More than five years after the September 11, 2001, terrorist attacks on the United States, many states are still unprepared to handle a major crisis, the nonpartisan Trust for America's Health (TFAH) said in its fourth annual Ready or Not? report.

Since 2003, TFAH has measured states' emergency preparedness capabilities based on 10 indicators.

The group said that it has undertaken the role of assessing states' emergency preparedness performance because, despite a $4 billion federal investment since 2002, the government has "yet to issue state-by-state information to Americans or policymakers about how prepared their communities are to respond to health threats."

Providing information about which states have weaknesses, the report's authors contended, helps identify where and how to make improvements or overcome obstacles.

TFAH evaluated all 50 U.S. states and the District of Columbia. Each state received one point for fully meeting each indicator.

Half of states scored 6 or less on the scale of 10 indicators, TFAH reported. Oklahoma was the only state to score 10 points. Kansas scored 9 points.

California, Iowa, Maryland, and New Jersey scored the lowest, with 4 out of 10 points, according to TFAH.

Stockpile failures. Only 15 states are prepared to distribute emergency supplies from the Strategic National Stockpile (SNS)—a national repository of antiinfectives, chemical antidotes, and other medications and medical supplies and equipment that can be deployed within 12 hours of a terrorist attack or major natural disaster.

The federal cache of antiviral medications to counter a pandemic influenza outbreak is contained in the SNS.
During the responses to Hurricanes Katrina and Rita in 2005, many responders criticized the government for failing to include medications to treat chronic diseases in the SNS.

The need for drugs to treat chronic conditions often arises as a serious issue during disasters, TFAH said, because regular supply chains for medications are generally unavailable.

Lack of beds. Half of U.S. states would run out of hospital beds within two weeks of a moderately severe pandemic influenza outbreak, according to TFAH.

"Patients would rapidly fill existing hospital beds and cause a surge in demand for critical medicines and equipment, such as antivirals, ventilators, and protective masks," the group maintained.

The Centers for Disease Control and Prevention (CDC) estimates that there will be 1 million hospital admissions during a minor influenza pandemic, TFAH noted. However, for a major pandemic, that number increases fourfold.

A pandemic influenza outbreak is anticipated to last for at least eight weeks, peaking at five weeks, according to CDC.

Influenza testing. Four states—Iowa, Louisiana, New Jersey, and Ohio—do not test year-round for influenza, TFAH researchers reported.

The federal pandemic influenza preparedness guidance requires states to be capable of testing for influenza on a year-round basis.

"Year-round testing is viewed as a critical component of monitoring for a potential pandemic outbreak," TFAH said.
Vaccinations. Seasonal influenza vaccination rates for seniors decreased last year in 13 states, TFAH researchers reported.

About 200,000 U.S. residents are hospitalized annually from influenza or its complications, and approximately 36,000 people in this country die each year from seasonal influenza, according to CDC.

"Seasonal flu vaccinations are viewed as a key part of planning for pandemic preparedness and other emergency responses that would require mass vaccination or distribution of medications," TFAH contended.

Staffing and funding shortages. Forty states have a shortage of registered nurses, TFAH reported.
According to the federal National Center for Health Workforce Analysis, if current trends continue, there will be a shortage of 1 million full-time registered nurses by 2020.

"The nursing shortage makes it challenging for the health care sector to meet current service needs," TFAH researchers said. "This problem would be compounded during emergencies, when there would be an influx of additional patients. If health care staff levels are insufficient on a day-to-day basis, they will be exponentially overtaxed during a mass emergency."

In nearly half of the states, 25% or more of the state public health work force will be eligible for retirement within the next five years, TFAH noted, adding that eight states face potential retiree levels of 40% or higher.

Six states—Arkansas, Maine, Michigan, Mississippi, Pennsylvania, and South Dakota—cut funding for public health from fiscal years 2004–05 to 2005–06.

Laboratories and scientists. Eleven states and the District of Columbia do not have adequate biosafety level 3 (BSL-3) laboratories—facilities capable of safely handling infectious agents that may cause serious or potentially lethal disease as a result of exposure—to meet anticipated preparedness needs as outlined in their state's bioterrorism preparedness plans, TFAH reported.

BSL-3 laboratories, which identify naturally occurring and man-made health threats, are "crucial for developing strategies to contain the spread and facilitate the rapid treatment of diseases," TFAH stated.

As of October 2006, the group reported, only 10 states have the facilities, technology, equipment, and personnel to adequately test for chemical threats. Although that number has not changed since 2005, "it is an increase from 0 in 2003 and five in 2004," TFAH declared.

While 46 states and the District of Columbia reported that they would have a sufficient number of trained laboratory scientists to manage tests for anthrax or pneumonic plague if there were to be a suspected outbreak, that increase can largely be attributed to cross-training of the scientists rather than to increases in the total number of staff at the facilities, TFAH said.

Electronic surveillance. Twelve states and the District of Columbia do not have an electronic disease surveillance system that is compatible with CDC's National Electronic Disease Surveillance System, researchers reported.

"Delivering effective public health services depends on timely and reliable information," TFAH said. "Health departments cannot protect people from existing or emerging health threats, such as a new disease outbreak or bioterror attack, without the right information."

The lack of timely and comprehensive data, TFAH argued, "can cause delays in identifying and responding to serious and mass emergency health problems."