Health Security National Action Plan

Objectives

The National Action Plan for Health Security provides a United States framework for implementing the International Health Regulations (IHR), strengthening the capacity to prevent, detect and respond to public health threats, and addressing other IHR-related hazards and points of entry. It uses the 2016 Joint External Evaluation (JEE) as its baseline, applies the JEE’s 19 technical areas, targets and performance indicators, and is intended to optimise health security according to national risks, challenges and resources.[1][2][3][4][5]

• Strengthen legal, policy, financing and coordination arrangements for IHR implementation across federal, state, local, tribal and territorial authorities.[6][7]
• Prevent health threats through antimicrobial resistance action, a formal One Health approach to zoonotic disease, food safety, biosafety, biosecurity, responsible life-sciences research and immunisation.[1][8][9][10][11][12]
• Improve detection through public health laboratory systems, safe specimen sharing, interoperable surveillance, timely international reporting and a skilled public health workforce.[13][14][15][16][17]
• Enhance response through multi-hazard preparedness planning, emergency operations centres, exercises, public health and security collaboration, medical countermeasures and risk communication.[18][19][20][21][22]
• Build capacity for points of entry and chemical, radiological and nuclear emergencies, including dose assessment, biodosimetry, bioassay, patient triage, treatment, environmental remediation and radiation-workforce development.[23][24][25][26][27]

The plan aligns its activities with wider national strategies on security, health security, biodefence and antibiotic-resistant bacteria, as well as international health-security partnerships.[28][29]It seeks both to address priority gaps and to sustain existing high-capacity systems, recognising that capacity can vary across subnational jurisdictions even where national arrangements are strong.[28][6]

Priority disease-security objectives include building animal and human laboratory capacity to detect and characterise antimicrobial-resistant pathogens; reducing the time to detect drug-resistant enteric pathogens; strengthening antimicrobial stewardship; and improving monitoring of antibiotic use and resistance across healthcare, animal-health and environmental settings.[30][31][32]Food safety objectives include whole-genome sequencing expansion, outbreak investigation, environmental assessment and pathogen-data sharing.[10][33]

For zoonotic threats, the plan aims to establish shared One Health goals, roles and responsibilities across human, animal and environmental sectors, prioritise nationally important zoonoses, integrate surveillance and laboratories, and improve joint prevention, preparedness and outbreak response.[34][35]For emergency preparedness, it aims to maintain multi-hazard plans, map risks and resources, improve post-event learning, and support capabilities across all levels of government.[18][36]

Implementation

Implementation follows a multisectoral, interagency model led by the Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response, which maintains the United States IHR National Focal Point and coordinates implementation towards the follow-up JEE planned for 2021.[2][29]More than 40 federal departments and agencies contribute across human, animal, plant and environmental health, while delivery depends on collaboration with state, local, tribal and territorial authorities, non-governmental organisations, academia, industry and international partners.[2][37][38]

• Coordinate action through the federal IHR Working Group, chaired by the Assistant Secretary for Preparedness and Response, which develops, updates, implements and tracks the National Action Plan.[39]
• Assign action items to named lead departments and agencies, with schedules primarily spanning 2018 to 2020, partner coordination and lead-agency progress reporting.[6][35]
• Integrate delivery with established programme cycles, regulatory arrangements, the National Response Framework and other preparedness, response and recovery frameworks.[29][6]
• Use laboratories, surveillance networks, electronic reporting, training, exercises, after-action reviews, corrective-action plans and operational guidance as core delivery mechanisms.[13][15][36][40]
• Adapt the framework to new legislation, policies, programmes, technologies and available financial resources.[2]

The plan operationalises One Health through a zoonotic disease prioritisation workshop, formalised interagency networks, joint investigations, data sharing, workforce development and implementation projects for priority diseases.[9][35][41]Antimicrobial-resistance delivery includes an Antibiotic Resistance Laboratory Network, whole-genome sequencing, susceptibility testing, hospital reporting infrastructure, state prevention programmes, veterinary outreach and public-private partnerships.[30][42][43][44]

Laboratory and surveillance actions include finalising a federal Sample Sharing Framework, testing it through exercises, strengthening electronic laboratory and case reporting, improving health-record interoperability, and integrating human, animal and environmental information.[13][45][46][47]Reporting actions seek to reduce delays in risk assessment and notification to the World Health Organization, Food and Agriculture Organization and World Organisation for Animal Health through revised procedures, training and interagency protocols.[48][49][16]

Preparedness and response implementation includes regional risk profiles, technology platforms, emergency operations centre standards, accreditation, safe patient transport arrangements, national exercise calendars and mechanisms linking public health with law enforcement during deliberate biological events.[36][19][50][20]Risk communication is delivered through professional training, partner and media surveys, community engagement assessments, plain-language guidance and exercises, including preparation for radiological hazards.[22][51]

Monitoring combines JEE indicators, self-assessment, voluntary peer-to-peer external evaluation, action-item reviews, exercises and progress reporting.[2][4][39]The plan scheduled federal monitoring from November 2018, a comprehensive interagency review in January 2019, publication of a 2018 progress report and revised plan if needed in February 2019, and biannual Working Group action-item reviews.[39]It also specifies selected technical targets, including food-safety sequencing coverage and reductions in antimicrobial-resistance detection times.[30][33]

