Discussion Requirements: Identify the question you decide to answer at the top of your post. Prompt responses should answer the question and elaborate in a

Requirements: Identify the question you decide to answer at the top of your post. Prompt responses should answer the question and elaborate in a meaningful way using 2 of the weekly class readings (250 words of original content). Do not quote the readings, paraphrase and cite them using APA style in text citations. You can only use ONE multimedia source for your minimum 2 sources each week. The readings must be from the current week. The more sources you use, the more convincing your argument. Include a reference list in APA style at the end of your post, does not count towards minimum word content.

Select ONE of the following:

1) Why is influenza such a complex virus to deal with? How do agencies deal with this challenge? What are the lessons learned from the H1N1 US experience?

2) Compare the Mitigation, Preparedness and Response actions of the H1N1 pandemic and the Coronavirus Pandemic in the US. Use class readings for the H1N1 and ONLY academic and official sources about the coronavirus. No news outlets or blogs or non academic sources allowed. 

Commentary

CDC’s Evolving Approach to Emergency Response

Stephen C. Redd and Thomas R. Frieden

The Centers for Disease Control and Prevention (CDC) transformed its approach to preparing for and responding to

public health emergencies following the anthrax attacks of 2001. The Office of Public Health Preparedness and Re-

sponse, an organizational home for emergency response at CDC, was established, and 4 programs were created or greatly

expanded after the anthrax attacks: (1) an emergency management program, including an Emergency Operations Center;

(2) increased support of state and local health department efforts to prepare for emergencies; (3) a greatly enlarged

Strategic National Stockpile of medicines, vaccines, and medical equipment; and (4) a regulatory program to assure that

work done on the most dangerous pathogens and toxins is done as safely and securely as possible. Following these

changes, CDC led responses to 3 major public health emergencies: the 2009-10 H1N1 influenza pandemic, the 2014-16

Ebola epidemic in West Africa, and the ongoing Zika epidemic. This article reviews the programs of CDC’s Office of

Public Health Preparedness, the major responses, and how these responses have resulted in changes in CDC’s approach

to responding to public health emergencies.

The Centers for Disease Control and Prevention(CDC) was established in 1946 with the primary
purpose of supporting state and local public health agen-
cies, particularly in responding to disasters and infectious
disease outbreaks.1 The capacity to respond to health
emergencies in order to protect the public has remained an
essential function of CDC. Over the decades, disease out-
break investigations have evolved to include larger and
more complex events, and CDC’s role has remained that of
providing support to state and local health departments
while sometimes taking a leadership or coordination role
with complex or interstate investigations. For international
investigations, CDC has worked with ministries of health
that requested assistance as well as with the World Health
Organization.2

Within weeks of the 9/11 World Trade Center attack,
CDC responded to a biological attack with anthrax in-
volving numerous domestic jurisdictions. The anthrax at-
tack required CDC to provide the public with frequent
updates on the progress of the investigation. The volume of
information and the expectations of the public created a
need for CDC to operate at an unprecedented scale and
tempo.3 To meet the challenges identified in the response
to the anthrax attacks, CDC created a new organizational
unit and approach to respond to large, complex public
health emergencies, whether naturally occurring, inten-
tional, or accidental. CDC’s approach to emergency re-
sponse continues to evolve.

In addition to the potential for bioterror attacks, such as
the anthrax attack, 2 global trends required that CDC

Stephen C. Redd, MD, is Director, Office of Public Health Preparedness and Response, and Thomas R. Frieden, MD, MPH, is CDC
Director, both at the Centers for Disease Control and Prevention, Atlanta, Georgia. The findings and conclusions in this report are
those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the
Department of Health and Human Services.

