Homeland Security Watch

News and analysis of critical issues in homeland security

April 29, 2009

Swine flu: strategic goals and operational plans

Filed under: General Homeland Security — by Philip J. Palin on April 29, 2009

Yesterday Secretary Napolitano confirmed some of our speculations and observations regarding the policy framework currently being implemented.

During her late afternoon news briefing the Secretary explained, “By Friday we were beginning to assemble the information, inform the inter-agency team that would need to work this issue over the weekend. And under HSPD-5 [Homeland Security Presidential Directive 5], I was designated as the principal federal official, and we began—that whole process was well underway as we worked throughout the weekend.”

Otherwise, I cannot — yet —  find any official documents or even semi-official statements regarding the operational plan per se.  Not surprisingly these kind of “inside-baseball” questions are not — yet – being asked.   Today the Secretary will testify before the Senate Homeland Security and Governmental Affairs Committee.   Her prepared  testimony may be a good source for this kind of information.

Can we discern the operational plan from behavior? In October 2007 Homeland Security Presidential Directive 21: Public Health and Medical Preparedness was released.   This was intended to set out the strategy and principal operational steps, “to plan and enable provision for the public health and medical needs of the American people in the case of a catastrophic health event through continual and timely flow of information during such an event and rapid public health and medical response that marshals all available national capabilities and capacities in a rapid and coordinated manner.”

I don’t know that anyone in the Homeland Security Council staff, DHS, or elsewhere has even glanced at this artifact of the Ancien Regime. But a quick review suggests they might have.  The HSPD argues, “the four most critical components of public health and medical preparedness are biosurveillance, countermeasure distribution, mass casualty care, and community resilience.”

In regard to biosurveillance, there is some controversy. Some of the key concerns have been set out in comments made on this blog in recent days (especially see the comments to this prior post). Basically it comes down to “what did you know, and when did you know it.” But there is also also a claim that investment in enhanced biosurveillance specifically paid off in this case (see editorial note at end of this prior post). What can be stated confidently is that since Tuesday April 14, the US biosurveillance system has been on high alert, and as far as we can tell seems to be operating effectively.

The second critical component is Countermeasures Distribution.  During yesterday’s news briefing the Secretary emphasized in her opening statement, “I issued a public health emergency declaration. That permitted today the—an emergency authorization that allows the FDA [U.S. Food and Drug Administration] to proceed to permit things like Tamiflu to be used for populations that they otherwise wouldn’t be used for—in this case, for example, very, very young children…  We are in the process of activating our national stockpile of antiviral drugs. The priority is placed on states that have been affected, as well as states along the border. And antivirals already are on the way to some of these states. All states will have access to the national stockpile and full deployment is expected by the third of May.” According to plan? 

There is not yet much mass media discussion of Mass Casualty Care. But we can see and hear signs of preparation.  For example, Winchester, Virginia health officials held a public meeting to confirm readiness and communicate confidence.  According to the Winchester Star, “Health officials say they are prepared for any cases of swine flu that might be diagnosed in the area.  The Lord Fairfax Health District and Winchester Medical Center have plans in place to isolate anyone diagnosed with the illness and to maintain necessary services should an outbreak occur.”   The HHS Agency for Healthcare Research and Quality has conducted several educational and planning events precisely to prepare for mass casualty care.  HHS has also developed a Medical Surge Capacity and Capability Handbook.  But, not surprisingly, a June 2008 report by the GAO found potential problems.

I hope Winchester’s self-assessment is accurate and reflective of most others.  I also hope we don’t have a real-world test. 

Community Resilience was identified by HSPD-21 as the fourth critical component.  The White House directive explains, “Where local civic leaders, citizens, and families are educated regarding threats and are empowered to mitigate their own risk, where they are practiced in responding to events, where they have social networks to fall back upon, and where they have familiarity with local public health and medical systems, there will be community resilience that will significantly attenuate the requirement for additional assistance.”

Yesterday Secretary Napolitano reported, “The Department of Homeland Security is conducting conference calls with state public health and homeland security officials on a daily basis to discuss developments related to swine flu, and I’ve reached out to the governors of each of the states where a confirmed case has arisen… We are reaching out to the private sector to make sure that they are preparing, and to inform them of the latest actions we are taking. It’s important that they be thinking ahead about what they would do should this erupt into a full-fledged pandemic, which it has not yet, by the way.”

Similar quotes could be generated from CDC, Governors, Mayors, and others.  Is there enough being done?  Is it possible too much is being done?  If we over-do this, will the public be resistant to risk readiness for future pandemic threats?  What’s the right balance?

