The rise of social media has transformed the way individuals share and consume information. Approximately two-thirds of Americans receive at least some of their news from social media channels such as Facebook, Twitter, YouTube, Instagram, and Snapchat.1 During an emergency, public health practitioners need to understand how to effectively use social media to rapidly disseminate information, so that the public health message goes viral,* instead of the disease. We propose a novel framework using a 3 Rs principle—Review, Recognize, and Respond—to help public health practitioners design tailored messages that prevent disease and promote health before, during, and after a public health emergency.

Although there are a number of definitions of “community preparedness,” we conceptualize it as the ability of communities to prepare for, withstand, and recover from natural or human-made disasters.1 Community preparedness has no bounds; a crisis, whether contained at the local level or as far reaching as a pandemic, will affect diverse community populations. Preparedness planning must account for and use the multitude of complex organizational and socioeconomic components that contribute to building community resilience following a large-scale tragedy. This supplement samples the broad-ranging topics that comprise the body of scientific and programmatic information available on the subject.

Evacuation plans can be activated to take lifesaving measures. Emergency evacuation is often recommended when authorities determine that moving people away from an area that contains an imminent threat will likely reduce morbidity and mortality related to the pending disaster (e.g., hurricanes, floods). This editorial offers that public health could be more effectively leveraged to promote evacuation recommendations in the face of an impending disaster.

Communities are societal extensions of family. Since early times, humans banded together for mutual aid, companionship, and protection from threats.1 Communities were forged by people living in the same geographic area with shared attitudes, interests, and goals for cultures, religions, and occupations.1 However, social scientists expressed concerns during the Industrial Revolution about changes observed in the human experience as populations retreated from rural areas and close-knit family units in favor of big cities and life among strangers.1 | | Sometime in the latter part of the 20th century, the way people interacted began to shift dramatically.2 In the United States, a decline in marriage and birthrates changed family dynamics and increased the number of adults living alone.2 In 2018, there were 35.7 million single-person households, composing 28% of all United States households—a significant increase from 13% in 1960.3 Social isolation is becoming more acute, with less community engagement as people rely on advances in technology to feel connected.2

In 2005, when Hurricane Katrina exposed troubling gaps in areas with inadequate resources, it also highlighted the ability of community and faith-based organizations (CFBOs) to respond quickly to the needs of vulnerable communities. However, these organizations were not well integrated into the federal response (see the box on page S275).1 In the years since Hurricane Katrina, there has been substantial progress in integrating CFBOs into public health preparedness, response, and recovery. We provide an overview of the Centers for Disease Control and Prevention’s (CDC’s) engagement with CFBOs in domestic responses to pandemic influenza (2009), Ebola (2014), and Zika (2016).

What makes a community ready to respond to the ever-expanding number and complexity of human-caused and natural disasters posing public health risks? Community preparedness is complex and involves multiple stakeholders and crosscutting sectors such as state and local governments; public health departments and agencies; law enforcement, fire, and rescue organizations; social service and faith-based organizations; and ordinary citizens from varied communities. How does community preparedness work? Community preparedness works when organizational and individual-level stakeholders collaborate.

On January 13, 2018, at 8:07 a.m. Hawaii Standard Time, an errant emergency alert was sent to persons in Hawaii. An employee at the Hawaii Emergency Management Agency (EMA) sent the errant alert via the Wireless Emergency Alert (WEA) system and the Emergency Alert System (EAS) during a ballistic missile preparedness drill, advising persons to seek shelter from an incoming ballistic missile. WEA delivers location-based warnings to wireless carrier systems, and EAS sends alerts via television and radio (1). After 38 minutes, at 8:45 a.m., Hawaii EMA retracted the alert via WEA and EAS (2). To understand the impact of the alert, social media responses to the errant message were analyzed. Data were extracted from Twitter* using a Boolean search for tweets (Twitter postings) posted on January 13 regarding the false alert. Tweets were analyzed during two 38-minute periods: 1) early (8:07-8:45 a.m.), the elapsed time the errant alert circulated until the correction was issued and 2) late (8:46-9:24 a.m.), the same amount of elapsed time after issuance of the correction. A total of 5,880 tweets during the early period and 8,650 tweets during the late period met the search criteria. Four themes emerged during the early period: information processing, information sharing, authentication, and emotional reaction. During the late period, information sharing and emotional reaction themes persisted; denunciation, insufficient knowledge to act, and mistrust of authority also emerged as themes. Understanding public interpretation, sharing, and reaction to social media messages related to emergencies can inform development and dissemination of accurate public health messages to save lives during a crisis.

