The state is applying to continue into the fourth year of a cooperative agreement with CDC and the second year with HRSA.  The applications include progress reports for 2003.  Activities were delayed by the implementation of the stage one smallpox response planning and vaccination clinics as required by CDC during 2002-2003.  Some of the activities carried out to this point include:

• Completing the assessment of local, state, and regional public health and hospital preparedness and response capacity.
• Initiating planning activities at the local level with a particular emphasis on creating local and regional plans that will link the efforts of hospitals, local health, physicians, nurses, emergency medical personnel and others.
• Adding state capacity to provide critical centralized support services including laboratory analysis and development and maintenance of a statewide information technology system that will support the transmission of critical data at all times.
• Establishing regional coordination of public health and hospital planning and response activities.
• Creating the state smallpox response plan and implementing the vaccination clinics in compliance with the national smallpox vaccination program.
• Establishing a core group of hospital and public health personnel vaccinated against smallpox and ready to respond to a smallpox outbreak.

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• Incident management
  States are required to prepare to participate in the National Incident Management System (NIMS) now being developed by the Department of Homeland Security.  NIMS will cover all incidents for which the federal government deploys emergency response assets.  In the coming year, Washington will review and comment on NIMS documents as requested.

• Joint advisory committee for CDC/HRSA agreements
  Grantees are required to form a committee to jointly oversee HRSA and CDC grant activities.  Washington merged its separate CDC and HRSA grant advisory committees into a single Joint Advisory Committee in early 2003.

• Laboratory connectivity
  Grantees are required to establish relationships between public health, hospital, veterinary, food testing, and environmental laboratories that will facilitate the appropriate routing of samples and sharing of results.  To promote these relationships, Washington will compile an inventory of laboratories that could participate during an emergency, inventory current cooperative agreements between labs and write additional agreements, and plan and implement laboratory improvements as needed.

• Laboratory data standard
  Laboratories are required to adopt a federally specified data exchange standard.  Washington will comply where possible.

• Jointly funded health department and hospital activities
  Grantees are required to create a database that allows them to track expenditures and progress of activities jointly funded by HRSA and CDC.  Washington will add the necessary coding to its state mandated accounting system.

• Integration of surveillance activities
  The grants require state programs to develop a system to rapidly report, capture and analyze disease-reporting data at the state and local levels.  Washington will work to establish a 24/7 disease reporting system that includes hospitals, clinics, emergency medical services, poison control centers and others.  Surveillance liaisons will be identified at these institutions, their duties will be specified, and policies and procedures for reporting notifiable diseases will be developed.

• Coordination with Indian tribes
  State programs are required to describe the steps they will take to more fully involve tribes in public health emergency planning.  Washington will work to involve tribal governments in regional planning efforts and continue to include tribal representatives on its Joint Advisory Committee.  The state program will identify tribal liaisons for its initiatives.

• Populations with special needs
  State programs are required to describe the steps they will take to provide information and services to people with disabilities or serious mental illness, minority groups, non-English speakers, children, and the elderly.  Washington will create a matrix of organizations that represent or work with these constituencies and devise appropriate communications and service programs to meet their needs.

• Psychosocial consequences of bioterrorism
  State programs are required to describe the steps they will take during an emergency to meet the psychosocial needs of victims, their families, the worried well, emergency responders, and public health personnel.  Washington will work with appropriate partners to develop a plan for providing necessary information and services.

• Education and training
  State programs are required to ensure that staff in hospitals, major community health care institutions, emergency response agencies, public safety agencies, and other entities are prepared to respond in a coordinated manner to a terrorist attack or other public health emergency.  Washington will establish training liaison positions for each focus area and other select areas of activity.  DOH will implement a learning management system capable of collecting and reporting data on all training and educational activities, as well as sharing best practices, with other health agencies.  In conjunction with its local partners the state will conduct a full-scale regional bioterrorism exercise testing all major components of the public health response system.

