Health Affairs, 23, no. 3 (2004): 201-209 doi: 10.1377/hlthaff.23.3.201 © 2004 by Project HOPE	New Online   Senate Health Reform Bill   Rewarding Providers   Public Option Policy Brief   Health Reform & Abortion   Delivery System Reform

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Health Tracking

TRENDS

How Prepared Are Americans For Public Health Emergencies? Twelve Communities Weigh In

Abstract

 
Since the terrorist attacks of 11 September 2001, emergency preparedness has become a top priority in metropolitan areas, and some of these areas have received considerable federal funding to help support improvements. Although much progress has been made, preparedness still varies across communities, with the larger ones exhibiting stronger response capabilities, and some weaknesses are evident, particularly in the areas of communications and workforce education. Experience with other public health emergencies, strong leadership, successful collaboration, and adequate funding contributed to high states of readiness. Important challenges include a shortage of funding, delay in the receipt of federal funding, and staffing shortages.

These studies have identified strengths and weaknesses of organizations such as hospitals and local health departments; however, few recent national evaluations have been undertaken using the community as the unit of analysis. Community-level analysis is important because preparation for terrorist attacks involves many organizations in a community (such as law enforcement, health care, and transportation). Also, using a more qualitative approach allows for the capture of market and policy factors that can affect preparedness.

In this paper we describe states of preparedness for public health emergencies in twelve nationally representative metropolitan areas in late 2002 and early 2003. Since public health received a boost in support and funding after the 2001 attacks, this is an important point in time for communities and policy-makers to reflect on emergency preparedness. We discuss changes in funding for public health activities over the past two years and - the involvement of various local agencies and - organizations. We also discuss progress and goals in six Centers for Disease Control and Prevention (CDC) focus areas designed to improve local public health jurisdictions’ preparedness for public health emergencies.³ We highlight three communities that exhibit relatively high states of preparedness, focusing on the factors that facilitate readiness. We also analyze some of the challenges that communities face in their preparedness efforts and explore the policy implications of our findings.

Methods

Top Editor's Notes Methods Emergency Preparedness... Factors That Facilitate... Preparedness Challenges Conclusions And Policy... NOTES

 
Our findings are based on data collected through the Community Tracking Study (CTS) site visits conducted in twelve metropolitan statistical areas (MSAs) between September 2002 and May 2003.⁴ In each community we attempted to interview a reporter, two hospital executives (from the largest hospital systems), a first responder (often the director of the local emergency management agency), at least one public health agency representative, a local government official, and an academic respondent (typically a professor/researcher).⁵ We also conducted several state-level interviews, including representatives from the primary care association, governor’s office, state association of health plans, state department of health, and state hospital association. A total of 132 semistructured telephone and in-person interviews were conducted across the twelve sites. Open-ended questions were structured around progress and goals in the six CDC focus areas. One limitation of our findings is that they are based on respondents’ self-assessment of preparedness. Although we can compare responses within sites for consistency, we cannot confirm that these responses are an unbiased assessment. Also, given the eight-month time frame of the site visits, progress across sites cannot be compared at a distinct point in time.

Emergency Preparedness Activities Since 9/11

Top Editor's Notes Methods Emergency Preparedness... Factors That Facilitate... Preparedness Challenges Conclusions And Policy... NOTES

 
Changes in funding. Given the widespread concern that public health had been woefully underfunded for decades, investment in public health preparedness has increased greatly since 9/11. Indeed, federal funding for bioterrorism preparedness jumped from $500 million in 2001 (before 9/11) to $2.9 billion in 2002.⁶ Beginning in January 2002, the U.S. Department of Health and Human Services (through the CDC and the Health Resources and Services Administration, or HRSA) designated $1.1 billion in grants for states to develop antibioterrorism plans.⁷ Among the twelve CTS communities, funding to the states ranged from approximately $12 million for Arkansas to almost $71 million for California for fiscal year 2002 (Exhibit 1). States used these funds for statewide planning and infrastructure development and allocated portions to local jurisdictions for similar activities.

Although HRSA allocated approximately $100 million to states for hospital prepared-ness, hospitals in most of the CTS communities had not yet received any of this funding at the time of our site visits, even though in many cases the states had received their distribution. Even where hospitals had received funds, the typical $5,000–$10,000 grant per hospital was considered insignificant. However, a few hospitals reported receiving funds in the range of $50,000–$100,000 from other federal sources, generally through U.S. Department of Justice (DOJ) grants. Other larger hospital systems reported using their own funds for preparedness activities, with little expectation of receiving state or federal reimbursement. At the high end, one hospital system in Miami reported spending more than $3 million on preparedness activities since 9/11.