On March 20, 1995, Sarin gas was released during morning rush hour in the Tokyo, Japan, subway system, killing 13 individuals and causing illness among thousands.1 The event received significant media coverage and signaled a call for action among officials in charge of national security. As a component of preparedness efforts against acts of bioterrorism, then President Clinton launched the first national biological weapons defense initiative, and in 1999, Congress appropriated $50 million dollars for the Department of Health and Humans Services, Centers for Disease Control and Prevention (CDC) to mobilize the public health system for protection against harmful biological agents.2 Ensuring safety of the public’s health led to the development of the National Pharmaceutical Stockpile, a repository of pharmaceuticals and medical supplies available for rapid deployment, and provision of direct support to local, state, and territorial health departments in the event of a large-scale public health emergency.3

Medical countermeasures (MCMs) are critical for minimizing morbidity and mortality in the event of a large-scale public health emergency. MCMs involve a broad spectrum of medical assets, including biological products and personal protective equipment. Whether the emergency results from a chemical, biological, radiological, or natural disaster or from widespread infectious disease and contagions, a well-prepared public health community will readily access and deploy lifesaving MCMs. Ensuring appropriate distribution and dispensing of MCMs can be logistically complex, but coordinated planning between local, state, and federal agencies facilitates an efficient public health response.

OBJECTIVES: To describe results of points of dispensing (POD) medical countermeasure drill performance among local jurisdictions. METHODS: To compare POD setup times for each year, we calculated descriptive statistics of annual jurisdictional POD setup data submitted by over 400 local jurisdictions across 50 states and 8 US territories to a Centers for Disease Control and Prevention (CDC) program monitoring database from July 2012 to June 2016. RESULTS: In data collected from July 2012 to June 2015, fewer than 5% of PODs required more than 240 minutes to set up, although the proportion increased from July 2015 to June 2016 to almost 12%. From July 2012 to June 2016, more than 60% of PODs were set up in less than 90 minutes, with 60 minutes as the median setup time during the period. CONCLUSIONS: Our results yield evidence of national progress for response to a mass medical emergency. Technical assistance may be required to aid certain jurisdictions for improvement. Public Health Implications. The results of this study may inform future target times for performance on POD setup activities and highlight jurisdictions in need of technical assistance.

Imagine this fictional scenario: an airline passenger returning to the United States after working in a foreign country suddenly develops chills, headache, muscle pains, and a high fever in flight. Seeking immediate medical attention after landing, the index patient discovers she has a novel strain of influenza. Meanwhile, the virus is transmitted in flight by the recirculated air on-board, exposure to coughing, touching contaminated bathroom door knobs, and at least 180 other passengers. The disease continues to spread as the other infected passengers encounter more people after disembarking.

Children spend the majority of their time at school and are particularly vulnerable to the negative emotional and behavioral impacts of disasters, including anxiety, depressive symptoms, impaired social relationships, and poor school performance (1). Because of concerns about inadequate school-based emergency planning to address the unique needs of children and the adults who support them, Healthy People 2020 includes objectives to improve school preparedness, response, and recovery plans (Preparedness [PREP]-5) (2). To examine improvements over time and gaps in school preparedness plans, data from the 2006, 2012, and 2016 School Health Policies and Practices Study (SHPPS) were analyzed to assess changes in the percentage of districts meeting PREP-5 objectives. Findings from these analyses indicate that districts met the PREP-5 objective for requiring schools to include post-disaster mental health services in their crisis preparedness plans for the first time in 2016. However, trend analyses did not reveal statistically significant increases from 2006 to 2016 in the percentage of districts meeting any of the PREP-5 objectives. Differences in preparedness were detected in analyses stratified by urbanicity and census region, highlighting strengths and challenges in emergency planning for schools. To promote the health and safety of faculty, staff members, children, and families, school districts are encouraged to adopt and implement policies to improve school crisis preparedness, response, and recovery plans.