• Involvement of academic health centers
  Grantees are required to describe the role state academic health centers will plan in preparedness efforts.  Washington will continue to contract with academic health centers to provide a variety of education and training opportunities to hospital and public health personnel.

• Interoperability of information technology systems
  States must ensure that state and local agencies and hospitals have technical systems that are compatible enough to share information effectively.  Washington will continue to work to ensure that key stakeholders are able to securely send and receive electronic information, and to generate electronic messages in a way that allows ready interpretation by recipients.  A key activity is the use of federal data standards in DOH projects and promotion of those standards among project partners.

• Border states
  States are required to describe planning efforts with neighboring nations (Canada) and to document agreements that provide for assistance in a mass casualty event.  Washington routinely invites British Columbia representatives to appropriate state and regional planning sessions and will continue to pursue agreements between Washington and British Columbia provincial or the Canadian federal government.  Washington also coordinates with the neighboring states of Oregon and Idaho.

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The CDC grant application consists of year 2003 progress reports and work plans for 2004.  This year for the first time, states were required to insert information into electronic templates provided by CDC.  As in past years, the work plans lay out the framework for a system that recognizes key critical capacities as focus areas.  These include:

• Focus Area A:   Preparedness, Planning and Readiness.
• Focus Area B:   Surveillance and Epidemiology.
• Focus Area C:   Laboratory Capacity – Biologic Agents.
• Focus Area D:   Laboratory Capacity – Chemical Agents.
• Focus Area E:    Communications and Information Technology.
• Focus Area F:    Public Information.
• Focus Area G:    Education and Training.

Within each focus area the CDC requires applicants to address one or more critical capacities —core expertise and infrastructure the CDC considers essential to an effective public health response to terrorism.  Also required are critical benchmarks that designate those activities that must be fully achieved during the proposed grant period.

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The HRSA grant application also requires work plans and a progress report, but in a narrative format.  HRSA activities are organized into six Priority Areas:

• Priority Area 1: Administration.
• Priority Area 2: Hospital Surge Capacity.
• Priority Area 3: Emergency Medical Services.
• Priority Area 4: Hospital Links to Public Health Departments.
• Priority Area 5: Education and Training.
• Priority Area 6: Preparedness Exercises

As in the CDC grant, each applicant is required to address a number of critical capacities and critical benchmarks within each priority area.  HRSA activities may be carried out over a period of time that extends up to three years.

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Focus Area A:  Preparedness Planning and Readiness Assessment addresses strategic leadership, direction, assessment, and coordination of activities (including Strategic National Stockpile).  The Focus Area A work plan emphasizes collaboration between agencies on the local, regional, state, intra-state, and international levels.  Proposed activities include:

Leadership – The agency will continue to support the Public Health Emergency Preparedness and Response Program’s Executive Director, Mary Selecky, and maintain the process for overseeing program implementation.  To ensure coordination of HRSA and CDC grant activities, the agency will continue support for the Joint Advisory Committee formed in early 2003.  To ensure the coordination of smallpox activities begun during the past year, the agency will hire a Smallpox Program Director.  The agency will maintain an accounting system capable of tracking program expenditures.

Assessment – The agency will conduct an analysis of data gathered through the local health jurisdiction and hospital assessments conducted during the most recent grant period.  The state and local health departments, and public health emergency planning and response regions will incorporate the results into their response plans.  The agency will consider conducting an abbreviated follow-up assessment to measure progress.

Preparedness and Response Planning – Washington will complete local and regional response plans.  Regional plans will include hospital preparedness and response.  The state Department of Health will update its related procedures and revise the section of the State Comprehensive Emergency Plan that describes health and medical preparedness.  All plans will be exercised.  Included in the exercises will be a full-scale regional bioterrorism exercise.