Rules governing federal funds. Federal funds for public health preparedness were distributed with strict rules that prevent supplantation of other state or local funds (that is, using new federal funds for nonpreparedness efforts such as restaurant inspections or nutrition activities). We found no evidence of supplantation; however, some preparedness activities clearly had positive spillover effects on traditional public health activities. For example, new federal funding was used to improve lab capacity and hire epidemiologists, which will improve public health capabilities generally, not just for bioterrorism. However, some respondents said that it is increasingly difficult to keep the funding streams separate.

Uses of federal funds. While a large portion of federal funds were used for one-time capital investments—such as lab equipment, communications systems, and decontamination equipment—funds were also used for operating expenses such as planning activities, personnel, training, and drills that, along with maintenance for the capital projects, will require ongoing funding.

Leadership and involvement. Although one would expect differences in perceived risk of a public health emergency occurring across communities, most believed that their risk was fairly high, either for a terrorist attack or accidents involving a nearby nuclear plant or large public event. Indeed, this sense of priority has aided collaboration among groups that were previously not involved.

In most communities, the county health department became the lead organization for local preparedness planning and activities and the recipient of most CDC funding allocated to the community. Local health departments have worked in tandem with other health care and public safety organizations—such as law enforcement, emergency management agencies, fire departments, and health care providers—to create comprehensive bioterrorism response plans. While preparedness generally is a county-level activity, six CTS states also created intermediate regional planning structures. These planning regions were created for organizational purposes; for example, they parallel state police regions in Michigan and the Federal Emergency Management Agency (FEMA) regions in Florida. Because CTS communities tend to be the largest communities in their regions, they often serve as regional leaders. The regions also help foster collaboration among neighboring jurisdictions where it was previously lacking.

Emergency preparedness leaders in most communities reported a high level of cooperation and collaboration, and numerous public health officials remarked on how the new attention to preparedness has brought public health and other sectors together, often for the first time.⁸ In Boston, Indianapolis, and Lansing, mayors have been closely involved in preparedness activities. A respondent in Cleve-land remarked, "The priorities across key entities involved...are pretty consistent. Everyone has worked together well."

Hospital activities. Whether or not they had received outside funds, most hospital respondents reported being involved in community planning meetings, updating their own response plans, and conducting drills more specific to bioterrorism threats yet had made few major investments. The hospitals that had made investments focused primarily on additional decontamination facilities and equipment, which some respondents considered important yet relatively small improvements. In some cases, preparedness activities and drills were considered a distraction for hospital employees but had little or no effect on hospitals’ financial viability or capacity. Indeed, hospitals described still lacking adequate surge capacity for a major emergency.

Physician and health plan activities. Physician practices were reportedly less involved than other organizations in public health preparedness. Although respondents in a few communities said that they had improved communication and disease reporting with physicians’ offices, most considered this area lacking. Health plans were largely on the sidelines, although we heard about some efforts to improve communication systems with hospitals and physicians, monitor unusual clinical trends, and communicate public health information to members.

Emergency preparedness in six focus areas. In its distribution of funds, the CDC requires grantees to address several critical focus areas, which were in various stages of implementation. The larger sites, particularly Orange County, Boston, and Miami, had stronger systems in place and had more ambitious plans and expectations for emergency preparedness than some of the smaller sites. However, all twelve sites have made noteworthy progress in at least some focus areas. These six areas are discussed below, in order of accomplishment according to respondents.

Emergency planning and readiness assessment. Respondents reported being further along in these areas than in any of the others. Indeed, all twelve CTS communities could identify at least some examples of these activities undertaken in the past two years. The communities shared a common goal: to develop a well-articulated plan where incidents are recognized quickly and everyone is familiar with their response roles.

In developing work plans for the CDC, many states used a regional or bottom-up approach, where localities conducted needs assessments and developed work plans that were then rolled into the state plan. To develop local plans, some communities built on existing protocols. For example, Miami had a preparedness plan in place after Hurricane Andrew in 1992, which served as a starting point. Still, some communities faced challenges that inhibited planning. For example, the health department director position in Cleveland was vacant at the time of our visit, and we were told that additional planning was "on hold" until a replacement was found. In addition, a few communities had not yet undertaken a comprehensive needs assessment.