Health Security
Volume 15, Number 1, 2017 ª Mary Ann Liebert, Inc.
DOI: 10.1089/hs.2017.0006

41

develop an expanded capability to respond at speed and
scale to future emergencies.4 First, the speed and volume of
long-distance travel have increased substantially. Over the
past 75 years, the widespread availability of air travel has
reduced the time for intercontinental travel from weeks to
hours.5 Along with shorter travel times, the volume of in-
tercontinental travel has increased exponentially. With in-
creased and faster global travel, the opportunity for a person
infected with a pathogen to travel to another part of the
world within hours has become increasingly likely.6 Sec-
ond, global population increases concentrated in Africa, the
Indian subcontinent, and East Asia have resulted in a dra-
matic increase in the number of cities with populations over
10 million.7 Ease of travel and urbanization, particularly
the concentration of poverty in urban areas, is creating the
opportunity for an increasing number of large infectious
disease epidemics affecting multiple urban areas.

Technological advances in medicine and public health
have created new tools to diagnose and quickly respond to
public health emergencies. Rapid and specific diagnostic
methods, vastly improved communication systems, and
evolving therapeutic and vaccine technologies create oppor-
tunities to detect and respond to health emergencies that
were unimaginable in the past. Unfortunately, these same
scientific and technologic advances allow the possibility to
create more deadly or transmissible pathogens that could be
released, intentionally or not, into the community.8

In this article we describe how CDC’s emergency re-
sponse preparations and execution have evolved with these
changing realities and expectations, with a particular focus
on changes beginning with the 2009 H1N1 pandemic.

Creation of the Office of Public

Health Preparedness and Response

After the 2001 anthrax attacks, the nation readied itself
for additional bioterror attacks. Government policy-
makers and public health officials created lists of mi-
croorganisms and chemical and biological toxins that
could be used as terror agents. Government funding
created a scientific-medical-production enterprise to de-
velop medical countermeasures—diagnostics, vaccines,
and therapeutics—to address these threats.9

The concerns and activities following the 2001 attacks
were similar to those that led to the 1951 creation of the
CDC Epidemic Intelligence Service, a 2-year training
program in field epidemiology, as part of a response to fears
of an attack with bioweapons during the Cold War.1 In
2002 CDC created a new organization—the Office of
Terrorism Preparedness and Emergency Response, later the
Coordinating Office for Terrorism Preparedness and
Emergency Response, predecessors to the current Office of
Public Health Preparedness and Response (OPHPR)—
with responsibility for preparing for large-scale emergen-
cies, including terrorism attacks. The office combined 3

smaller existing programs: support of state and local emer-
gency preparedness activities, the Strategic National Stock-
pile, and the regulatory program for select agents and toxins.
In addition, the Bernie Marcus Foundation, through the
CDC Foundation, funded renovations and equipment pro-
curement for CDC’s first Emergency Operations Center.10

Each division or program in the Office of Public Health
Preparedness and Response has specific responsibilities to as-
sure that CDC and the nation’s public health system is as
ready as possible to respond to future health threats (Table 1).

Regulatory Program on Select
Agents and Toxins
The mission of the Division of Select Agents and Toxins
(DSAT) is to assure that work done with dangerous path-
ogens and toxins in the United States is done as safely and
securely as possible (Table 1). The Federal Select Agent
Program consists of CDC’s DSAT and the US Department
of Agriculture’s Agriculture Select Agent Services Program.
Examples of select agents and toxins include the organisms
that cause anthrax, smallpox, and bubonic plague, as well as
the toxins ricin and botulinum neurotoxin. The program
has an enabling mission: to assure that laboratories working
with select agents and toxins are able to do their work, to
create new knowledge to detect and respond to the threats
these pathogens and toxins could cause.11 As of November
2016, 279 laboratories were registered with the Federal
Select Agent Program (a decrease from a high of 336 lab-
oratories in 2006); 241 are registered with CDC’s Select
Agent and Toxins program and 38 with USDA’s Agri-
culture Select Agent Services Program. The CDC Select
Agent Program conducted 183 inspections in 2015, in-
cluding 72 unannounced inspections. Since its inception,
the program has denied 361 individuals access to select
agent laboratories through the Security Risk Assessment
process, which includes background investigations con-
ducted by the FBI.