The agency will oversee development of a coordinated system for 24/7 notification and activation of the public health emergency response system at the state, local, and regional levels.  At the CDC’s request, the agency will review and comment on federal documents regarding establishment of the National Incident Management System (NIMS) and determine how state public health emergency response is compatible with NIMS.

Strategic National Stockpile – The agency will continue developing its program to ensure its ability to effectively receive and distribute critical emergency medicine, vaccine, and other medical supplies from the Strategic National Stockpile (SNS).  The agency will continue to provide funding, technical support, and other resources to local jurisdictions, which would respond should the SNS be deployed.  Those local jurisdictions and the public health emergency preparedness and response regions will complete their SNS plans and validate them through exercises.  The agency will develop training programs for local SNS personnel and support public communications campaigns.

Focus Area B:  Surveillance and Epidemiology encompasses efforts to improve the detection, reporting, investigation, and response to disease outbreaks.  Activities proposed for the upcoming grant period will address the following critical capacities:

Mandatory reportable disease surveillance system
The agency will:

·         Develop guidelines for responding to urgent disease reports on a 24/7 basis.  The agency will specify the duties of local duty officers.

·         Coordinate and provide training to partner agencies and organizations on surveillance and epidemiological investigation planning issues.

·         Apply standardized evaluation to assess timeliness and completeness of state, regional and local disease surveillance systems.

·         Develop an animal disease surveillance system by creating protocols for zoonotic disease investigation and facilitating communication and efforts with other animal disease resources in Washington State (WADDL (Washington Animal Disease Diagnostic Laboratory), veterinary coordinators, etc).

·         The agency will continue to develop statewide information technology projects including PHIMS  (Public Health Information Management System – a Web-based system for reporting notifiable conditions) and WA SECURES (Washington State Electronic Communications and Urgent Response Exchange System for notification and alerting).

Comprehensive and exercised epidemiological response plan
The agency will:

·         Revise the Smallpox Surveillance and Epidemiological Investigation Appendix.

·         Identify, register and train Smallpox Response Team members.

·         Develop an Epidemiology Response Plan (in conjunction with Regional and Local Public Health Emergency Response Plans) that provides for:

o        Disease investigation protocol development.

o        Epidemiology response team identification and training.

o        Surge capacity (Memorandum of Agreement development).

o        Mass Vaccination Plan revisions (in conjunction with Focus Area A and SNS Program).

Investigation and response to disease outbreak
The agency will:

·         Maintain State and Regional Surveillance and Epidemiology Response Coordinators. Maintain existing epidemiology capacity positions in lead and non-lead local health jurisdictions.

·         Establish Epidemiology Learning Liaison at DOH to identify, catalogue, evaluate and develop training in coordination with Focus Area G, Regional Learning Specialists and Regional Epidemiology Coordinators.

·         Link with DOH Health Care Professions Licensing and WEDSS (Washington Electronic Disease Surveillance System) to develop a registry of providers and volunteers.

·         Create and participate in tabletops and exercises to evaluate and improve response plans and protocols.

Focus Area C:  Laboratory Capacity – Biologic Agents addresses development of a network of laboratories that can rapidly and accurately identify select biologic agents likely to be used in a terrorist attack.  The Focus Area C work plan identifies activities that will achieve the following critical capacities:

Develop a program to provide rapid, effective laboratory services in response to public health threats and emergencies
The agency will:

·         Develop and maintain Washington’s Level A (sentinel) laboratory program.

·         Complete and implement an integrated response plan describing the roles of public health, hospital-based, food testing, veterinary, and environmental testing laboratories during a bioterrorism incident, and address needs for testing food specimens for critical bioterrorism pathogens.

·         Establish and maintain relationships with local members of HazMat teams, first responders, local law enforcement, and the Federal Bureau of Investigation.

·         The Public Health Laboratories (PHL) will build on existing relationships with hospital-based laboratory practitioners, university laboratories, and infectious disease physicians.

