OBJECTIVE: Limited guidance exists for public health agencies to use existing data sources to conduct monitoring and surveillance of behavioral health (BH) in the context of public health emergencies (PHEs). METHODS: We conducted a literature review and environmental scan to identify existing data sources, indicators, and analytic methods that could be used for BH surveillance in PHEs. We conducted exploratory analyses and interviews with public health agencies to examine the utility of a subset of these data sources for BH surveillance in the PHE context. RESULTS: Our comprehensive search revealed no existing dedicated surveillance systems to monitor BH in the context of PHEs. However, there are a few data sources designed for other purposes that public health agencies could use to conduct BH surveillance at the substate level. Some of these sources contain lagging indicators of BH impacts of PHEs. Most do not consistently collect the sociodemographic data needed to explore PHEs' inequitable impacts on subpopulations, including at the intersection of race, gender, and age. CONCLUSIONS: Public health agencies have opportunities to strengthen BH surveillance in PHEs and build partnerships to act based on timely, geographically granular existing data.

The Centers for Disease Control and Prevention (CDC) responds to public health emergencies at various levels within its organization. Overtime, CDC's response capabilities have matured across the organization due to years of emergency management investment and experience across the agency. In 2019, CDC began to implement the Graduated Response Framework to formalize an approach for managing public health emergencies that recognizes its response capabilities and meets the evolving needs of the country. This brief report summarizes CDC's Graduated Response Framework structure, and how response management escalates and de-escalates according to resource needs and complexity.

Since 2013, the US Centers for Disease Control and Prevention has offered the Public Health Emergency Management Fellowship to health professionals from around the world. The goal of this program is to build an international workforce to establish public health emergency management programs and operations centers in participating countries. In March 2021, all 141 graduates of the fellowship program were invited to complete a web survey designed to examine their job roles and functions, assess their contributions to their country's COVID-19 response, and identify needs for technical assistance to strengthen national preparedness and response systems. Of 141 fellows, 89 successfully completed the survey. Findings showed that fellowship graduates served key roles in COVID-19 response in many countries, used skills they gained from the fellowship, and desired continuing engagement between the Centers for Disease Control and Prevention and fellowship alumni to strengthen the community of practice for international public health emergency management.

OBJECTIVE: We aimed to understand the current training environment for developing public health emergency response leaders and highlight facilitators and barriers in accessing targeted training. DESIGN: We designed 4 focus groups to gather organizational perspectives on public health emergency response leadership development. Discussions were recorded, transcribed, coded, and analyzed to synthesize key themes. SETTING: Focus groups were convened at the 2019 Preparedness Summit (March 27-28) in St Louis, Missouri. PARTICIPANTS: Twenty-three public health professionals from 9 Public Health Emergency Preparedness (PHEP) Cooperative Agreement award recipient jurisdictions and 12 local health departments participated. MAIN OUTCOME MEASURES: We examined the current availability, relevance, specificity, and utility of educational content and delivery modalities. Facilitators and barriers were identified as opportunities to improve training access. RESULTS: Generic emergency management training is considered important and widely available but with limited application in public health practice. Existing leadership training opportunities in public health emergency response are limited and not widely known. While organizational support and accessible training facilitate participation, resource constraints (ie, funding, time, and staff) exist as key barriers. In addition, frequent staff turnover and attrition that result in loss of institutional knowledge likely hinder effective public health emergency responses. CONCLUSION: Effective public health emergency response depends on capable leaders not only well versed in specialized technical disciplines and practices but also familiar with-or preferably fluent in-emergency management principles and functions. This study demonstrated that well-aimed training strategies and organizational planning are essential in developing public health emergency response leaders. Specifically, leadership development may accrue considerable benefit from a standardized training curriculum. In addition, scalable training programs developed through public, private, and academic partnerships may lessen resource demands on individual organizations to facilitate training access. Finally, training practicums (eg, mentoring, shadowing) may provide opportunities to facilitate active learning and preserve institutional knowledge through leadership transitions.

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.

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.

Emergence of a novel infectious disease, such as pandemic influenza, is the one global crisis most likely to affect the greatest number of people worldwide. Because of the potentially severe and contagious nature of influenza, a rapid multifaceted pandemic response, which includes nonpharmaceutical interventions (NPIs) and effective strategies for communication with the public are essential for a timely response and mitigating the spread of disease. A web-based questionnaire was administered via email in July 2015 to 62 Public Health Emergency Preparedness (PHEP) directors across jurisdictions that receive funding through the Centers for Disease Control and Prevention PHEP cooperative agreement. This report focuses on two modules: Public Information and Communication and Community Mitigation. Consistent and targeted communication are critical for the acceptability and success of NPIs. All 62 jurisdictions have developed or are in the process of developing a communications plan. Community-level NPIs such as home isolation, school closures, and respiratory etiquette play a critical role in mitigating the spread of disease. Effective, ongoing communication with the public is essential to ensuring wide spread compliance of NPI's, especially among non-English-speaking populations. Planning should also include reaching vulnerable populations and identifying the correct legal authorities for closing schools and canceling mass gatherings.

