Since the 2014 Ebola outbreak many public- and private-sector leaders have seen a need for improved management of global public health emergencies. The effects of the Ebola epidemic go well beyond the three hardest-hit countries and beyond the health sector. Education, child protection, commerce, transportation, and human rights have all suffered. The consequences and lethality of Ebola have increased interest in coordinated global response to infectious threats, many of which could disrupt global health and commerce far more than the recent outbreak. In order to explore the potential for improving international management and response to outbreaks the National Academy of Medicine agreed to manage an international, independent, evidence-based, authoritative, multistakeholder expert commission. As part of this effort, the Institute of Medicine convened four workshops in summer of 2015 to inform the commission report. The presentations and discussions from the Workshop on Resilient and Sustainable Health Systems to Respond to Global Infectious Disease Outbreaks are summarized in this report. Table of Contents Front Matter 1 Introduction 2 Fundamental Principles of Strong Health Systems 3 Health Systems Strengthening: Building Day-to-Day Care and Public Health Capacities 4 Strengthening Information Management Systems 5 Strengthening Outbreak Management and Emergency Response Systems 6 Closing Remarks Appendix A: References Appendix B: Statement of Task Appendix C: Agenda Appendix D: Speaker Biographies

When disaster strikes, it rarely impacts just one jurisdiction. Many catastrophic disaster plans include support from neighboring jurisdictions that likely will not be available in a regional disaster. Bringing multiple stakeholders together from sectors that do not routinely work with each other can augment a response to a disaster, but can also be extremely difficult because of the multi-disciplinary communication and coordination needed to ensure effective medical and public health response. As many communities within a region will have similar vulnerabilities, a logical step in planning is to establish responsibilities and capacities, and be able to work toward common goals to address all-hazards when the entire region is affected. To explore these considerations, the Institute of Medicine's Forum on Medical and Public Health Preparedness for Catastrophic Events organized a series of three regional workshops in 2014 to explore opportunities to strengthen the regional coordination required in response to a large scale multijurisdictional disaster. The purpose of each regional workshop was to discuss ways to strengthen coordination among multiple jurisdictions in various regions to ensure fair and equitable treatment of communities from all impacted areas. Regional Disaster Response Coordination to Support Health Outcomes summarizes the presentation and discussion of these workshops. Table of Contents Front Matter 1 Introduction 2 Evacuation, Patient Tracking, and Information Sharing in a Regional Response 3 Public Health Surge Capacity and Community Resilience 4 Coordination of a Community Response 5 Final Remarks A-- References B-- Acronyms C-- Statement of Task D--Agendas E-- Biographical Sketches of Invited Speakers and Panelists F-- Speakers and Registered Attendees

The most recent Ebola epidemic that began in late 2013 alerted the entire world to the gaps in infectious disease emergency preparedness and response. The regional outbreak that progressed to a significant public health emergency of international concern (PHEIC) in a matter of months killed 11,310 and infected more than 28,616. While this outbreak bears some unique distinctions to past outbreaks, many characteristics remain the same and contributed to tragic loss of human life and unnecessary expenditure of capital: insufficient knowledge of the disease, its reservoirs, and its transmission; delayed prevention efforts and treatment; poor control of the disease in hospital settings; and inadequate community and international responses. Recognizing the opportunity to learn from the countless lessons of this epidemic, the National Academies of Sciences, Engineering, and Medicine convened a workshop in March 2015 to discuss the challenges to successful outbreak responses at the scientific, clinical, and global health levels. Workshop participants explored the epidemic from multiple perspectives, identified important questions about Ebola that remained unanswered, and sought to apply this understanding to the broad challenges posed by Ebola and other emerging pathogens, to prevent the international community from being taken by surprise once again in the face of these threats. This publication summarizes the presentations and discussions from the workshop. Table of Contents Front Matter 1 Introduction 2 The Outbreak 3 Global Preparedness and Response Efforts 4 Current and Future Research Opportunities Appendix A: References Appendix B: Ebola: A View from the National Institute of Allergy and Infectious Diseases Appendix C: Ebola Virus Disease Preparedness in Germany: Expertise Focused in Specialized Laboratories, Competence, and Treatment Centers Appendix D: Statement of Task Appendix E: Workshop Agenda Appendix F: Speaker Biographies