·         Appoint a liaison from the state or local Laboratory Response Network (LRN) member laboratory to participate in meetings and conference calls.

Ensure properly equipped and secure laboratory facilities are available to rapidly detect and correctly identify biological agents likely to be used in a bioterrorist incident
The agency will:

·         Continue to develop or enhance laboratory public health emergency plans and protocols.

·         Ensure capacity exists for LRN validated testing for all Category A agents and other Level B/C agents.

·         Ensure one PHL laboratory has the instrumentation and trained staff to perform PCR (Polymerase Chain Reaction, a DNA test) and TRF (Time-Released Fluorometry) assays.

·         Conduct at least one simulation exercise.

·         Ensure the availability of at least one operational Biosafety Level 3 (BSL-3) facility.

·         Ensure that laboratory registration, operations, safety, and security are consistent with the requirements of the federal Select Agent Regulation.

·         Enhance electronic communications and LRN electronic laboratory reporting.

·         Identify the laboratories that have the capacity for LRN-validated testing and reporting of smallpox.

Focus Area D:  Laboratory Capacity – Chemical Agents addresses the ability of public health laboratories to measure chemical threat agents in human specimens (e.g. blood, urine) or to refer specimens to partner laboratories for analysis.

Establish competency in collection and transport of clinical specimens to laboratories capable of measuring chemical threat agents

Washington’s Public Health Laboratories will:

·         Hire and train a chemical terrorism program coordinator and assistant coordinator.

·         Develop protocols for proper collection, labeling and shipment of lab specimens, and for proper communication of data.

·         Develop a plan for creating a statewide laboratory capacity to respond to chemical terrorism events including local, hospital, state, and federal laboratory facilities.

·         Establish relationships with local, state and federal first responders as partners and develop a plan of coordinated actions in chemical terrorism events.

·         Establish relationships with the Poison Control Center, local medical emergency units, Food and Drug Administration laboratory, medical toxicologists and others the state will support with laboratory services during a chemical emergency.
 

Establish Level-One Laboratory Capacity and establish secure laboratory facilities and equipment to rapidly detect and measure in clinical specimens Level two chemical agents such as cyanide, arsenic, and lewisite
The Public Health Laboratories will:

·         Develop plans and protocols for safe and accurate receiving, handling and analysis of clinical specimens collected in response to chemical terrorism event.

·         Hire professional staff to implement analytical methods, purchase necessary equipment and supplies, and participate in quality assurance programs.

·         Participate in at least one laboratory chemical terrorism exercise involving state, regional, hospital, and federal partners.

·         Implement Biosafety Level 2 practices to process clinical specimens.  In collaboration with CDC, first responders, hospitals, federal partners and other state laboratories develop a protocol for handling a specimen/sample of unknown threat.

·         Enhance Internet connectivity to enable rapid communication and data transfer with other chemical laboratories in the LRN.

Focus Area E:  Health Alert Network/Communications and Information Technology addresses state efforts to provide information technology that will allow public health partners to exchange information and data quickly and securely.

Ensure effective communications connectivity between state and local public health agencies, hospitals, and emergency management
The Department of Health will provide 24/7 connectivity and communications between key stakeholders by defining the roles of duty officers for stakeholders and providing the duty officers with required communications equipment.  The agency will also continue implementation of WA-SECURES (an automated alerting system), establish an alerting process that uses existing Internet systems, and maintain the Prophylaxis and Vaccine Management System (PVMS) created to support Stage I of the national smallpox vaccination program.

Ensure availability of multiple means of emergency communications among public health emergency response partners
Washington will acquire alternative voice and data communications mechanisms and deploy them as needed in communities that do not already have them.  The agency will continue to implement the hospital communications plan funded by HRSA.

Ensure the protection of critical data and information systems
The Department of Health will use its 2002 survey of local health partner information security needs to identify improvements and work with partners to implement them.  Security features will be incorporated in the ongoing design of SECURES and PHIMS.