Disease surveillance and epidemiology. The twelve communities shared the goal of having real-time surveillance capacity to detect unusual clusters of disease. Only Boston and Seattle had well-established surveillance systems in place at the time of our visits, but planning for similar systems was under way in six sites. Such systems require a massive investment of resources ($1.7 million to connect just local emergency rooms, said one respondent), one to three years to implement, and the collaboration of a number of organizations. Also, most of the new systems (except Seattle’s) cannot conduct syndromic surveillance (detection of constellations of symptoms that might indicate a particular disease agent).

Communities relied on different methods for disease surveillance in the absence of electronic reporting systems. Cleveland used a more passive system, where local hospitals were responsible for reporting suspected diseases to the health department. Other communities, such as Syracuse, had more active systems where the local health department was in daily contact with hospitals and emergency care centers to note unusual trends. In all cases, private physicians are required to contact the health department, but at least one community respondent said that more work is necessary to boost physician reporting.

In addition to upgrading systems, at least ten sites were increasing the number of epidemiologists on staff. In many cases, particularly in smaller areas, the state was leading the hiring and was sending epidemiologists to local communities. Most local respondents were confident in their ability to detect and respond to infectious disease outbreaks, although some concern was raised regarding staff’s ability to respond to emerging diseases.

Lab capacity. Local efforts to develop lab capacity varied considerably. For instance, using funds from the DOJ and the state health department, Miami set up its renowned lab prior to 9/11. This is the lab that analyzed the Palm Beach anthrax letters and coanalyzed those received in Washington, D.C. In several other sites the local public health agency did not run its own lab but instead relied on state labs. This arrangement worked fairly well in Boston, where the state lab was located nearby. However, in other locations such as Greenville and Cleveland, some respondents noted having to wait up to two weeks for results.

Respondents in several sites claimed that their labs were overwhelmed by the anthrax scare and, despite recent upgrades, had not yet met their capacity goals. A respondent from Cleveland mentioned that if the community were able to use private labs during an emergency, capacity would probably be adequate. However, it appears that few CTS communities are forging partnerships with private labs.

Communicating health risks and disseminating information. A common goal expressed by respondents was to get information out to the public and key organizations as quickly as possible to facilitate emergency response. Common methods used for information dissemination included direct mailings, postcards, Web updates, blast faxes, mass media, and, in some communities, reverse 911 calls, which allow police to mass-distribute alerts by telephone.

Respondents noted difficulty keeping up with the public’s demand for information during the anthrax scare. Call centers were "flooded," causing local public health agencies, first responders, and hospitals to consider making improvements to their systems. Respondents in Lansing noted that the county does not have the budget to hire an information officer, and funds are limited for public education. They rely on the state and the CDC to educate the public on these matters. Greenville previously relied on the state but recently hired a public information specialist. In Syracuse and Boston, local public health agency education departments widely distributed new brochures on bioterrorism.

Communication and information technology. Respondents rated communication among key agencies and organizations and information technology (IT) to be among the weakest areas of emergency readiness. Although this has been a neglected area for some communities, there have been improvements recently. Some of the smaller communities have procured basic technologies—for example, computers and e-mail—for employees. Other communities with more advanced technology have focused on connecting response organizations under a common system. In Seattle, the police and fire departments were not able to communicate with each other during the World Trade Organization (WTO) protests in 1999. Since then, the city has implemented a new system that links police, fire, hospitals, and the local public health agency. Orange County has a new paramedic radio system, with which they hope to link hospitals, using CDC funds. In addition, local hospitals in that community implemented "Ready Net," a combination text-messaging and radio system that allows hospitals to communicate in real time. Lansing is moving toward a fully integrated radio system for all emergency personnel.

Education and workforce training. Many communities have faced challenges in educating and training their public health work- force for emergencies. Goals varied widely across the sites; some focused on certain types of training—for example, how phone operators should handle terrorist threats or how first responders should react to a radiological attack. Often respondents noted that first responders have received more training than other groups.

Training strategies varied across communities. Drills were a common method used to practice for a terrorist attack, particularly in cities that host large spectator events, and they served as a mechanism to strengthen relationships among organizations. The organizations most often involved in drills were health departments, law enforcement, emergency medical services, fire and rescue, and hospitals. Those involved to a lesser extent were medical societies, schools of public health, community health centers, the Red Cross, private physicians, and health plans. In Phoenix a professional trainer was recently hired; the local public health agency in Miami wants to create a similar position. In Boston a training institute was created using CDC funds to establish a common language and set of skills across responders. In the smaller communities, training sessions were more informal and ad hoc.