The underlying challenge for the Federal Select Agent
Program is to balance competing priorities: (1) transpar-
ency to the public regarding the work and safety of the
laboratories registered with the program with the need to
protect information about the work from those that might
use such information to cause harm; (2) the regulatory
burden necessary to assure safety and security with fostering
an environment where the greatest scientific output is
possible; and (3) ultimately, assuring that the benefits of the
research justify its inherent risks. Even the most stringent
regulations cannot ensure that work with select agents and
toxins has zero risk; the program works to keep risk to the
minimum possible. Determining whether potential benefit
outweighs irreducible risks is complex and requires recon-
ciling numerous points of view.

Within the purview of the regulatory program, work
continues to improve in the following areas: (1)

CDC’S EVOLVING APPROACH TO EMERGENCY RESPONSE

42 Health Security

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(c
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Volume 15, Number 1, 2017 43

T
ab

le
1

.
(C

o
n

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u
ed

)

D
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is
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p
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to
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p
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:
(1

)
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ev
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la

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(2
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re
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in
sp

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(4

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;
(5

)
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;

(6
)

en
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44 Health Security

standardizing the inspection process through ongoing ef-
forts to improve training of inspectors, (2) improving the
science of biosafety and biosecurity, and (3) preparing for
biosafety and biosecurity risks of the future as a result of the
ongoing revolution in biology. These ongoing advances in
biology, including sequencing technologies and synthetic
biology, will make regulation and oversight in these areas
increasingly complex.

Emergency Operations at CDC
The Division of Emergency Operations manages CDC’s
Emergency Operations Center (EOC). The division’s mission is
to serve as a hub for communication, decision making, and
operations during emergency activations and to plan and train
for that function. When activated, the EOC serves as a tempo-
rary home for responders: scientists, communication specialists,
laboratory experts, and program managers from throughout
CDC who are deployed to respond to a specific emergency.
Since April 2009, the start of the H1N1 pandemic response,
CDC’s EOC has been activated over 91% of the time.12

By activating the EOC, CDC is able to perform many of the
functions it was not able to carry out during the 2001 anthrax
attack: managing a scalable system for travel and shipping of
equipment; recruiting and managing volunteer responders;
assuring a uniform system of deployment, including pre-
deployment, during deployment, and postdeployment activi-
ties; and providing software tools to visualize data, thereby
improving situational awareness. Although the health and
safety of deployed staff have always been of concern during
responses, the risks in the Ebola response led to the creation of a
Deployment Risk Mitigation Unit, which provided a focal
point for assuring a standard approach to safety and security
training for staff deployed in responses.

The division has taken on an important new activity:
training future incident commanders to lead CDC emer-
gency responses. The training is based on the real-world
experiences of large emergency responses in which CDC
has played a leading role. The intent is to provide a setting
for experiential learning in initiating a response, making
recommendations or decisions, and understanding the
needs of senior leaders during a large emergency response
and how to meet those needs.

Improving emergency response capacity globally is a sec-
ond, related function the division has undertaken as part of
the Global Health Security Agenda.13 CDC staff have led
emergency management training sessions in 40 countries
since 2014. This training has been put to use in 6 countries in
2015 and 2016, where ministry of health officials have acti-
vated their emergency operations centers 11 times to respond
to emergencies ranging from cholera and influenza outbreaks
to a train derailment. The training sessions and establishment
of emergency operations centers have resulted in earlier and
more effective responses to health emergencies. For those
emergencies that have the potential to spread, more effective
responses overseas protect Americans.

The Strategic National Stockpile
The Strategic National Stockpile’s purpose is to assure that
medical material needed to respond to a public health
emergency is available when, where, and in the quantity
needed to respond effectively. The stockpile’s inventory
includes vaccines, medications, chemical antidotes, ancillary
supplies needed to administer the countermeasures, me-
chanical ventilators, respirators, and other medical equip-
ment. The stockpile is a part of the Public Health Emergency
Medical

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