Ensure secure exchange of data and information in standard formats between the computer systems of public health partners
DOH will continue to strengthen its Electronic Data Interchange (EDI) program by identifying security issues; adapting, testing and implementing software; and deploying the program to prioritized laboratories.

Identify communications needs and barriers within individual communities and identify effective channels of communication for reaching the general public and special communities during public health threats and emergencies

DOH will continue to build partnerships with stakeholders, emergency system and community organizations to ensure information is created for and effectively disseminated to partners, the general public and special populations.  The agency will create a Community and Agency Partnership Matrix to strengthen mental health and special population resources and information channels.

The agency will continue to coordinate communications planning efforts with local, regional, state, federal and hospital partners, and test those plans in a series of internal and external drills and regional communication exercises.

The agency will continue building the Regional Emergency Communication Liaison Network to assist local health jurisdictions (LHJs) with local communication planning, resource development, and training.

The agency will maintain the emergency phone bank that serves LHJs and the media, and enhance the general public hotline.

DOH will expand access to critical information by meeting ADA standards for the Web and print materials and by tailoring material to the language, cultural, and socio-economic backgrounds of users.

The agency will continue working with the CDC and appropriate LHJs and regions to strengthen partnerships with border states.

The agency will continue to offer crisis and risk communication training to system partners and enhance related resources.  The agency will also co-host (with LHJs) regional media briefings and expand media education resources.  The agency will work with the Washington State Hospital Association to develop communication protocols and related training.

Focus Area G:  Education and Training activities are designed to create a system for delivering education and training to public health officials, infectious disease specialists, emergency department personnel, and other healthcare (including mental health) providers through multiple channels.  This will include the Centers for Public Health Preparedness, other schools of public health, schools of medicine, other academic institutions, healthcare professionals, CDC, HRSA and other sources.

Ensure delivery of appropriate education and training to key public health professionals, infectious disease specialists, emergency department personnel, and other healthcare providers either directly or through the use of existing curricula and other sources

 The agency will:

·         Support a Focus Area G Coordinator.

·         Create a learning management system that will collect and report data on all training and educational activities and share best practices with other public health agencies.

·         Initiate a one-year training plan for delivering preparedness training on a prioritized basis across all focus areas to the state and local public health workforce, healthcare professionals, and laboratory staff.

·         Collaborate with Centers for Public Health Preparedness, other schools of public health, schools of medicine, and academic medical centers to develop, deliver, and evaluate competency-based preparedness training.

·         Develop and provide education and training sessions on all components of the smallpox response plan.  Following exercise, assess training needs for smallpox preparedness as it pertains to large-scale vaccination clinics.  Identify and train staff needed to support large-scale smallpox vaccination clinic operations.

·         Create a community-based online inventory that lists those with technical, clinical epidemiological, and other expertise that could provide needed services during a smallpox outbreak.  Regularly update the inventory.

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Priority Area 1: Administration

Provide program direction
The agency will:

·         The agency will expand efforts to include tribes in emergency preparedness and response activities by identifying tribal liaisons, assessing best practices employed in other states for working with tribal governments, and providing DOH staff with government-to-government training.

·         Washington will continue to seek cooperation and coordination of public health emergency preparedness and response efforts with border states and Canada.  The state will seek to amend existing emergency management agreements with British Columbia to include public health emergencies.

The Department of Health will adapt the uniform chart of accounts mandated by Washington law to meet HRSA requirements.

Priority Area 2 – Regional Surge Capacity for the Care of Adult and Pediatric Victims of Terrorism addresses building a system that can treat unprecedented numbers of adult and child casualties resulting from a bioterrorism incident.

Hospital Bed Capacity — Hospitals will work with public health regions to upgrade the regional hospital plan portion of regional public health plans to create the capacity to triage, treat, and hospitalize up to 500 patients per 1,000,000 population with acute illness or trauma resulting from a terrorist incident. This will include working with a EMS, community and migrant health centers, tribal health clinics, outpatient facilities, poison control centers, and other health care provider organizations to incorporate a full spectrum of patient care into Washington’s response.

