HSPD-21: National Strategy for Public Health and Medical Preparedness

By Michael Mair and Crystal Franco

On October 18, 2007, the White House released Homeland Security Presidential Directive 21 (HSPD-21) establishing a “National Strategy for Public Health and Medical Preparedness.”1 This directive is an important and commendable development in national biodefense policy. It offers clear strategic direction and is in keeping with the best professional judgments of many medical, public health, disaster response and community engagement experts in and out of government.

HSPD-21 specifically addresses preparedness for catastrophic health events, which are defined as “any natural or manmade incident, including terrorism, that result in a number of ill or injured persons sufficient to overwhelm the capabilities of immediate local and regional emergency response and health care systems.”1 HSPD-21 stresses the importance of:

Establishing a biosurveillance capability that can provide “early warning” of a biological attack or naturally occurring disease outbreak and can provide ongoing “near real-time” information about an event as it unfolds;
Fostering medical countermeasure stockpiling and distribution so that communities are able to “distribute and dispense countermeasures to their populations within 48 hours after a decision to do so”;
Transforming the “national approach to health care in the context of a catastrophic health event” and developing a “disaster medical capability that can immediately re-orient and coordinate existing resources within all sectors to satisfy the needs of the population during a catastrophic health event”;
Formulating a “comprehensive plan for promoting community public health and medical preparedness to assist State and local authorities in building resilient communities.”

HSPD 21 establishes a Public Health and Medical Preparedness Task Force that comprises: The Secretaries of HHS, Homeland Security, Defense, State, Agriculture, Commerce, Labor, Transportation, and Veterans Affairs; the Directors of the Office of Management and Budget and National Intelligence; and the Attorney General. The task force is required to submit an implementation plan for HSPD-21 to the President within 120 days of the release of HSPD-21 and to report annually on the status of the implementation of HSPD-21 and to recommend any changes. The directive also articulates a series of specific actions that are to be executed by specific agencies over the next year (summarized below in Table 1).

Table 1: Actions Required for Implementation of HSPD-21 - National Strategy for Public Health and Medical Preparedness