OBJECTIVES: To evaluate the Public Health Emergency Preparedness (PHEP) program's progress toward meeting public health preparedness capability standards in state, local, and territorial health departments. METHODS: All 62 PHEP awardees completed the Centers for Disease Control and Prevention's self-administered PHEP Impact Assessment as part of program review measuring public health preparedness capability before September 11, 2001 (9/11), and in 2014. We collected additional self-reported capability self-assessments from 2016. We analyzed trends in congressional funding for public health preparedness from 2001 to 2016. RESULTS: Before 9/11, most PHEP awardees reported limited preparedness capabilities, but considerable progress was reported by 2016. The number of jurisdictions reporting established capability functions within the countermeasures and mitigation domain had the largest increase, almost 200%, by 2014. However, more than 20% of jurisdictions still reported underdeveloped coordination between the health system and public health agencies in 2016. Challenges and barriers to building PHEP capabilities included lack of trained personnel, plans, and sustained resources. CONCLUSIONS: Considerable progress in public health preparedness capability was observed from before 9/11 to 2016. Support, sustainment, and advancement of public health preparedness capability is critical to ensure a strong public health infrastructure.

The events of September 11, 2001, forever altered how disaster preparedness was perceived and understood in the United States.1 Rapidly evolving technology, increasing globalization, social and economic crises, and the natural evolution of infectious diseases increased the complexity of public health preparedness and emergency response.2 In 2011, the Centers for Disease Control and Prevention (CDC) published the Public Health Capabilities: National Standards for State and Local Planning3 as the foundation for successful public health preparedness programs. The articles in this volume of AJPH provide detailed accounts of preparedness in action, showcasing competencies in 15 capabilities that are summarized across six domains: biosurveillance, incident management, community resilience, information management, countermeasures and mitigation, and surge management.

OBJECTIVES: To evaluate and describe outcomes of state and local medical countermeasure preparedness planning, which is critical to ensure rapid distribution and dispensing of a broad spectrum of life-saving medical assets during a public health emergency. METHODS: We used 2007 to 2014 state and local data collected from the Centers for Disease Control and Prevention's Technical Assistance Review. We calculated descriptive statistics from 50 states and 72 local Cities Readiness Initiative jurisdictions that participated in the Technical Assistance Review annually. RESULTS: From 2007 to 2014, the average overall Technical Assistance Review score increased by 13% for states and 41% for Cities Readiness Initiative jurisdictions. In 2014, nearly half of states achieved the maximum possible overall score (100), and 94% of local Cities Readiness Initiative jurisdictions achieved a score of 90 or more. CONCLUSIONS: Despite challenges, effective and timely medical countermeasure distribution and dispensing is possible with appropriate planning, staff, and resources. However, vigilance in training, exercising, and improving plans from lessons learned in a sustained, coordinated way is critical to ensure continued public health preparedness success.

The International Health Regulations (IHR), an international law under the auspices of the World Health Organization (WHO), mandates that countries notify other countries of "travelers under public health observation." Between November 10, 2014, and July 12, 2015, the US Centers for Disease Control and Prevention (CDC) made 2,374 notifications to the National IHR Focal Points in 114 foreign countries of travelers who were monitored by US health departments because they had been to an Ebola-affected country in West Africa. Given that countries have preidentified focal points as points of contacts for sharing of public health information, notifications could be made by CDC to a trusted public health recipient in another country within 24 hours of receipt of the traveler's information from a US health department. The majority of US health departments used this process, offered by CDC, to notify other countries of travelers intending to leave the United States while being monitored in their jurisdiction.

