activities mandated by the act. In May 2014, ASPR officials completed and the Secretary of HHS submitted the Public Health and Medical Situational Awareness Strategy to Congress. The department submitted the accompanying implementation plan to Congress in September 2015. Figure 2 provides an overview of the submission requirements and delivery time frames of the strategy and plan. Maintaining a situational awareness capability involves an active, continuous, and timely exchange of information that enhances the ability of public health officials to make decisions related to emergency preparedness and response. For about two decades, public health officials at the federal, state, local, tribal, and territorial levels have used IT systems and tools to collect and share information in their day-to-day functions, such as tracking vaccinations and outbreaks of seasonal influenza. Public health officials also use these systems to create the situational awareness needed to enable early detection of, and effective response to, emerging diseases and other public health events. For example, electronic biosurveillance systems are used to collect data such as complaints from emergency department patients and lab test results related to disease syndromes, and to provide these data to public health officials. These data collection and information-sharing techniques are employed not only to detect the initial signs of emerging threats, but also to track the spread of syndromes, diseases, and other biological events throughout the duration of a public health emergency. Additionally, geographic information systems and mapping tools that support emergency response are useful to public health officials, as these tools provide visual and quantitative data such as maps of available hospital facilities and bed capacity, the location of electrical grid generators, and information regarding regional populations. At the federal level, several agencies have implemented and continue to use IT systems and tools as part of their efforts to collect, integrate, and share critical public health and medical information. In our December 2010 report, we described 25 systems in use by HHS’s Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), Indian Health Service, and the Office of ASPR to support public health situational awareness. These systems had been developed and implemented to enable emergency response information-sharing in support of various other public-health-related department initiatives or mandates. In its role as the federal focal point for coordinating response support for public health and medical services, HHS coordinates national emergency response efforts for public health emergencies through ASPR’s Secretary’s Operations Center (SOC). This center was established in 2002 primarily in response to the events of September 11, 2001. The SOC is a 24-hour-a-day, 7-day-a-week emergency operations center that uses information systems and tools to collect and analyze data from other federal emergency operations centers, such as those at CDC and FDA. The systems are also used to share information with other federal agencies that have responsibility for public health and other emergency support functions, such as the Departments of Homeland Security, Agriculture, and Transportation, and with state and local entities. ASPR officials stated that they have used information systems operating from the SOC to support situational awareness during recent emergencies. For example, during the Louisiana flooding in August 2016, HHS deployed regional teams to the field to collect public health data from electronic health records of patients injured or otherwise affected during the flooding. The teams integrated the data into one of the SOC analytical tools, called Fusion Analytics, which layered the patient data with other data, such as information regarding the location of medical facilities that were available and able to treat certain patients. The HHS teams were then able to provide the information to local public health officials to help them make decisions regarding where to transport victims for treatment. In addition, the department used maps and images produced by another system, the HHS emPOWER Map, to identify populations of Medicare beneficiaries who use electricity-dependent medical equipment, such as ventilators and powered wheelchairs. This information was used to support planning and response efforts in the field in case of a power outage. The system also provided graphical information about areas likely to flood in support of emergency responders making preparations. Figure 3 shows an example of the type of information provided by emPOWER Map. ASPR officials noted other ways in which HHS has used IT systems operating from the SOC to help provide situational awareness for the early detection of illnesses in the Zika virus outbreak during the summer of 2016. For example, HHS used its interactive geographical information system tool, called GeoHEALTH, to map the number of cases within the country by state and county. This information was collected from state and local public health officials via CDC’s disease surveillance systems and from the National Biosurveillance Information Center via open source reporting.