For the purpose of identifying  key elements of the policy-and-practice nexus, is HSPD-21 a fundamental document or –  if the document is unknown to current decision-makers — are the principles and priorities articulated in HSPD-21 being efffectively implemented?  Are you observing gaps in either the principles or the implementation?

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7 Comments »

Comment by Peter J. Brown

April 29, 2009 @ 8:28 am

HSPD-21 provides guidance, but all planning, implementation and budgetary allocations incuding personnel support at all levels right on dowen to ranks of volunteers have been coordinated and decided upon at the state level with a regional overlay.

Last July, for example, the Providence (RI) Journal looked at this closely. See “U.S. stockpiling antidotes to counter a biological threat” july 23 by Amanda Milkovits, Providence Journal Journal Staff Writer. Note in particular her mention of the potential impact of any possible albeit unlikely decision to close a state’s borders.

Her article covered a field hearing in Providence convened by U.S. Rep. James Langevin, chairman of the House Subcommittee of Emerging Threats, Cybersecurity, Science and Technology, “to gauge the progress of the state and nation’s preparedness for a biological threat. He was joined by committee members U.S. Rep. Bill Pascrell, D-N.J., and Rep. Donna Christensen, D-Virgin Islands.”

“State and federal officials told the subcommittee that plans and preparation had progressed, but more work needed to be done. The national stockpile of antidotes is being built, the federal government is working with companies to develop vaccines and antidotes to biological threats and more technology is needed to detect an airborne biological hazard.

“On a state level, while hospital officials and medical professionals have become more prepared to deal with a sudden surge of patients, they know a large-scale disaster would leave them struggling to maintain care.

“While much of the federal government’s focus has been on explosive devices, Rear Adm. W. Craig Vanderwagen, the assistant secretary for preparedness and response at the U.S. Department of Health and Human Services, told the committee that he believes that biological attacks and the spread of pandemic flu would have a more widespread effect, touching every level of society.

“What’s also problematic with biological threats, it is not geographically limited,” Vanderwagen said. “So you’re not sure exactly when it started and you’re not sure when it’s going to end.”

“The U.S. Department of Health and Human Services has set a goal for antiviral antidotes to stockpile enough to treat 81 million people: 50 million from the HHS and 31 million from state supplies. Most of the states have enrolled in a federally subsidized program to purchase their own antiviral supplies.

“Vanderwagen said he didn’t believe that every state would be able to complete building up the stockpile of medications because they can’t afford to and some don’t want to participate. “This is a federal republic,” Vanderwagen said. “We can’t force states to make those purchases. … They’ll get the federal share [of antidotes], but they are at risk.”

“In Rhode Island, the state’s Disaster Medical Assistance Team (DMAT) is made up of 250 medical professionals with access to a cache of medical and logistical equipment to deal with a disaster, including setting up a field hospital –– all deployable anywhere in the country within six hours.

“But last month, the cache that the Rhode Island team uses was moved north of Boston, and its warehouse here was closed because the National Disaster Medical System (NDMS) decided to regionalize all of the disaster medical teams caches, said Tom Kilday, the homeland security program manager at the Rhode Island Emergency Management Agency. So, if a biological disaster happens and the state borders are closed, the Rhode Island team wouldn’t be able to get to its equipment to help people in this state.

“In some ways, the state has prepared itself since the Station nightclub fire. The hospitals have improved their communications and can track capacity in any hospital statewide quickly, which would help if there’s a sudden surge of sick people needing care, said Peter Ginaitt, the director of emergency preparedness for the Lifespan Hospital Network, and Dr. David Gifford, the director of the state Department of Health.”

Again, this article underscores the fact that a tragic nightclub fire served as an important catalyst in RI. Otherwise, with 50 state pandemic response plans now fully in motion, while the hope is that HSPD-21 along with the National Response Framework will serve as a strong glue to bond these into an effective national response, there is a need to get the regional apparatus running in high gear quickly.

Among other things, this includes mobilizing and activating the proper backups for public health, hospital and EMS communications at all levels in support of any and all MMRS and DMAT surge-related operations that might now fall under the Regional Emergency Communications Coordination Working Groups (RECCWGs) in each of the 10 FEMA regions. RECCWGs were created, “to assess emergency communications capabilities within their respective regions, facilitate disaster preparedness through the promotion of multijurisdictional and multiagency emergency communications networks, and ensure activities are coordinated with all emergency communications stakeholders within the RECCWG’s specific FEMA region.”