During November 3, 2014-December 27, 2015, CDC implemented guidance on movement and monitoring of persons in the United States with potential exposure to Ebola virus (Ebola) (1). Monitoring was concluded in December 2015. After CDC modified the guidance for monitoring travelers from Guinea (the last country for which monitoring of travelers was recommended) in late December 2015, jurisdictional reports were no longer collected by CDC. This report documents the number of persons monitored as part of the effort to isolate, test, and, if necessary, treat symptomatic travelers and other persons in the United States who had risk for exposure to Ebola during the period the guidance was in effect. Sixty jurisdictions, including all 50 states, two local jurisdictions, and eight territories and freely associated states, reported a total of 29,789 persons monitored, with >99% completing 21-day monitoring with no loss to follow-up exceeding 48 hours. No confirmed cases of imported Ebola were reported once monitoring was initiated. This landmark public health response demonstrates the robust infrastructure and sustained monitoring capacity of local, state, and territorial health authorities in the United States as a part of a response to an international public health emergency.

The unique characteristics of children dictate the need for school-based all-hazards response plans during natural disasters, emerging infectious diseases, and terrorism. Schools are a critical community institution serving a vulnerable population that must be accounted for in public health preparedness plans; prepared schools are adopting policies and plans for crisis preparedness, response, and recovery. The importance of having such plans in place is underscored by the development of a new Healthy People 2020 objective (PREP-5) to "increase the percentage of school districts that require schools to include specific topics in their crisis preparedness, response, and recovery plans". Because decisions about such plans are usually made at the school district level, it is important to examine district-level policies and practices. Although previous reports have provided national estimates of the percentage of districts with policies and practices in place, these estimates have not been analyzed by U.S. Census region* and urbanicity.dagger Using data from the 2012 School Health Policies and Practices Study (SHPPS), this report examines policies and practices related to school district preparedness, response, and recovery. In general, districts in the Midwest were less likely to require schools to include specific topics in their crisis preparedness plans than districts in the Northeast and South. Urban districts tended to be more likely than nonurban districts to require specific topics in school preparedness plans. Southern districts tended to be more likely than districts in other regions to engage with partners when developing plans. No differences in district collaboration (with the exception of local fire department engagement) were observed by level of urbanicity. School-based preparedness planning needs to be coordinated with interdisciplinary community partners to achieve Healthy People 2020 PREP-5 objectives for this vulnerable population.

On October 27, 2014, CDC released guidance for monitoring and movement of persons with potential Ebola virus disease (Ebola) exposure in the United States. For persons with possible exposure to Ebola, this guidance recommended risk categorization, daily monitoring during the 21-day incubation period, and, for persons in selected risk categories, movement restrictions. The purpose of the guidance was to delineate methods for early identification of symptoms among persons at potential risk for Ebola so that they could be isolated, tested, and if necessary, treated to improve their chance of survival and reduce transmission. Within 7 days, all 50 states and two local jurisdictions (New York City [NYC] and the District of Columbia [DC]) had implemented the guidelines. During November 3, 2014-March 8, 2015, a total of 10,344 persons were monitored for up to 21 days with >99% complete monitoring. This public health response demonstrated the ability of state, territorial, and local health agencies to rapidly implement systems to effectively monitor thousands of persons over a sustained period.

We conducted the first study that estimates the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a population-based autism spectrum disorders (ASD) surveillance system developed at the Centers for Disease Control and Prevention. The system employs a records-review methodology that yields ASD classification (case versus non-ASD case) and was compared with classification based on clinical examination. The study enrolled 177 children. Estimated specificity (0.96, [CI(.95) = 0.94, 0.99]), PPV (0.79 [CI(.95) = 0.66, 0.93]), and NPV (0.91 [CI(.95) = 0.87, 0.96]) were high. Sensitivity was lower (0.60 [CI(.95) = 0.45, 0.75]). Given diagnostic heterogeneity, and the broad array of ASD in the population, identifying children with ASD is challenging. Records-based surveillance yields a population-based estimate of ASD that is likely conservative.