Although several respondents said that they are better prepared for a nonterrorist public health emergency than a terrorist event, the vast majority said that their assessment of the six focus areas would be the same for terrorist- and nonterrorist-related public health emergencies because they have applied an "all hazards" approach to emergency planning. However, the perception of the community’s preparedness in each area often varied by respondent type. Representatives from the local health departments and first responders tended to be more optimistic than hospital respondents. The disparity in perceptions of preparedness may indicate a lack of communication or coordination between hospitals and health departments.

Factors That Facilitate Preparedness: Three Communities

Top Editor's Notes Methods Emergency Preparedness... Factors That Facilitate... Preparedness Challenges Conclusions And Policy... NOTES

 
While new federal funds are often considered the catalyst for preparedness efforts, some communities made major strides before receiving the bulk of the new funds. Recognizing that community size can affect the level of staff, funding, and other resources, we selected three communities of varying sizes to highlight: Syracuse, Indianapolis, and Orange County.⁹ These communities appeared relatively strong, based on site respondents’ subjective assessments, but study limitations prevent us from accurately ranking the twelve sites from weakest to strongest. In describing these communities’ achievements, we focus on the factors that have facilitated their success, including strong leadership, early attention to and funding for emergency preparedness, previous experience with public health threats, and successful collaborative efforts.

Syracuse. Respondents gave Syracuse high marks for its level of preparedness, particularly in comparison with other small cities. Public health preparedness activities in Syracuse have expanded since 9/11, although a number of public health events prompted preparations before the terrorist attacks occurred, including outbreaks of West Nile virus, pandemic flu, and meningitis. In addition, the existence of a nuclear power plant nearby generated extra focus on emergency planning, as the plant could be the target for a terrorist attack or wreak havoc in the event of an accident. As one respondent commented, "The directives after 9/11 were not a big deal for us because we were not starting from scratch."

After 9/11 Syracuse received $400,000 through the MMRS program to boost preparedness efforts. These funds, along with New York’s allocation of CDC funds to the local health department, were primarily used to improve staff, lab capacity, equipment, and software and to build drug stockpiles. Hospitals had not yet received their share of HRSA funding but were creating decontamination plans and buying equipment. University Hospital was awarded federal funds for an innovative proposal to transform the state fairgrounds infirmary into a training facility and an emergency room in the event of a public health emergency.

Coordination and collaboration across agencies and local organizations have been essential to public health preparedness in Syracuse. Most respondents noted the strong leadership of the local health department director as facilitating closer working relationships among the agency, hospitals, the medical society, and area physicians. Collaboration in Syracuse extends beyond the usual organizations to include community-based organizations, food banks, and home health care workers. In fact, the latter check in with elderly residents after emergencies and keep track of seniors using a database.

Indianapolis. Preparedness in Indianapolis was particularly impressive since the community had received little federal funding for these efforts by the time of our visit. The local health department has been focused on emergency preparedness efforts since 1998, when the city dealt with an anthrax hoax. Also before 9/11, the local health department hired a bioterrorism coordinator, reflecting the city’s early priority on emergency preparedness. Planning for the Indianapolis 500 and other large sporting events and responding to West Nile virus outbreaks have also strengthened the community’s preparedness efforts.

Strong local leadership was another asset and helped facilitate collaboration among local agencies and providers. The mayor’s office, with the help of the health department, began a planning process after 9/11 that involved about twelve different task forces, including local hospitals and first responders. The mayor reportedly has made preparedness a top priority, and respondents widely cited his leadership, support, and participation in preparedness activities, including a four-hour-long drill. In addition, the local health department director’s training as an infectious disease specialist and involvement in national preparedness activities bolstered local efforts.

Finally, the strong sense of community was another factor reported to improve collaboration in Indianapolis. When asked about what major factors helped public health preparedness efforts since 9/11, a respondent said, "Community values—when there is a crisis, competitors [hospitals] pull together." Drawing on this collaborative spirit, the local health department strengthened relationships with various entities for preparedness, including hospitals, a medical research organization, and pharmaceutical companies.