Comment by Quin

April 29, 2009 @ 8:34 am

FYI,

The NRF Incident Annex on Biological Incidents:

http://www.fema.gov/pdf/emergency/nrf/nrf_BiologicalIncidentAnnex.pdf

Comment by William R. Cumming

April 29, 2009 @ 10:04 am

Fact: No HSPD ever carried with it authority for obligation of funds. The theory is that agencies might, almost none did, use the HSPD system in their budget requests to OMB, which of course turned most down. Just because theoretically approved by the President does not cut ice with OMB that has always been hostile to preparedness and is largely the source of the reactive policy stance of the Executive Branch to Preparedness and Mitigation. Hey OMB cheered when OEP (Office of Emergency Preparedness–in the Executive Offices of the White House)was broken up by President Nixon and OMB Director Frank Carlucci and the OEPauthority to provide so-called “delegate agency funding” by OEP (meaning they could approve the preparedness budgets of the Executive Branch organizations under old EO 11490 (1969). Since then any attempt to give delegate agency funding to FEMA or otherwise for preparedness has been stopped cold by OMB. A rival is no rival if stillborn.

Actually, I think HSPD-21 is a terrific document and would love to know its drafting process. Note that it is a fall 2007 document and both the National Strategy for Pandemic Influenza (2005)and the Implementation Strategy (2006) were not amended subsequent to HSPD-21. I refrain from ever mentioning names in my comments, but I am taking this opportunity to mention a highly competent civil servant who to my mind really really understood the systems, processes, and weaknesses in the system and hoping she is available to DHS and HHS. That person is Dr. Anne Norwood, M.D. who is also a Lt.Colonel in the Army Reserves. I also hope “Peggy” Hanburg and Amy Smithson and Julie Gerberding are brought in to give advice. Time for the first team.
By the way just so we know there is no self-promotion or self-appointment involved, could we see the document naming Secretary DHS as Principal Federal Official for this event? To my mind, just citing HSPD-5 is not enough for several reasons. Intervening events and statutory amendments for one thing. Second, basic competence of DHS in Pandemic Flu situation. Also is Anthony Fauci still at NIH? He is also one the Administration needs on hand for this one. This is the big time folks in my judgement so let’s get this right and get the first team in action. AS to Senator Lieberman’s statement that at least we are prepared for this one–time will answer that question very specifically!

Comment by Philip J. Palin

April 29, 2009 @ 12:12 pm

The Secretary and the Homeland Security Advisor have each referenced HSPD-5 on several occasions. HSPD-21 not at all.

At Wednesday’s Senate hearing, the Secretary and Senators made several references to the National Pandemic Strategy and Implementation Plan. This document is much more detailed than HSPD-21 and — as noted in another comment — already existed at the time HSPD-21 was being written.

What then was (is) the differentiated purpose and value of HSPD-21? I have an analysis derived from available evidence. But it would be great if someone reading this discussion might have actually been involved in crafting HSPD-21 and could explain the original intent.

Comment by Peter J. Brown

April 29, 2009 @ 3:02 pm

I am puzzled by the fact that no mention is made of HSPD-21, too. Is the leadership role of DHS in this instance a factor and is HHS simply not being provided any opportunity to highlight the importance and status of its HSPD-21-related work or what? Would DHS really even be focused on it? I don’t think so.

Go back and look, for example, at Sec. Leavitt’s testimony a year ago — “HHS Leadership in Federal Emergency Preparedness Efforts” — before the House Committee on Oversight and Government Reform,

He reminded everyone that HSPD-21 — “Public Health and Medical Preparedness” established the new National Strategy for Public Health and Medical Preparedness.

“The Strategy aims to improve the Nation’s ability to plan for, respond to, and recover from public health and medical emergencies at the Federal, State, Territorial, Tribal, and local levels. It calls for the continued development of a National Health Security Strategy, as well as a robust infrastructure — including healthcare facilities, responders and providers — which can be drawn upon in the event of an emergency. The Strategy also requires actions to ensure the adequate flow of information before, during, and after an event, including critical biosurveillance data and risk analysis. Finally, the Strategy calls for the development of resources at the community level to ensure that individuals and families are empowered to protect themselves in the event of an emergency.

He went on to say that he chaired the interagency Public Health and Medical Preparedness Task Force, and that HHS ASPR had “chaired two interagency Action Officer level meetings to provide guidance on implementation.”
HHS also chaired the interagency Writing Team that drafted the Implementation Plan, he said, and 6 workgroups had been established to oversee implementation of HSPD-21.

“Four workgroups are being chaired by HHS:
1) Medical Countermeasure Stockpiling and Distribution;
2) Biosurveillance;
3) Mass Casualty Care; and
4) Community Resilience.

“A fifth workgroup on Education and Training is co-chaired by HHS and DOD and a sixth workgroup on Risk Awareness is being chaired by the Department of Homeland Security.

