managing-emergency-preparedness

# Managing Emergency Preparedness

## Why This Skill Exists

Public health emergency preparedness (PHEP) is the capability to prevent, protect against, quickly respond to, and recover from health emergencies. CDC funds 62 PHEP awardees (states, territories, and local jurisdictions) through the PHEP cooperative agreement — the primary federal funding mechanism for state and local preparedness. PHEP awardees must demonstrate capability across the 15 CDC Public Health Preparedness Capabilities, maintain operational readiness through exercises evaluated under HSEEP (Homeland Security Exercise and Evaluation Program), and comply with the National Health Security Strategy. Additionally, PHAB accreditation Domain 2 requires health departments to investigate and respond to health threats. The fundamental tension in preparedness is that success is invisible — averted crises are never seen. This makes sustained investment and workforce readiness a constant challenge. This skill structures the operational framework for maintaining and demonstrating preparedness across the full capability spectrum.

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## Checkpoint A — Intake and Scoping

### Intake Questions

1. Which of the 15 CDC PHEP capabilities are being assessed or developed (e.g., Community Preparedness, Emergency Operations Coordination, Medical Countermeasure Dispensing)?
2. What hazards are highest priority for the jurisdiction — per the Hazard Vulnerability Analysis (HVA)?
3. What is the current PHEP cooperative agreement cycle and budget?
4. What is the exercise schedule — tabletop exercises (TTX), functional exercises (FE), or full-scale exercises (FSE)?
5. What is the status of the jurisdiction's Emergency Operations Plan (EOP) and its annexes?
6. What mutual aid agreements are in place (EMAC, local MAAs, MOU with hospitals and healthcare coalitions)?
7. What Medical Countermeasure (MCM) distribution plans exist — Strategic National Stockpile (SNS) reception, storage, and distribution?
8. What is the readiness status of the public health Emergency Operations Center (EOC) — activation levels, staffing rosters, communication systems?

### Required Documents

- Jurisdiction's All-Hazards Emergency Operations Plan (EOP) with public health annexes
- Hazard Vulnerability Analysis (HVA) / Threat and Hazard Identification and Risk Assessment (THIRA)
- CDC PHEP capability self-assessment (annual operational readiness review)
- HSEEP-compliant After-Action Reports (AARs) and Improvement Plans (IPs) from exercises and real-world events
- MCM/SNS reception, storage, and distribution plan
- EMAC and local mutual aid agreements
- Healthcare Coalition (HCC) MOU and regional preparedness plan
- Public Health EOC SOPs and activation criteria
- Continuity of Operations Plan (COOP) for the health department

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## Step 1 — Conduct Hazard Vulnerability Analysis

Identify and prioritize threats using a structured methodology:

- Use THIRA/SPR (Threat and Hazard Identification and Risk Assessment / Stakeholder Preparedness Review) per FEMA guidance, or the Kaiser Permanente HVA tool adapted for public health.
- Assess each hazard on three dimensions:
  - **Probability**: Historical frequency, scientific evidence, and intelligence assessments.
  - **Severity**: Potential magnitude of health impact (morbidity, mortality, displacement, infrastructure damage).
  - **Preparedness**: Current capability to respond (plans, training, equipment, partnerships).
- Risk score = Probability × Severity × (1 − Preparedness). Higher scores indicate higher priority for planning.
- Standard hazard categories for public health: infectious disease outbreak/pandemic, natural disaster (hurricane, earthquake, flood, wildfire), chemical release (industrial accident, terrorism), radiological/nuclear event, food/water contamination, mass casualty incident, cyberattack on health infrastructure.
- Rank hazards and allocate planning effort proportionate to risk scores.

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## Step 2 — Develop and Maintain the Emergency Operations Plan

The EOP is the master planning document. Structure per CPG 101 (FEMA Comprehensive Preparedness Guide 101):

- **Basic Plan**: Purpose, scope, situation overview, assumptions, concept of operations, roles and responsibilities, direction and control.
- **Functional Annexes**: One per PHEP capability area — Emergency Operations Coordination, Community Preparedness, Information Sharing, Medical Countermeasure Dispensing, Mass Care, Fatality Management, etc.
- **Hazard-Specific Annexes**: Pandemic influenza, chemical terrorism, hurricane response, radiological event, etc.
- **Appendices**: Contact rosters, resource inventories, maps, SOPs, mutual aid agreements.

Plan maintenance cycle:
- **Annual review**: Full EOP reviewed for currency — contact information, organizational changes, policy updates, lesson-learned incorporation.
- **Post-event update**: Within 90 days of any real-world activation, incorporate AAR findings.
- **Post-exercise update**: Within 60 days of each exercise, address improvement plan items.

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## Step 3 — Build and Sustain Workforce Readiness

- Maintain an EOC staffing roster with at least 2-deep coverage for every ICS position.
- All EOC staff must complete: ICS-100, ICS-200, ICS-700, ICS-800. Section chiefs and above: ICS-300, ICS-400.
- Conduct training on jurisdiction-specific plans, SOPs, and communication systems at least annually.
- Maintain a Medical Reserve Corps (MRC) or equivalent volunteer registry with: enrollment, background checks, credential verification, and activation protocols.
- Implement a responder health and safety program: mental health screening, respiratory protection program, prophylaxis planning for first responders.
- Track workforce credentials and training currency in a readiness management system (e.g., ESAR-VHP, state registry).