Orange County, California. The ongoing threat of earthquakes and fires in California gave communities like Orange County experience in disaster planning before 9/11. Moreover, the existence of a nuclear power plant south of Orange County has required county leaders to perform disaster planning, including annual testing of emergency response, that involves public health leaders, first responders, and health care providers. Although this planning is focused on nuclear disasters, the general planning processes and collaboration required have helped preparations for other types of emergencies. In addition, the location of large amusement parks in Orange County has spurred preparation and planning for potential bioterrorism, including a dirty bomb or anthrax.

Strong leadership of county officials was cited as another contributing factor to improved readiness in Orange County. The county sheriff, who was referred to as a "star among stars," convened a local antiterrorism work group as early as 1998 and was appointed to a national antiterrorism task force. In addition, the county’s health officer was widely recognized as providing strong leadership on bioterrorism preparedness, making the issue a priority early on, and serving on related state committees. Respondents cited a local congressman for his special interest in terrorism and disaster preparedness efforts—he sponsored a symposium in the county that involved medical, fire, and police representatives.

Orange County has also benefited from federal funding that precedes 9/11. Funds to three cities in Orange County from the federal MMRS program were used for countywide planning and to develop a local drug stockpile. At the time of our site visit, Orange County had not yet received the $4 million in CDC funding that it expected. However, the state has been supportive of preparedness planning, allocating $200,000 to Orange County to improve lab capacity.

Preparedness Challenges

Top Editor's Notes Methods Emergency Preparedness... Factors That Facilitate... Preparedness Challenges Conclusions And Policy... NOTES

 
Lack of funding. The most obvious challenge facing communities in their efforts to improve public health preparedness is lack of funding. Despite the large inflow of federal dollars to some communities, the cost of implementing or improving communications and surveillance systems, training, planning, and labs remains daunting. In addition, toward the end of our site visit cycle, communities were undertaking resource-intensive smallpox planning, which many respondents considered an unfunded mandate.

Although many emergency preparedness efforts had been undertaken locally, almost half of the CTS sites had not yet received their allocation of CDC funds from the states, and most hospitals had not yet received HRSA funds by the time of our site visits. The delay in the passthrough of federal funding has important consequences, including the delay of purchases, planning, and training. Also, some health department respondents were displeased by the way their state chose to distribute federal funding. In some cases, the distribution was based on the population size or perceived level of threat to the region; in others, funding was distributed evenly across regions without regard to population size or threat level. Where funding was not distributed based on population, respondents in the larger communities felt that they had not received their fair share.

Budget deficits. Furthermore, each of the twelve CTS states faced budget deficits in FY 2004, and some local public health agency budgets were threatened. The trimming of state funds creates general concerns for local public health agencies, although the impact may be felt in areas other than emergency preparedness. Because federal funds cannot be used to supplant state or local funding, respondents were more concerned about traditional public health programs’ surviving state or local budget cuts.¹⁰

Staffing. Finally, local public health staffing continues to be a challenge for communities. Respondents in some communities reported difficulties in hiring qualified public health workers, particularly nurses and epidemiologists, because of the short supply and inability to offer salaries competitive with the private sector.

Conclusions And Policy Implications

Top Editor's Notes Methods Emergency Preparedness... Factors That Facilitate... Preparedness Challenges Conclusions And Policy... NOTES

 
Communities have made considerable progress improving their readiness for public health emergencies since 9/11, and some improvements proved timely. Toward the end of our site visits, severe acute respiratory syndrome (SARS) presented the communities with a new public health challenge. One respondent in Boston said that improvements in its communications system and collaboration helped public health leaders disseminate information more effectively than in the past. With additional federal funding expected and continued plans for improvements, communities should be able to sustain the improvements made since 9/11 and make even more progress over the next year. Indeed, the federal government increased funding for FY 2003 to $1.4 billion for states and localities, through additional CDC and HRSA funding.¹¹ While CDC and HRSA funding to states is relatively stable for FY 2004, additional grants for urban areas were made available through the U.S. Department of Homeland Security.¹²

Primary deficiencies. Policymakers should take note of the perceived deficiencies reported by respondents, particularly in the areas of communication and IT and workforce education and training. These are areas where the communities have not had the right mix of funding, expertise, and staff availability to meet their goals; additional support by policy-makers could bolster progress.

In communication and IT, the shortfalls were mainly attributable to a lack of funding for new systems. In education and training, communities would likely benefit from more technical assistance in workforce training. Certainly local public health agencies would also benefit from any federal help in recruiting public health staff—for example, loan forgiveness programs or recruitment campaigns for the public health workforce.