Implementation is subject to funds authorised or appropriated by Congress and to subnational funding limitations.[28][29]The plan is not a budget document and generally does not provide total budgets, activity costs, allocations, funding gaps or economic assumptions.[29]Some activities, particularly biosafety, laboratory surge capacity, research and radiological preparedness, are explicitly contingent on available funding or resources.[52][26][27]

Monitoring & Evaluation

Monitoring and accountability are anchored in the 2016 United States Joint External Evaluation (JEE), which assessed International Health Regulations capacities across four thematic areas and 19 technical areas using specific targets, performance indicators and capacity scores from 1 to 5.[2][4][5]The 2016 results included level 5 for 20 indicators, level 4 for 21 and level 3 for seven, establishing a baseline for addressing strengths, gaps and external recommendations.[5]

• Coordinate monitoring and evaluation through the Office of the Assistant Secretary for Preparedness and Response, which maintains the United States International Health Regulations National Focal Point and leads implementation towards the next JEE, planned for 2021.[29][16]
• Use the federal International Health Regulations Working Group, chaired by the Assistant Secretary for Preparedness and Response, to develop, update, implement and track the National Action Plan with federal, governmental and non-governmental partners.[39]
• Report progress through a federal monitoring and evaluation process beginning in November 2018, a comprehensive interagency review in January 2019, publication of the 2018 progress report and any revised plan in February 2019, and biannual action-item reviews.[39][6]
• Maintain annual progress reporting for fiscal years 2018 and 2019, update priorities, determine whether the plan should continue beyond 2020, and prepare for the follow-up JEE.[8]

Technical monitoring combines JEE indicators with surveillance, reporting, exercises, validation and after-action learning. The plan uses indicator-based and event-based surveillance, interoperable electronic reporting, syndromic surveillance and analysis of human, animal, laboratory, environmental and bioinformatics data.[15][47]It also seeks to reduce delays in International Health Regulations notifications, improve event risk assessment and harmonise reporting to the World Health Organization, Food and Agriculture Organization and World Organisation for Animal Health.[48][49][16]

• Monitor antimicrobial resistance through laboratory detection, near-real-time resistance data, whole-genome sequencing, susceptibility testing, antibiotic-use reporting and stewardship measures.[30][53][31][54]
• Target a 50% reduction in the time needed to detect and characterise drug-resistant enteric pathogens and a 25% reduction in time from initial notification to reporting susceptibility results for multistate outbreaks.[30]
• Track food-safety laboratory expansion through targets for state sequencing capacity, PulseNet whole-genome sequencing certification and sequencing of specified clinical isolates.[33]
• Measure vaccination progress against Healthy People adult immunisation objectives, annual Immunization Information Systems assessments and National Immunization Surveys.[55][56]
• Test laboratory, emergency operations, specimen-sharing, patient-transport, chemical, biological and radiological capabilities through functional, tabletop, regional and national exercises.[13][45][57][26]

Accountability mechanisms include lead-agency responsibility for action-item status reporting, biosafety inspections and incident reporting, review of dual-use research, and standardised corrective-action plans and after-action reviews following events and exercises.[6][52][58][36]The document does not provide one consolidated indicator dashboard, uniform reporting format or comprehensive set of quantitative targets across all technical areas.[37][59][60][61][62]

Costing & Financing

The National Action Plan is not a budget or funding-commitment document: it does not specify a total budget, activity-level costs, quantified funding allocations, financing gaps, resource-mobilisation targets or economic assumptions.[2][28][29]Implementation is subject to funds authorised or appropriated by the United States Congress, annual federal budget formulation, competing priorities, required approvals and financial limitations faced by state, local, tribal and territorial authorities.[28][29]

• Use existing departmental and agency budgets and programme cycles to deliver approved activities within the mandates and budgets of federal and state, local, tribal and territorial partners.[29]
• Recognise inadequate public health financing in some subnational jurisdictions as a constraint on rapid and effective responses and as a barrier to adequate International Health Regulations implementation.[6]
• Provide federal funds and technical assistance to state and local immunisation programmes, including efforts to reduce vaccination disparities, without specifying monetary amounts.[56]
• Use the Epidemiology and Laboratory Capacity for Infectious Diseases cooperative agreement as an implementation mechanism for workforce, surveillance, laboratory and information-system strengthening, without a stated allocation.[46]
• Assess federal contracting and existing programme or operational funding options for emergency specimen collection, shipment and management.[14]
• Develop a crisis-response funding option for complex incidents without Stafford Act declarations and adjust exercise and organisational budgets to reflect process improvements.[63]

Several actions are expressly conditional on funds or resources, including biosafety and biosecurity measures, research activities, radiation laboratory bioassay expansion, biodosimetry capability and surge-capacity performance testing.[52][60][61][26][27][64]A five-year spend plan is envisaged for bioassay surge capacity, but no monetary value, currency or expenditure profile is provided.[65]The document also identifies a need for resources for workforce development, risk-communication surge capacity, non-designated points of entry and subnational radiation programmes, without quantifying these needs.[66][67][51][23][68]