Emerging infectious disease threats that may not have available treatments or vaccines can directly affect the security of the world's health since these diseases also know no boundaries and will easily cross borders. Sustaining public and private investment in the development of medical countermeasures (MCMs) before an emerging infectious disease becomes a public health emergency in the United States has been extremely challenging. Interest and momentum peak during a crisis and wane between events, and there is little interest in disease threats outside the United States until they impact people stateside. On March 26 and 27, 2015, the Institute of Medicine convened a workshop in Washington, DC to discuss how to achieve rapid and nimble MCM capability for new and emerging threats. Public- and private-sector stakeholders examined recent efforts to prepare for and respond to outbreaks of Ebola Virus Disease, pandemic influenza, and coronaviruses from policy, budget, and operational standpoints. Participants discussed the need for rapid access to MCM to ensure national security and considered strategies and business models that could enhance stakeholder interest and investment in sustainable response capabilities. This report summarizes the presentations and discussions from this workshop. Table of Contents Front Matter 1 Introduction 2 A Wake-Up Call: The 2014 Ebola Outbreak Response 3 Preparedness as an Issue of National Security 4 Rapid Development of Ebola Vaccines 5 Influenza Risk Assessment and Pandemic Preparedness 6 Developing MCMs for Coronaviruses 7 Sustainable Business Models to Ensure Rapid and Nimble Responses 8 Supporting MCM Development Across Threats and Funding Cycles A References B Acronyms and Abbreviations C Statement of Task D Agenda E Biosketches of Invited Speakers and Facilitators

Over the past decade, preparedness and response capacities of government agencies, hospitals and clinics, public health agencies, and academic researchers in the United States and abroad have been challenged by a succession of public health emergencies, ranging from radiological threats to pandemics to earthquakes. Through After Action Reports, each of these emergencies has yielded important information and lessons learned that can inform future disaster response and recovery efforts. However, important information that needs to be collected during and immediately following these emergencies is often missed because of barriers and obstacles to gathering such data, such as varying institutional review board restrictions in different states, no sustainable funding network for this type of work, uncertainty on who should be involved in research response, and a lack of knowledge around how best to integrate research into response and recovery frameworks. Taking action to enable medical and public health research during disasters was the focus of a workshop held on June 12 and 13, 2014, coordinated and supported jointly by the Institute of Medicine Forum on Medical and Public Health Preparedness for Catastrophic Events, National Institute of Environmental Health Sciences, the National Library of Medicine, the U.S. Department of Health and Human Services' Office of the Assistant Secretary for Preparedness and Response, and the Centers for Disease Control and Prevention. Invited speakers and participants from federal, state, and local government, academia, and community and worker organizations came together to discuss how to integrate research into existing response structures; identify critical research needs and priorities; identify obstacles and barriers to research; discuss structures and strategies needed for deployment of a research study; share ideas, innovations, and technologies to support research; and explore data collection tools and data-sharing mechanisms for both rapid and longitudinal research. Enabling Rapid and Sustainable Public Health Research During Disasters summarizes the presentations and discussion of the workshop. Table of Contents Front Matter 1 Introduction 2 Science Preparedness: Conducting Research During Public Health Emergencies 3 Health Research Needs and Actions: Lessons from Recent Disasters 4 Addressing Institutional Review Board Barriers to Health Research Implementation 5 Partnering with the Community to Enable Research 6 Improving Data Collection Capabilities and Information Resources 7 Considerations for Rapid and Sustained Funding Mechanisms for Research in Disasters 8 Improving the Role of Extramural Research Networks 9 Coordinating Logistics to Execute Rapid Research in Disaster Response 10 Actions to Build the Future of Disaster Research Appendix A: References Appendix B: Acronyms Appendix C: Agenda Appendix D: Biographical Sketches of Invited Speakers and Panelists Appendix E: Speakers and Registered Attendees Appendix F: Statement of Task

Many of the elements of the Affordable Care Act (ACA) went into effect in 2014, and with the establishment of many new rules and regulations, there will continue to be significant changes to the United States health care system. It is not clear what impact these changes will have on medical and public health preparedness programs around the country. Although there has been tremendous progress since 2005 and Hurricane Katrina, there is still a long way to go to ensure the health security of the Country. There is a commonly held notion that preparedness is separate and distinct from everyday operations, and that it only affects emergency departments. But time and time again, catastrophic events challenge the entire health care system, from acute care and emergency medical services down to the public health and community clinic level, and the lack of preparedness of one part of the system places preventable stress on other components. The implementation of the ACA provides the opportunity to consider how to incorporate preparedness into all aspects of the health care system. The Impacts of the Affordable Care Act on Preparedness Resources and Programs is the summary of a workshop convened by the Institute of Medicine's Forum on Medical and Public Health Preparedness for Catastrophic Events in November 2013 to discuss how changes to the health system as a result of the ACA might impact medical and public health preparedness programs across the nation. This report discusses challenges and benefits of the Affordable Care Act to disaster preparedness and response efforts around the country and considers how changes to payment and reimbursement models will present opportunities and challenges to strengthen disaster preparedness and response capacities. Table of Contents Front Matter 1 Introduction 2 How the ACA Will Change the Health Care Delivery System 3 Preparedness Impacts of the Changes to Health Care System Financing and Delivery Infrastructure 4 The Evolving Health Workforce 5 Needs and Logistics of Data Sharing and Health Information Technology 6 Potential Opportunities to Enhance Preparedness Through Health Information Exchanges and Predictive Analytics 7 Leveraging the Affordable Care Act and Information Technology to Innovate 8 The Continuing Role for Public Health Preparedness and Response Appendix A: References Appendix B: Acronyms Appendix C: Statement of Task Appendix D: Agenda Appendix E: Biographical Sketches of Invited Speakers and Panelists Appendix F: Key Features of the Affordable Care Act by Year