	Implementation Action	Responsible Party	Due Date
Biosurveillance
	Establish an operational national epidemiologic surveillance system for human health	Secretary of HHS
	Establish an Epidemiologic Surveillance Federal Advisory Committee ensure that the Federal Government is meeting the goal of enabling State and local government public health surveillance capabilities	Secretary of HHS in coordination with the Secretaries of Defense, Veterans Affairs, and Homeland Security	Within 180 days after the date of HSPD-21
Countermeasure Stockpiling and Distribution
	Develop templates that provide minimum operational plans to enable communities to distribute and dispense countermeasures to their populations within 48 hours after a decision to do so	Secretary of HHS in coordination with the Secretary of Homeland Security
	(1) Publish an initial template or templates; (2) establish standards and performance measures for State and local government counter-measure distribution systems; and (3) establish a process to gather performance data from State and local participants on a regular basis to assess readiness	Secretary of HHS in coordination with the Secretary of Homeland Security	Within 270 days after the date of HSPD-21
	Commence collecting and using performance data and metrics as conditions for future public health preparedness grant funding	Secretary of HHS in coordination with the Secretary of Homeland Security	Within 180 days after the completion of the tasks set in the previous row
	Develop Federal Government capabilities and plans to complement or supplement State and local government distribution capacity, as appropriate and feasible, if such entities’ resources are deemed insufficient to provide access to countermeasures in a timely manner in the event of a catastrophic health event	Secretary of HHS in coordination with the Secretaries of Defense, Veterans Affairs, and Homeland Security and the Attorney General	Within 270 days after the date of HSPD-21
	Ensure that the priority-setting process for the acquisition of medical countermeasures and other critical medical materiel for the Strategic National Stockpile (SNS) is transparent and risk-informed with respect to the scope, quantities, and forms of the various products	Secretary of HHS
	Establish a formal mechanism for the annual review of SNS composition and development of recommendations that utilizes input from accepted national risk assessments and threat assessments, national planning scenarios, national modeling resources, and subject matter experts	Secretary of HHS in coordination with the Secretaries of Defense, Homeland Security, and Veterans Affairs	Within 180 days after the date of HSPD-21
	Establish a process to share relevant information regarding the contents of the SNS with Federal, State, and local government health officers with appropriate clearances and a need to know	Secretary of HHS	Within 90 days after the date of HSPD-21
	Develop protocols for sharing countermeasures and medical goods between the SNS and other Federal stockpiles and shall explore appropriate reciprocal arrangements with foreign and international stockpiles of medical countermeasures to ensure the availability of necessary supplies for use in the United States	Secretary of HHS in coordination with the Secretaries of State, Defense, Agriculture, Veterans Affairs, and Homeland Security	Within 180 days after the date of HSPD-21
Mass Casualty Care
	Directly engage relevant State and local government, academic, professional, and private sector entities and experts to provide feedback on the review of the National Disaster Medical System (NDMS) and national medical surge capacity required by the Pandemic and All-Hazards Preparedness Act (PAHPA) (Public Law 109-417)	Secretary of HHS in coordination with the Secretaries of Defense, Veterans Affairs, and Homeland Security
	Identify…high-priority gaps in mass casualty care capabilities, and shall submit to the Assistant to the President for Homeland Security and Counterterrorism a concept plan that identifies and coordinates all Federal, State, and local government and private sector public health and medical disaster response resources, and identifies options for addressing critical deficits, in order to achieve the system attributes described in this Strategy	Secretary of HHS	Within 270 days after the completion of the review of NDMS and national medical surge capacity
	Build upon the analysis of Federal facility use to provide enhanced medical surge capacity in disasters required by section 302 of PAHPA to analyze the use of Federal medical facilities as a foundational element of public health and medical preparedness; and develop and implement plans and enter into agreements to integrate such facilities more effectively into national and regional education, training, and exercise preparedness activities	Secretary of HHS in coordination with the Secretaries of Defense, Veterans Affairs, and Homeland Security	Within 180 days after the date of HSPD-21
	Lead an interagency process, in coordination with the Secretaries of Defense, Veterans Affairs, and Homeland Security and the Attorney General, to identify any legal, regulatory, or other barriers to public health and medical preparedness and response from Federal, State, or local government or private sector sources that can be eliminated by appropriate regulatory or legislative action and…submit a report on such barriers to the Assistant to the President for Homeland Security and Counterterrorism	Secretary of HHS	Within 120 days after the date of HSPD-21
	Establish a Federal Advisory Committee for Disaster Mental Health	Secretary of HHS in coordination with the Secretaries of Defense, Veterans Affairs, and Homeland Security	Within 180 days after the date of HSPD-21
	Submit to the Secretary of Health and Human Services recommendations for protecting, preserving, and restoring individual and community mental health in catastrophic health event settings, including pre-event, intra-event, and post-event education, messaging, and interventions	Federal Advisory Committee for Disaster Mental Health	Within 180 days after the establishment of the Federal Advisory Committee for Disaster Mental Health
Community Resilience
	Ensure that core public health and medical curricula and training developed pursuant to PAHPA address the needs to improve individual, family, and institutional public health and medical preparedness, enhance private citizen opportunities for contributions to local, regional, and national preparedness and response, and build resilient communities	Secretary of HHS in coordination with the Secretaries of Defense, Veterans Affairs, and Homeland Security
	Submit to the President for approval, through the Assistant to the President for Homeland Security and Counterterrorism, a plan to promote comprehensive community medical preparedness	Secretary of HHS in coordination with the Secretaries of Defense, Commerce, Labor, Education, Veterans Affairs, and Homeland Security and the Attorney General	Within 270 days after the date of HSPD-21
Risk Awareness
	Prepare an unclassified briefing for non-health professionals that clearly outlines the scope of the risks to public health posed by relevant threats and catastrophic health events (including attacks involving weapons of mass destruction); coordinate such briefing with the heads of other relevant executive departments and agencies; ensure that full use is made of Department of Defense expertise and resources; and ensure that all State governors and the mayors and senior county officials from the 50 largest metropolitan statistical areas in the United States receive such briefing, unless specifically declined	Secretary of Homeland Security, in coordination with the Secretary HHS	Within 150 days after the date of HSPD-21
	Establish a mechanism by which up-to-date and specific public health threat information shall be relayed, to the greatest extent possible and not inconsistent with the established guidance relating to the Information Sharing Environment, to relevant public health officials at the State and local government levels and shall initiate a process to ensure that qualified heads of State and local government entities have the opportunity to obtain appropriate security clearances so that they may receive classified threat information when applicable	Secretary of Homeland Security, in coordination with the Attorney General, the Secretary of HHS, and the Director of National Intelligence	Within 180 days after the date of HSPD-18
Education and Training
	Develop and thereafter maintain processes for coordinating Federal grant programs for public health and medical preparedness using grant application guidance, investment justifications, reporting, program performance measures, and accountability for future funding in order to promote cross-sector, regional, and capability-based coordination, consistent with section 201 of PAHPA and the National Preparedness Guidelines developed pursuant to Homeland Security Presidential Directive-8 of December 17, 2003 (“National Preparedness”)	Secretary of HHS in coordination with the Secretary of Homeland Security	Within 180 days after the date of HSPD-21
	Develop a mechanism to coordinate public health and medical disaster preparedness and response core curricula and training across executive departments and agencies, to ensure standardization and commonality of knowledge, procedures, and terms of reference within the Federal Government that also can be communicated to State and local government entities, as well as academia and the private sector	Secretary of HHS in coordination with the Secretaries of Defense, Transportation, Veterans Affairs, and Homeland Security, and consistent with section 304 of PAHPA	Within 1 year after the date of HSPD-21
	Establish an academic Joint Program for Disaster Medicine and Public Health housed at a National Center for Disaster Medicine and Public Health at the Uniformed Services University of the Health Sciences	Secretaries of HHS and Defense, in coordination with the Secretaries of Veterans Affairs and Homeland Security	Within 1 year after the date of HSPD-21
Disaster Health System
	Commission the Institute of Medicine to lead a forum engaging Federal, State, and local governments, the private sector, academia, and appropriate professional societies in a process to facilitate the development of national disaster public health and medicine doctrine and system design and to develop a strategy for long-term enhancement of disaster public health and medical capacity and the propagation of disaster public health and medicine education and training	Secretary of HHS	Within 180 days after the date of HSPD-21
	Submit to the President through the Assistant to the President for Homeland Security and Counterterrorism, and commence the implementation of, a plan to use current grant funding programs, private payer incentives, market forces, Center for Medicare and Medicaid Services requirements, and other means to create financial incentives to enhance private sector health care facility preparedness in such a manner as to not increase health care costs	Secretary of HHS	Within 120 days after the date of HSPD-21
	Establish within the Department of Health and Human Services an Office for Emergency Medical Care	Secretary of HHS in coordination with the Secretaries of Transportation and Homeland Security	Within 180 days after the date of HSPD-21
Source: Homeland Security Presidential Directive/HSPD-21 [news release]. Washington, DC: The White House; October 18, 2007. http://www.whitehouse.gov/news/releases/2007/10/20071018-10.html. Accessed October 19, 2007.

References

Homeland Security Presidential Directive/HSPD-21 [news release]. Washington, DC: The White House; October 18, 2007. http://www.whitehouse.gov/news/releases/2007/10/20071018-10.html. Accessed October 19, 2007.