The Centers for Disease Control and Prevention (CDC) coordinates the Public Health Emergency Preparedness (PHEP) program through cooperative agreements with 62 jurisdictions, including all 50 states, eight US territories and freely associated states, and four local jurisdictions.1 Jurisdictions are required to maintain plans to ensure that large volumes of medical countermeasures, both pharmaceutical and nonpharmaceutical, can be distributed and dispensed in a timely manner. Plans must consider both the characteristics of the emergency and the medical countermeasures being dispensed. For example, differences in skills, infrastructure, and equipment should be expected when dispensing antibiotics or antiviral medications compared with administering vaccines in mass vaccination settings. Jurisdictions that receive PHEP funding are required to conduct at least one full-scale exercise or functional exercise every five years to test the operational status of their distribution or dispensing plans.1

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.

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.

OBJECTIVES: To assess how US Public Health Emergency Preparedness (PHEP) awardees plan to respond to an influenza pandemic with vaccination. METHODS: The Centers for Disease Control and Prevention developed the Pandemic Influenza Readiness Assessment, an online survey sent to PHEP directors, to analyze, in part, the readiness of PHEP awardees to vaccinate 80% of the populations of their jurisdictions with 2 doses of pandemic influenza vaccine, separated by 21 days, within 16 weeks of vaccine availability. RESULTS: Thirty-eight of 60 (63.3%) awardees reported being able to vaccinate their populations within 16 weeks; 38 (63.3%) planned to allocate more than 20% of their pandemic vaccine supply to points of dispensing (PODs). Thirty-four of 58 (58.6%) reported staffing as a challenge to vaccinating 80% of their populations; 28 of 60 (46.7%) reported preparedness workforce decreases, and 22 (36.7%) reported immunization workforce decreases between January 2012 and July 2015. CONCLUSIONS: Awardees relied on PODs to vaccinate segments of their jurisdictions despite workforce decreases. Planners must ensure readiness for POD sites to vaccinate, but should also leverage complementary sites and providers to augment public health response.

OBJECTIVES: To assess the readiness to vaccinate critical infrastructure personnel (CIP) involved in managing public works, emergency services, transportation, or any other system or asset that would have an immediate debilitating impact on the community if not maintained. METHODS: We analyzed self-reported planning to vaccinate CIP during an influenza pandemic with data from 2 surveys: (1) the Program Annual Progress Assessment of immunization programs and (2) the Pandemic Influenza Readiness Assessment of public health emergency preparedness programs. Both surveys were conducted in 2015. RESULTS: Twenty-six (43.3%) of 60 responding public health emergency preparedness programs reported having an operational plan to identify and vaccinate CIP, and 16 (26.2%) of 61 responding immunization programs reported knowing the number of CIP in their program's jurisdictions. CONCLUSIONS: Many programs may not be ready to identify and vaccinate CIP during an influenza pandemic. Additional efforts are needed to ensure operational readiness to vaccinate CIP during the next influenza pandemic.

BACKGROUND: During an influenza pandemic, to achieve early and rapid vaccination coverage and maximize the benefit of an immunization campaign, partnerships between public health agencies and vaccine providers are essential. Immunizing pharmacists represent an important group for expanding access to pandemic vaccination. However, little is known about nationwide coordination between public health programs and pharmacies for pandemic vaccine response planning. METHODS: To assess relationships and planning activities between public health programs and pharmacies, we analyzed data from Centers for Disease Control and Prevention assessments of jurisdictions that received immunization and emergency preparedness funding from 2012 to 2015. RESULTS: Forty-seven (88.7%) of 53 jurisdictions reported including pharmacies in pandemic vaccine distribution plans, 24 (45.3%) had processes to recruit pharmacists to vaccinate, and 16 (30.8%) of 52 established formal relationships with pharmacies. Most jurisdictions plan to allocate less than 10% of pandemic vaccine supply to pharmacies. DISCUSSION: While most jurisdictions plan to include pharmacies as pandemic vaccine providers, work is needed to establish formalized agreements between public health departments and pharmacies to improve pandemic preparedness coordination and ensure that vaccinating pharmacists are fully utilized during a pandemic.

Our objective was to inform state and community interventions focused on increasing household preparedness by examining the association between self-reported possession of household disaster preparedness items (ie, a 3-day supply of food and water, a written evacuation plan, and a working radio and flashlight) and perceptions of household preparedness on a 3-point scale from "well prepared" to "not at all prepared." Data were analyzed from 14 states participating in a large state-based telephone survey: the 2006-2010 Behavioral Risk Factor Surveillance System (BRFSS) (n = 104,654). Only 25.3% of the population felt they were well prepared, and only 12.3% had all 5 of the recommended items. Fewer than half the households surveyed had 4 or more of the recommended preparedness items (34.1%). Respondents were more likely to report their households were well prepared as the number of preparedness items possessed by their household increased. Risk factors for having no preparedness items were: younger age, being female, lower levels of education, and requesting the survey to be conducted in Spanish. To increase household disaster preparedness, more community-based preparedness education campaigns targeting vulnerable populations, such as those with limited English abilities and lower reading levels, are needed.