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## Step 4 — Exercise the Plan per HSEEP

HSEEP (Homeland Security Exercise and Evaluation Program) provides the standard exercise methodology:

- **Progressive exercise cycle**: Discussion-based (seminars, workshops, TTX) → Operations-based (drills, functional exercises, full-scale exercises). Each exercise builds on findings from the prior one.
- **Annual exercise requirement** per PHEP cooperative agreement: at least one operations-based exercise per year testing a PHEP capability.
- **Multi-year Training and Exercise Plan (MTEP)**: 3-5 year plan that systematically tests all priority capabilities against all priority hazards.
- For each exercise:
  - Develop an Exercise Plan (ExPlan) with objectives linked to PHEP capabilities.
  - Conduct the exercise with trained evaluators using Exercise Evaluation Guides (EEGs).
  - Produce a formal AAR within 60 days identifying strengths, areas for improvement, and root causes.
  - Develop an Improvement Plan (IP) with corrective actions, timelines, responsible parties.
  - Track IP completion through the jurisdiction's corrective action tracking system.

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## Step 5 — Medical Countermeasure Operations Planning

- Develop a plan for receiving, staging, storing, and distributing SNS assets within 48 hours of federal deployment decision.
- Plan for Points of Dispensing (PODs):
  - Open PODs: Community locations (schools, community centers) for mass prophylaxis of the general public. Target throughput: 1,000 people per hour per POD.
  - Closed PODs: Pre-arranged with employers, hospitals, universities to dispense to their populations (reduces open POD burden by 20-40%).
- Develop dispensing SOPs: screening algorithm, medication dispensing protocols (standing orders), adverse event management, documentation (into IIS or MCM tracking system).
- Plan for special populations: homebound individuals, persons with disabilities, non-English speakers, incarcerated populations, homeless individuals.
- Test MCM operations through a functional or full-scale exercise at least every 3 years.

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## Step 6 — Communication and Information Sharing

- Maintain Health Alert Network (HAN) notification capability for rapid alerting of healthcare providers, emergency management, and the public. Test HAN with a live alert at least quarterly.
- Maintain Crisis and Emergency Risk Communication (CERC) plan with pre-drafted messages for priority hazards, spokesperson designation, media briefing protocols, and social media strategy.
- Ensure interoperable communications: test radio, phone, and digital communication systems with partner agencies (emergency management, law enforcement, hospitals) at least biannually.
- Establish information-sharing protocols with Healthcare Coalitions, EMS, poison control, and state/federal partners.

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## Checkpoint B — Preparedness Review

- [ ] HVA/THIRA completed and updated within the last 2 years
- [ ] EOP current with all annexes reviewed within the last 12 months
- [ ] EOC staffing roster 2-deep for all ICS positions with training currency verified
- [ ] HSEEP-compliant exercise conducted in the current fiscal year
- [ ] AAR completed within 60 days of each exercise/event with IP tracked to completion
- [ ] MCM/SNS plan tested through exercise within the last 3 years
- [ ] HAN tested quarterly with documented results
- [ ] Mutual aid agreements current and exercised
- [ ] COOP plan in place and tested

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## Quality Audit

- [ ] PHEP capability self-assessment completed for all 15 capabilities per CDC guidance
- [ ] HVA risk scores calculated consistently with documented methodology
- [ ] EOP follows CPG 101 structure and is accessible to all response staff
- [ ] ICS training records verified for all EOC-rostered personnel
- [ ] Exercise objectives traceable to PHEP capabilities and HVA priority hazards
- [ ] AAR findings tracked through a corrective action system with completion rates reported
- [ ] MCM throughput targets documented and achievable based on exercise performance
- [ ] Vulnerable population planning addresses access and functional needs per CDC PHEP Capability 1 (Community Preparedness)
- [ ] All plans reviewed by legal counsel for consistency with jurisdiction's emergency authority statutes

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## Guidelines

- Plans that are not exercised are plans that will fail. The exercise program is not a compliance checkbox — it is the mechanism through which plans are tested, staff gain experience, and gaps are identified before real emergencies.
- Preparedness is a perishable capability. Staff turnover, budget cuts, organizational changes, and memory fade degrade readiness continuously. Annual plan reviews and quarterly training are minimum maintenance requirements.
- Access and functional needs populations (persons with disabilities, LEP, transportation-dependent, medically dependent) must be explicitly addressed in every plan — not as an afterthought annex but integrated into operations planning. The Post-Katrina Emergency Management Reform Act (2006) requires this.
- Medical countermeasure planning must account for the entire logistics chain: federal decision to deploy → transportation to state → RSS (Receipt, Stage, Store) operations → last-mile distribution to PODs → administration to individuals. Failure at any link breaks the chain.
- Real-world events are the ultimate exercise. After every activation (no matter how small), conduct an AAR. The small-scale activations build the muscle memory for large-scale responses.
- Coordinate with Healthcare Coalitions for healthcare system preparedness. Health department plans that do not integrate with hospital surge plans, EMS, and long-term care facilities will fail when surge demand crosses organizational boundaries.
- Escalate to the health officer or emergency management director when: an HVA reveals an unmitigated high-risk hazard, exercise performance reveals a critical capability gap, MCM distribution timeline exceeds 48-hour target, or mutual aid agreements lapse without renewal.