In February 2014, the United States joined 28 other countries, the World Health Organization, and others to support the global health security agenda with the vision to keep the world safe through an interconnected global network from health threats posed by infectious diseases.1 The need for a global health security agenda has become especially apparent as the world struggles to contain the Ebola outbreak in West Africa and limit the spread of Ebola to other countries. Local health departments, within the United States and abroad, are the first to respond to infectious disease threats and, as such, play a critical role in achieving the global health security agenda. Specifically, local health departments help strengthen global health security through activities that prevent or slow disease transmission, reduce antimicrobial resistance, strengthen biosurveillance, convey critical information to the public, increase immunization rates, and improve real-time electronic reporting systems. As an illustration of this point, the World Health Organization has suggested that crumbling public health systems in West Africa limited the ability of these countries to contain the current Ebola outbreak.2

The National Association of County & City Health Officials (NACCHO) is the voice of the 2800 local health departments in the United States that work every day to protect and promote health and well-being for all people in their communities. It helps local health departments prepare for disasters and emergencies by providing tools, guidance, and resources for developing policies and programs, sharing up-to-date, timely information about public health threats, and conveying the needs of local health departments to the Centers for Disease Control and Prevention (CDC), Assistant Secretary for Preparedness and Response, and other national partners.

Since July 2014, NACCHO has been monitoring the outbreak of Ebola in West Africa and working with local health departments, CDC, Assistant Secretary for Preparedness and Response, and other national partners to determine what is necessary for coordinated national preparedness and response efforts. With the first case of imported Ebola in Dallas announced on September 30, 2014, the CDC escalated its domestic response to Ebola and engaged several public health partners, including NACCHO, the Association of State and Territorial Health Officials, the Council of State and Territorial Epidemiologists, and the Association of Public Health Laboratories, to assist them in the response. The CDC also engaged with the American Hospital Association and the National Association of State EMS Officials. NACCHO's partnership with the CDC and these other national organizations ensures that the concerns of local health departments are addressed in plans for a coordinated national response. One critical role that NACCHO has played in the response to Ebola has been to provide ongoing technical assistance to local health departments. Several themes emerged in the requests that NACCHO received that provide insights into difficulties that local health departments are most likely to face during emerging infectious disease threats to global health security. The following 3 main themes in these requests highlight areas where local health departments may want to prioritize staff and resources in response to Ebola and other infectious disease threats: interpreting and implementing federal guidance; forming partnerships to prepare for and coordinate response; and communicating accurate and timely risk information.

Interpreting and Implementing Federal Guidance

Ebola presented many unprecedented challenges for all sectors of government, including local health departments. In Dallas, for example, lack of precedent for the disposal of Ebola-contaminated waste led to the accumulation of waste at Texas Health Presbyterian Hospital Dallas and delays transporting waste to appropriate disposal facilities.3 Because of the unprecedented nature of Ebola and the need to act quickly to mitigate potential threats, federal guidance for Ebola management protocols was frequently updated, sometimes vague or confusing, and occasionally did not cover sectors that were requesting information from local health departments. In the months following the first domestic case of Ebola infection, local health departments struggled with accessing and implementing the guidance due to the large investment of time necessary to find the most current guidance, interpret what was applicable to them, and ensure that the guidance did not conflict with guidance issued at the state or local level.

NACCHO received the most requests for technical assistance from local health departments regarding guidance for personal protective equipment (PPE). Federal guidance on PPE was ambiguous and often under scrutiny, particularly when it did not seem adequate in protecting health care workers in Dallas. Initially, federal guidance on PPE was specific to health care settings and it was not always clear who, and under what circumstances, should wear PPE. For example, NACCHO received many requests for guidance that could be applied to law enforcement, as it was unclear whether or not law enforcement should be wearing PPE when responding to calls when someone was ill. Although federal PPE guidance was eventually clarified and adapted for non-health care settings, the unprecedented nature of Ebola meant that some stakeholders were left without a reliable source of information in the early stages of the response.

Perceived and real conflicts between federal and state-level guidance also presented challenges for local health departments. Federal guidance was often intentionally broad to allow flexibility for states and locals to tailor guidance to their local circumstances. As such, NACCHO fielded many requests from local health departments seeking clarity on the isolation and quarantine of returning travelers and suspected cases. Because CDC isolation and quarantine authority applies to individuals entering the United States and traveling between states, local health departments were subject to varied state legal requirements for individuals within the state. For example, some governors implemented mandatory isolation and quarantine procedures in their states that public health officials and medical experts believed were far stricter than what the scientific, medical, and epidemiologic evidence supported. This varying guidance not only created legal burdens for local health departments but also raised resource challenges for implementation.

Finally, NACCHO received several requests for additional guidance about waste treatment, cleaning, and decontamination of non-health care facilities. For example, some local health departments wanted information about specific and acceptable cleaning agents and companies that could perform cleaning and decontamination. Others were looking for more general guidance on which agency was responsible for coordinating cleaning and decontamination. Some sought additional information about the risks to waste water facilities and workers.

Forming Partnerships to Prepare for and Coordinate Response

The need to constantly evaluate and adapt new federal guidance demonstrated the importance of strong community partnerships that would allow local health departments to quickly act on guidance in coordination with existing partners. The need for strong partnerships between local health departments and the health care sector became clear when the Department of Health and Human Services asked that all hospitals be prepared to identify potential cases of Ebola infection (ie, patients with temperatures and recent travel history to the affected countries in West Africa) and isolate suspected cases.