Preparedness, Response and Recovery Considerations for Children and Families is the summary of a workshop convened in June, 2013 by the Institute of Medicine Forum on Medical and Public Health Preparedness for Catastrophic Events to discuss disaster preparedness, response, and resilience relative to the needs of children and families, including children with special health care needs. Traditional and non-traditional medical and public health stakeholders from across federal, state, and local government health care coalitions, community organizations, school districts, child care providers, hospitals, private health care providers, insurers, academia, and other partners in municipal planning met to review existing tools and frameworks that can be modified to include children's needs; identify child-serving partners and organizations that can be leveraged in planning to improve outcomes for children; highlight best practices in resilience and recovery strategies for children; and raise awareness of the need to integrate children's considerations throughout local and state emergency plans. Communities across the United States face the threat of emergencies and disasters almost every day, natural and man-made, urban and rural, large and small. Although children represent nearly 25 percent of the U.S. population, current state and local disaster preparedness plans often do not include specific considerations for children and families. The preparedness and resilience of communities related to children will require a systems framework for disaster preparedness across traditional and non-traditional medical and public health stakeholders, including community organizations, schools, and other partners in municipal planning. This report examines resilience strategies that lead to successful recovery in children after a disaster and discusses current approaches and interventions to improve recovery in children.

Engaging the Public in Critical Disaster Planning and Decision Making is the summary of a workshop held in March 2013 to discuss the key principles of public engagement during the development of disaster plans, the response phase, and during the dissemination phase when interested community partners and the general public are informed of the policies that have been adopted. Presenters provided specific examples of resources to assist jurisdictions in planning public engagement activities as well as challenges experienced and potential solutions. This report introduces key principles of public engagement, provides practical guidance on how to plan and implement a public engagement activity, and presents tools to facilitate planning. Table of Contents Front Matter Engaging the Public in Critical Disaster Planning and Decision Making Appendix A: References Appendix B: Statement of Task Appendix C: Workshop Agenda Appendix D: Biographical Sketches of Speakers and Panelists

Our nation faces the distinct possibility of a catastrophic terrorist attack using an improvised nuclear device (IND), according to international and U.S. intelligence. Detonation of an IND in a major U.S. city would result in tens of thousands to hundreds of thousands of victims and would overwhelm public health, emergency response, and health care systems, not to mention creating unprecedented social and economic challenges. While preparing for an IND may seem futile at first glance, thousands of lives can be saved by informed planning and decision making prior to and following an attack. In 2009, the Institute of Medicine published the proceedings of a workshop assessing the health and medical preparedness for responding to an IND detonation. Since that time, multiple federal and other publications have added layers of detail to this conceptual framework, resulting in a significant body of literature and guidance. However, there has been only limited planning effort at the local level as much of the federal guidance has not been translated into action for states, cities and counties. According to an informal survey of community preparedness by the National Association of City and County Health Officials (NACCHO), planning for a radiation incident ranked lowest in priority among other hazards by 2,800 local health departments. The focus of Nationwide Response Issues After an Improvised Nuclear Device Attack: Medical and Public Health Considerations for Neighboring Jurisdictions: Workshop Summary is on key response requirements faced by public health and health care systems in response to an IND detonation, especially those planning needs of outlying state and local jurisdictions from the detonation site. The specific meeting objectives were as follows: - Understand the differences between types of radiation incidents and implications of an IND attack on outlying communities. -Highlight current planning efforts at the federal, state, and local level as well as challenges to the implementation of operational plans. -Examine gaps in planning efforts and possible challenges and solutions. -Identify considerations for public health reception centers: how public health and health care interface with functions and staffing and how radiological assessments and triage be handled. -Discuss the possibilities and benefits of integration of disaster transport systems. -Explore roles of regional health care coalitions in coordination of health care response.