Using CASPER, we were able to obtain feedback from Burleigh county residents on a new NWS product piloted in their geographic location. CASPERs can be used to augment public feedback provided via the Web-based survey methodology typically used by NWS to gather feedback. Web-based surveys are useful since they are inexpensive to administer and generate information quickly; however, they require the participant to have an Internet connection and typically attract "weather enthusiasts" who visit NWS web pages regularly. Therefore, Web-based survey responses may not be representative of the general public, whereas CASPERs produce generalizable results and data collection can be done quickly. This is one of the first times NWS has partnered with public health to assess extreme-weather warnings. Collaborations for similar studies could be done in the future to assess other existing or new warnings, particularly with NWS's growing interest to add public health messaging to their warnings to improve the public response and hopefully prevent weather-related morbidity and mortality.

OBJECTIVES: We describe the demographics of the decedents from the tornado outbreak in Alabama on April 27, 2011; examine the circumstances of death surrounding these fatalities; and identify measures to prevent future tornado-related fatalities. METHODS: We collected information about the decedents from death certificates, disaster-related mortality surveillance, and interview data collected by American Red Cross volunteers from the decedent's families. We describe demographic characteristics, circumstances and causes of death, and sheltering behaviors before death. RESULTS: Of the 247 fatalities, females and older adults were at highest risk for tornado-related deaths. Most deaths were directly related to the tornadoes, on scene, and trauma-related. The majority of the deceased were indoors in single-family homes. Word of mouth was the most common warning mechanism. CONCLUSIONS: This tornado event was the third deadliest in recent US history. Our findings support the need for local community shelters, enhanced messaging to inform the public of shelter locations, and encouragement of word-of-mouth warnings and personal and family preparedness planning, with a special focus on assisting vulnerable individuals in taking shelter. (Am J Public Health. Published online ahead of print June 13, 2013: e1-e7. doi:10.2105/AJPH.2013.301291).

STUDY OBJECTIVE: To characterize the demographic, clinical, and epidemiologic features of levamisole-associated neutropenia in cocaine or heroin users. METHODS: State health departments were recruited for participation when the Centers for Disease Control and Prevention (CDC) was notified of potential cases by a clinician, a health department official, or a poison center between October 15, 2009, and May 31, 2010. A case was defined as a person with an absolute neutrophil count less than 1,000 cells/mcL (or a WBC count <2,000 cells/mcL) and a self-reported history or laboratory confirmation of cocaine or heroin use. Health department officials abstracted data from medical charts, attempted a patient interview, and submitted data to CDC for descriptive analysis. RESULTS: Of the 46 potential cases reported from 6 states, half met eligibility criteria and had medical chart abstractions completed (n=23; 50%). Of these, close to half of the patients were interviewed (n=10; 43%). The average age was 44.4 years; just over half were men (n=12; 52%). The majority of patients presented to emergency departments (n=19; 83%). More than half presented with infectious illnesses (n=12; 52%), and nearly half reported active skin lesions (n=10; 44%). The majority of interview respondents used cocaine greater than 2 to 3 times a week (n=9; 90%), used cocaine more than 2 years (n=6; 60%), and preferred crack cocaine (n=6; 60%). All were unaware of exposure to levamisole through cocaine and of levamisole's inherent toxicity (n=10; 100%). CONCLUSION: Physicians should suspect levamisole exposure in patients using illicit drugs, cocaine in particular, who present with unexplained neutropenia. Most patients reported chronic cocaine use and were unaware of levamisole exposure. Cocaine use is more prevalent among men; however, our results identified a higher-than-expected proportion of female users with neutropenia, suggesting women may be at higher risk. Emergency physicians and practitioners are uniquely positioned to recognize these patients early during their hospital course, elucidate a history of cocaine or other drug exposure, and optimize the likelihood of confirming exposure by arranging for appropriate drug testing.

The United States Public Health Service Substance Abuse and Mental Health Services Administration is alerting medical professionals that a substantial percentage of cocaine imported into the United States is adulterated with levamisole, a veterinary pharmaceutical that can cause blood cell disorders such as severe neutropenia and agranulocytosis. Levamisole HCl is the active ingredient in a number of veterinary drugs approved to treat worm infestations in animals. Levamisole HCl was also the active ingredient in a human drug for oral administration approved on June 18, 1990, as adjuvant treatment in combination with fluorouracil after surgical resection in patients with Duke's stage C colon cancer. This drug was withdrawn from the U.S. market around 2000, and it has not been marketed in the U.S. since then. The objective of this study was to develop a method to determine the amount of levamisole in urine samples. The procedure will be provided to state health laboratories as needed to be used in the evaluation of patients that have developed neutropenia or agranulocytosis in the setting of recent cocaine use. A gas chromatography-mass spectrometry method was validated and tested at two different laboratories, and the method limit of detection for levamisole is 1 ng/mL in urine when using a 5-mL sample. Confirmation of the stereoisomer of levamisole was done by high-performance liquid chromatography using a chiral column.