Local health departments looked to NACCHO for guidance and technical assistance in working with hospitals and health care coalitions to prepare for Ebola. Health care coalitions are groups of public agencies and private organizations within a community that work together to plan, train, exercise for, and respond to public health emergencies. A robust health care coalition allows for the facilitation of information and resource sharing among the members of the coalition. For example, individual health care facilities that did not have PPE, supplies, or other equipment on hand could turn to their coalitions for pooling and sharing of available resources among partners. Coalitions may also have stronger purchasing power than individual facilities.

Initially, some local health departments reported that health care facilities were not receiving the information and training they needed for responding to Ebola. After the release of the PPE guidance, many local health departments were requesting a training video that demonstrated the steps for donning and doffing protective equipment. Their health care partners felt that a visual demonstration would be a more efficient and effective way to train health care workers than written guidance or photographs. In addition to the critical need for strong partnerships with hospitals and health care coalitions, local health departments also requested assistance from NACCHO in finding information to share with emergency medical services (EMS), law enforcement, local businesses, schools, and others, indicating that many local health departments were casting a wide net in developing partnerships to respond to potential Ebola cases.

Communicating Accurate and Timely Risk Information

NACCHO's local health department members reported intense public interest in Ebola that was apparent from increased calls from media outlets and the general public. NACCHO received several requests for technical assistance to support a broad array of risk communication activities. Local health departments were primarily seeking tools and resources such as Ebola messages, fact sheets, and infographics that were translated into appropriate languages and written at an appropriate reading level. Many felt that the communication resources available from federal sources were written at a reading level that was too advanced. In addition, federal resources translated into different languages were not readily available at first. For example, the first CDC materials available in another language were in Spanish, although most travelers from West Africa were more likely to speak French or English. Local health departments were concerned that the lack of Ebola communication materials translated or written at an appropriate reading level would lead to health inequities due to lack of accessible information and fear of discrimination among certain populations.

Many local health departments noted instances of stigmatization of West African communities and refusal of service at health care facilities to those who reported recent travel to Africa, regardless of whether or not their travel history involved a country with active Ebola cases. Local health departments noted a large disparity between the perceived and actual risks among their communities regarding Ebola and reported significant efforts to stem the panic by countering misinformation through dissemination of accurate risk information and rumor control on social media. In fact, many local health departments reported implementing risk communication strategies to reduce fear and panic in several aspects of their Ebola response. Strategies included incorporating risk communication principles into the interactions of epidemiologists conducting contact tracing investigations and scripts for hotlines that health departments set up to field calls from anxious and sometimes hostile callers.

Recommendations

Ebola has been described as a test of America's public health system that has been weakened because of budget cuts.4 While the number of cases were low, the level of response necessary to mitigate both perceived and actual risks to the public was extremely high. On the basis of an evaluation of nearly 100 requests for technical assistance, NACCHO has several recommendations for local health departments to better prepare for global health security threats such as Ebola. First, NACCHO recommends that local health departments have dedicated preparedness, epidemiology, and communications staff who are trained to interpret federal guidance, work with community partners, respond to requests for information, and disseminate risk information. On the basis of the requests for technical assistance, these areas appeared to be the most directly impacted in terms of staff time and resources.

Second, NACCHO encourages local health departments to develop or participate in health care coalitions within their communities to improve coordination between health care and public health and leverage collective resources. This coordination is extremely important in response to an emergency such as Ebola in which the local health department and the affected health care facilities must work together and share resources to protect the community. The necessary level of partnership that facilitates such coordination cannot be achieved overnight; it must be built through consistent and ongoing communication and the completion of joint training and exercise activities to prepare for a response. Health care coalitions that are equipped to respond to global health security threats may need partners in addition to local hospitals. Local health departments may need to work closely with agencies and private organizations that support law enforcement, the judicial system, emergency management, municipal services, EMS, medical examiners, medical waste management, veterinary services, volunteers, and others.

Third, NACCHO recommends that local health departments work with state health departments to review, exercise, and test isolation and quarantine plans and ensure that the plans are adaptable to future global health security threats from emerging infectious diseases. In addition, local health departments should use these exercises to evaluate anticipated administrative burdens that are likely to arise during the response to global health threats, such as the need to expedite purchases of equipment (eg, PPE) or services, hire additional staff, and track time and expenses that could be eligible for reimbursement from federal emergency response funds.

Finally, local health departments and other public health entities should consider seeking educational opportunities for learning more about global health security threats, such as the 2015 Preparedness Summit. The Preparedness Summit provides a unique opportunity for cross-disciplinary learning among attendees that include professionals working in local, state, and federal public health agencies, emergency management, volunteer organizations, and health care coalitions. The theme for this year's Preparedness Summit is "Global Health Security: Preparing a Nation for Emerging Threats," and sessions will include lessons learned from responding to Ebola. (Learn more at http://PreparednessSummit.org.)

Local health departments cannot respond to global health security threats alone. With federal preparedness funding subject to a reactionary cycle that is driven in part by political process, local health departments have been struggling as federal budgets shrink. Public Health Emergency Preparedness grants have been cut nearly in half from their highest point after 9/11.5 The National Hospital Preparedness Program, which supports health care coalitions focused on local preparedness, was cut by $100 million in 2014 alone.6 In addition, although the federal government has started to align the Public Health Emergency Preparedness and National Hospital Preparedness Program programs, the disconnect between local health departments and health care was evident during the initial stages of response to Ebola and illustrates the need for full integration of these programs. With more than half of local health departments relying solely on federal funding for emergency preparedness activities,7 many do not have enough staff due to budget cuts. The response to Ebola demonstrates the importance of sustainable preparedness, epidemiology, and laboratory capacity funding for local health departments to support dedicated staff and resources, as many struggled to keep up with the demands of monitoring hundreds of travelers, contact tracing, communicating with the public, and managing suspected cases. Fully achieving the global health security agenda will require an ongoing investment in developing the capacity and capability of local health departments to prepare for and respond to threats such as Ebola.

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