Role of local public health leaders. Local leaders play an important role, not only because of their specialized knowledge but also because of their potential to motivate organizations to participate in preparedness activities. Communities could benefit from leaders’ sharing of experiences and best practices with one another. Leaders having recent experience in public health emergencies could assist those who lack experience.

States also could benefit from guidance on how best to distribute new federal funding. Although the CDC requires evidence of a process that shows consensus between the state and local levels on how the funding should be spent, it was clear that there was not always agreement between the states and their major metropolitan areas. The CDC also should encourage states to distribute the funding to the local level as quickly as possible.

Editor's Notes

Top Editor's Notes Methods Emergency Preparedness... Factors That Facilitate... Preparedness Challenges Conclusions And Policy... NOTES

 
Megan McHugh (mmchugh{at}mathematica-mpr.com) is a health research analyst at Mathematica Policy Research in Washington, D.C. Andrea Staiti is a health research assistant at the Center for Studying Health System Change (HSC); Laurie Felland is a health research analyst there.

This research was conducted as part of the Center for Studying Health System Change’s Community Tracking Study, which is funded by the Robert Wood Johnson Foundation. The authors gratefully acknowledge the work of their research team: John Hoadley, Aaron Katz, Peter Cunningham, Suzanne Felt-Lisk, and Larry Brown. They also thank Katz, Paul Ginsburg, Cara Lesser, and two anonymous reviewers for their valuable comments.

NOTES

Top Editor's Notes Methods Emergency Preparedness... Factors That Facilitate... Preparedness Challenges Conclusions And Policy... NOTES

 

1. U.S. General Accounting Office, Bioterrorism: Preparedness Varied across State and Local Jurisdictions (Washington: GAO, April 2002).
2. National Association of City and County Health Officials, Local Public Health Agencies Better Equipped to Handle Bioterrorist Attacks (Washington: NACCHO, January 2003); and GAO, Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response (Washington: GAO, August 2003).
3. We combined the CDC’s focus areas of lab capacity for biological agents and lab capacity for chemical agents into one area called "lab capacity." As a result, our analysis consists of six rather than seven focus areas. U.S. Department of Health and Human Services, "Guidelines for Bioterrorism Funding Announced," 9 May 2003, www.hhs.gov/news/press/2003pres/20030509.html (18 February 2004).
4. The CTS communities are Boston; Cleveland; Indianapolis; Lansing, Michigan; Little Rock, Arkansas; Greenville, South Carolina; Miami; northern New Jersey; Orange County, California; Phoenix; Seattle; and Syracuse. They are statistically representative of areas with populations of more than 200,000. For more information on the CTS, see C. Lesser, P. Ginsburg, and K. Devers, "The End of an Era: What Became of the Managed Care Revolution in 2001?" Health Services Research 38, no. 1, Part 2 (2003): 337–355.[CrossRef][Web of Science][Medline]
5. We did not define preparedness for respondents but told them that a highly prepared community "is one that is as prepared as the community could reasonably expect to be" for a public health emergency.
6. Alliance for Health Reform, "Bioterrorism and Public Health Funding: Current Threats and Proposed Responses" (Washington: Alliance for Health Reform, 2002).
7. Ibid.
8. A.B.Staiti, A. Katz, and J.F. Hoadley, "Has Bioterrorism Preparedness Improved Public Health?" Issue Brief no. 65 (Washington: Center for Studying Health System Change, 2003).
9. We used the U.S. Census Bureau’s metropolitan statistical area (MSA) population data to classify small sites (fewer than one million people), medium sites (1–2.5 million), and large sites (more than 2.5 million). Population data are based on U.S. Census Bureau, "American Community Survey," Profile 2002, Continuous Measurement Office (last revised 2 September 2003): Syracuse MSA, 707,874; Indianapolis MSA, 1,619,983; Orange County PMSA, 2,896,130. See www.census.gov/acs/www/index.html (18 February 2004).
10. Staiti et al., "Has Bioterrorism Preparedness Improved Public Health?"
11. DHHS, "HHS Provides $1.4 Billion More to States and Hospitals for Terrorism Preparedness," www.dhhs.gov/news/press/2003pres/20030902.html (5 March 2004).
12. DHHS, FY 2004 Budget in Brief, www.hhs.gov/budget/04budget/fy2004bib.pdf (16 March 2004); and Department of Homeland Security, "Securing the Homeland: Helping Our State and Local First Responders and First Preventers," 13 November 2003, www.dhs.gov/dhspublic/display?content=3009 (16 March 2004).

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