Hospital Isolation Capacity — Washington will upgrade its capacity to isolate, evaluate, and treat patients that may have smallpox, plague, or hemorrhagic fever by making capital improvements in facilities identified through a needs assessment. This will be a three-year program.

Health Care Personnel — Washington will create the capacity to immediately deploy additional patient care personnel during an emergency. This will include developing a system for credentialing and supervising clinicians not normally working in those facilities that would respond to a terrorist incident.

Pharmaceutical Caches — Washington will develop a plan to ensure that hospital pharmacies and other pharmacies participating in its public health emergency response program have supplies of pharmaceuticals adequate to meet the increased demand created by a terrorist incident.

Personal Protection and Decontamination — Washington will continue efforts begun in 2002 to equip hospitals with portable decontamination shelters and a minimum number of sets of personal protective equipment.

Mental Health — Washington will implement a plan to address the mental health and special needs of health care workers and the victims of a bioterror attack.

Communication and Information Technology — Washington will establish a secure and redundant communications system that ensures connectivity during a terrorist incident between health care facilities and state and local health departments. (See CDC focus area E).

Priority Area 3 – Emergency Medical Services addresses the ability of emergency management systems (EMS) to respond effectively to terrorist incidents.

DOH will work with Regional Emergency Management Systems/Trauma Care (EMS/TC) Councils to assess the training and equipment needs of first response and EMS agencies, assess existing mutual aid agreements between EMS/TC agencies for first response to terrorist incidents, and develop a mutual aid plan for upgrading and deploying EMS units in jurisdictions they do not normally cover.

Hospital Laboratories — The Washington State Public Health Laboratories (WAPHL) will integrate hospital laboratories into public health laboratory preparedness efforts. This will include establishing procedures for coordinating screening, testing and reporting, creating an electronic system for reporting laboratory results to hospitals and clinicians, and jointly implementing a plan to support regional hospital laboratories capable of assisting in a biological, chemical or radiological terrorism response. Upgrade hospital lab capabilities related to weaponizable biological, chemical or radiological materials.

Surveillance and Patient Tracking — Hospitals and public health agencies will work to improve notifiable condition reporting by identifying hospital staff to serve as surveillance liaisons with local health jurisdictions, and developing policies and procedures for reporting notifiable conditions, particularly immediately notifiable conditions and syndromes or clusters that may indicate bioterrorism. Additionally, DOH will guide efforts to build a technology system that will support electronic data interchange among a variety of partners. DOH will develop a pilot, Web-based secure reporting system.

Priority Area 5: Education and Preparedness Training
DOH will assess the PHEPR training needs of medical professionals in hospital settings. The agency will create a plan to meet those needs by integrating training with CDC funded public health training programs, collaborating with academic institutions, improving learning technology, and defining the requirements of a state computerized learning management system. A number of liaisons will be identified to improve the integration of training between programs. Smallpox response training will be included in the training plan.

Priority Area 6: Terrorism Preparedness Exercises
Washington will test the practicability of its hospital preparedness plan through the use of exercises. Each jurisdiction will conduct at least one exercise that covers a large-scale epidemic scenario affecting both adults and children. The state will also conduct a large-scale regional bioterrorism exercise that will test all major components of the public health and medical emergency response system.

A high level of dedication and cooperation between state, local public health, and hospital staff along with many other partners made it possible to create this set of applications and resulting work plans.  This level of involvement is necessary as we face the challenge of integrating public health, hospital as well as emergency and other public and private entities into a statewide system prepared to protect our citizens during any public health emergency including those resulting from an act of terrorism.  We will build on the work we have begun in previous years as well as implement new activities that bring us closer to a prepared Washington.