“HSPD-21 directed the establishment of two advisory committees. The National BioSurveillance Advisory Committee has been established as a subcommittee to the CDC Advisory Committee to the Director (ACD) and a Disaster Mental Health Advisory Committee is being established as a subcommittee under the National Biodefense Science Board (NBSB) which advises the HHS Secretary.

He stated that as part of the implemention process, the new Emergency Care Coordination Center (ECCC) was being established.

“This new center, an intradepartmental and interdepartmental collaborative effort involving the Departments of Defense, Homeland Security, Transportation and Veterans Affairs, will serve as the coordinating focal point for an Emergency Care Enterprise, coordinating with the Federal Interagency Committee on Emergency Medical Services. Its vision is exceptional daily emergency care for all persons of the United States and its mission is to promote Federal, State, local, tribal and private sector collaboration to support and enhance the nation’s emergency medical care.

“The ECCC will assist the USG with policy implementation and guidance on daily emergency care issues and promote both clinical and systems-based research. Through these efforts, ASPR and its federal partners will improve the effectiveness of pre-hospital and hospital based emergency care by leveraging research outcomes, private sector findings and best practices. The ECCC will promote improved daily emergency care capabilities to improve resiliency of our local community healthcare systems. This will provide a stronger foundation on which to advance disaster preparedness efforts and strengthen our Nation’s ability to respond to mass casualty events. Currently, the ECCC Charter is being finalized and we anticipate having the Center up and running by the end of the year.’

In other words, as you look at all the HSPD-21 activity outlined above — at least as described just a few months after its issuance — HHS and not DHS is really in charge of most if not all aspects of its implementation. So, I wonder if this explains the fact that the DHS Sec. and Homeland Security Advisor did not mention it in their presentations. And with everything on her plate over the past two weeks, I doubt the Sec. DHS has been briefed on where things stand with respect to HSPD-21.

Comment by Peter J. Brown

April 29, 2009 @ 4:14 pm

Evidence that HSPD-21 was having some impact as of late 2008 is easily found. Take a look for example at UPMC Center for Biosecurity’s “Biosecurity News in Brief” reported in “NBSB Report Suggests Improvements for NDMS” (by Crystal Franco, September 29, 2008).

http://www.upmc-biosecurity.org/website/biosecurity_briefing/archive/hosp_prep/2008-09-29-nbsbrptsuggestimprovndms.html

“National Biodefense Science Board (NBSB)—an advisory body to the HHS Assistant Secretary for Preparedness and Response (ASPR)—held a meeting to discuss a report titled Strategic Improvements to the National Disaster Medical System (NDMS), which was issued by the NBSB Disaster Medicine Working Group.

“As mandated by the Pandemic and All Hazards Preparedness Act (PAHPA) and Homeland Security Presidential Directive (HSPD)-21, HHS has been conducting an ongoing review of NDMS and national medical surge capacity. NBSB was called upon by HHS to provide feedback on the ongoing review. To conduct its analysis, the NBSB Disaster Medicine Working Group formed an NDMS Assessment Panel composed of NDMS subject matter experts from the public and private sectors. This expert panel reviewed documents on NDMS, with specific focus on the “Joint Review of National Disaster Medical System, Consolidated Report of Recommendations, Stakeholder Review Draft, Version 3.0” authored by the MITRE Corporation (“the MITRE report”), which they concluded was an “inadequate and inaccurate…review of the NDMS and medical surge capacity.

“The NBSB report contains recommendations for the future of the program based on the NDMS Assessment Panel’s evaluation of NDMS and the review process thus far:

(I only include a few of the recommendations here.)

“Medical Response Personnel: Enhancing the NDMS medical response teams is critical. Teams should be staffed fully, and there should be a streamlined application process. Issues regarding equipment, logistics, communication, and command and control should be addressed, and a “uniform, consistent training curriculum” should be created and implemented.

“NDMS Personnel Capability and Gap Analysis: It is important to ensure that NDMS volunteers do not have “conflicting obligations and have time to respond” during a disaster. Also, given the current Department of Defense (DoD) commitments abroad, availability of DoD assets and staff for NDMS assistance should be evaluated.

Improved Communication with State/Local Representatives: Better integration is needed between federal and state and local resources.

Federal Regulations: Criteria specifying which federal health-regulations will be suspended during a disaster response should be developed in advance of a disaster. These criteria should be widely communicated to the healthcare community so that they are taken into account in preparedness efforts.

NDMS Funding: Funding for NDMS is inadequate and requires at least a 15% increase over current levels. However, in order to truly accomplish its mission, NDMS will require a doubling of its current funding level.

“The NBSB submitted its recommendations to HHS, and HHS is to provide a written response to the report during the NBSB 2009 summer meeting.”

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April 30, 2009 @ 6:49 am

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