Introduction
Over the past decade, our Nation has renewed its efforts to address large-scale incidents that
have threatened human health, such as natural disasters, disease outbreaks, and terrorism,
including the use of weapons of mass destruction (WMD). The responses to incidents such as the
September 11, 2001, attacks and the 2001 anthrax attacks; the outbreak of Severe Acute
Respiratory Syndrome (SARS); multiple hurricanes; and the 2009 H1N1 influenza outbreak have
highlighted challenges while also providing valuable lessons to help the Nation prevent, protect
against, respond to, and recover from future incidents.
Major progress has been made in improving the Nation’s ability to address the public health and
medical consequences of the full range of potential threats. For example, states and localities
have developed and exercised emergency response and recovery plans; laboratory capacity has
increased; disaster communication systems have improved; and plans have been put in place to
deliver medical countermeasures to communities, if needed. Numerous local responses to health
incidents have improved as a result of these efforts. In addition, U.S. government programs have
been working with global partners to enhance capacity to rapidly detect and contain emerging
health threats (including bioterrorist threats) and to increase capacity for rapid response to
outbreaks and other health incidents, laboratory diagnostic testing, surveillance, and workforce
recruitment and training.
Nonetheless, many challenges remain. Emergency response efforts are sometimes disparate; and
effective coordination is often lacking across governmental jurisdictions, communities, and the
health and emergency response systems.3 Additional steps must be taken to ensure that adequate
medical surge capacity and a sufficiently sized and competent workforce are available to respond
to health incidents, a sustainable medical countermeasure enterprise sufficient to counter health
incidents is fostered, and increased attention is paid to building more resilient communities and
integrating the public, including at-risk individuals4, into national health security efforts.
Moreover, considerable variation remains in the degree to which individual states, territories,
tribes, and local jurisdictions are prepared to address large-scale health threats. At the same
time, few evidence-based performance measures and standards exist to gauge the effectiveness
of national health security efforts and progress toward goals5—that is, to assess the extent to
3The health system includes all parts of the health care delivery system (e.g., primary and hospital care, disaster
medicine, and behavioral health care) and the public health system. The emergency services system includes police,
fire, emergency medical services, and emergency management.
4 As defined in section 2802(b)(4)(B) of the PHS Act, at-risk individuals include “children, pregnant women, senior
citizens and other individuals who have special needs in the event of a public health emergency, as determined by
the Secretary.” For purposes of this document, the category of at-risk individuals also includes individuals who may
need additional response assistance during an emergency, such as persons who have disabilities, live in
institutionalized settings, are from diverse cultures, have limited English proficiency or are non-English speaking,
are transportation disadvantaged, have chronic medical disorders, or have pharmacological dependency. See also
the definition in Appendix C Glossary of Key Terms.
5Section 319C-1(g)(1), of the Public Health Service (PHS) Act (42 U.S.C. 247d-3a(g)(1)), as amended by section
201 of the Pandemic and All-Hazards Preparedness Act (PAHPA), Public Law No. 109-417, requires that standards
be developed to measure levels of preparedness with respect to activities carried out by recipients of the Centers of
Disease Control and Prevention’s Public Health Emergency Preparedness (PHEP) grants and the Assistant Secretary
for Preparedness and Response’s Hospital Preparedness Program (HPP) grants. “Not later than 180 days after the
date of enactment of the Pandemic and All-Hazards Act, the Secretary shall develop or where appropriate adopt, and
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which the Nation is prepared for the types of health incidents that we have experienced in the
past and may have to confront in the future.