Investigations of selected historically important syndromic outbreaks: impact and lessons learned for public health preparedness and response.

Public health readiness has increased at all jurisdictional levels because of increased sensitivity to threats. Since 2001, with billions of dollars invested to bolster the public health system's capacity, the public expects that public health will identify the etiology of and respond to events more rapidly. However, when etiologies are unknown at the onset of the investigation but interventions must be implemented, public health practitioners must benefit from past investigations' lessons to strengthen preparedness for emerging threats. We have identified such potentially actionable lessons learned from historically important public health events that occurred primarily as syndromes for which the etiological agent initially was unknown. Ongoing analysis of investigations can advance our capability to recognize and investigate syndromes and other problems and implement the most appropriate interventions.

Classifying infectious disease outbreaks to improve timeliness and efficiency of response.

Following the intentional dissemination of B.anthracis through the U.S. Postal Service in 2001, use of the term "naturally occurring" to classify some infectious disease outbreaks has become more evident. However, this term is neither a scientific nor an epidemiologic classification that is helpful in describing either the source or the mode of transmission in outbreaks. In this paper, the authors provide examples of how and when the public health community has recognized potentially flawed or misleading taxonomy in the past and taken steps to improve the taxonomy's accuracy and usefulness. We also offer examples of alternative terms for classifying outbreaks since inaccurate descriptions of outbreaks could potentially lead to a flawed or incomplete set of underlying assumptions about the outbreak's causal factors. This, in turn, could lead to implementing a flawed or incomplete intervention or response strategy which could extend the duration of the outbreak, resulting in avoidable morbidity and mortality.

Public health emergencies and responses: what are they, how long do they last, and how many staff does your agency need?

Responding to outbreaks is one of the most routine yet most important functions of a public health agency. However, some outbreaks are bigger, more visible, or more complex than others, prompting discussion about when an "outbreak" becomes a "public health emergency." When a public health emergency is identified, resources (eg, funding, staff, space) may need to be redirected from core public health programs to contribute to the public health emergency response. The need to sustain critical public health functions while preparing for public health emergency responses raises a series of operational and resource management questions, including when a public health emergency begins and ends, why additional resources are needed, how long an organization should expect staff to be redirected, and how many staff (or what proportion of the agency's staff ) an organization should anticipate will be needed to conduct a public health emergency response. This article addresses these questions from a national perspective by reviewing events for which the Centers for Disease Control and Prevention redirected staff from core public health functions to respond to a series of public health emergencies. We defined "public health emergency" in both operational and public health terms and found that on average each emergency response lasted approximately 4 months and used approximately 9.5% of our workforce. We also provide reasons why public health agencies should consider the impact of redirecting resources when preparing for public health emergencies.

From SARS to 2009 H1N1 influenza: the evolution of a public health incident management system at CDC.

The organization of the response to infectious disease outbreaks by public health agencies at the federal, state, and local levels has historically been based on traditional public health functions (e.g., epidemiology, surveillance, laboratory, infection control, and health communications). Federal guidance has established a framework for the management of domestic incidents, including public health emergencies. Therefore, public health agencies have had to find a way to incorporate traditional public health functions into the common response framework of the National Incident Management System. One solution is the development of a Science Section, containing public health functions, that is equivalent to the traditional incident command system sections. Public health agencies experiencing difficulties in developing incident management systems should consider the feasibility and suitability of creating a Science Section to allow a more seamless and effective coordination of a public health response, while remaining consistent with current federal guidance.

SARS: mobilizing and maintaining a public health emergency response.

During the spring and summer of 2003, the Centers for Disease Control and Prevention (CDC) mobilized the resources of the entire agency in a concerted effort to meet the challenges posed by the outbreak of Severe Acute Respiratory Syndrome (SARS). Over the 133 days that comprised the emergency response phase of the SARS outbreak, CDC utilized the skills of more than 850 people. These staff were deployed from every Center, Institute, and Office within CDC and the Agency for Toxic Substances and Disease Registry. They provided technical assistance to countries reporting large numbers of cases and requesting assistance, met passengers and crew from these locations upon arrival in the United States, and assured that the syndrome was reported and thoroughly investigated within the United States. This paper describes the operational requirements that were established and the resources that were used to conduct this investigation.