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If a bioterrorist flew over New York City releasing smallpox from an airplane, the city's Department of Health and Mental Hygiene would alert the public through the media and set up vaccination centers to immunize people against the disease. Running such an operation smoothly, however, requires that the staff of the public health agency has been adequately trained to respond to the emergency and enact the city's plan. Two years ago, the Centers for Disease Control and Prevention asked Dr. Kristine Gebbie, the Elizabeth Standish Gill Associate Professor of Nursing and director of the School of Nursing's Center for Health Policy, to outline the knowledge, or competencies, all public health workers, from doctors to administrative assistants, must have to respond well to a bioterrorism emergency. Containing the ideas of 60 emergency response experts and 125 public health workers, a report (available at was released by Dr. Gebbie and Jacqueline Merrill, the project's director, on Oct. 16. Public health agencies nationwide will now use the findings to help train staff members about bioterrorism response. Dr. Gebbie spoke to Susan Conova from In Vivo about the report.

What's the most important thing workers need to know?

The highlight from what we learned is that you need to know your role in your agency and where your agency fits in with others.

If your role is going into the field where dangerous chemicals or agents may be, you need to know how to use protective gear. If your job is to communicate information to the public, you need to know how to use every piece of communication equipment in the office.

It seems like common sense, and when we say a public information officer needs to know how to use the communication equipment, everyone says: "Well, duh." But do you know how to transfer a phone call without asking support staff? I would have never guessed this would have come up when we started. Writing down all the general things people need to know actually takes a bit of work.

It's also important to know your own limits and where to go for help. There's a tendency for people in emergencies to put on a Superman shirt. Even though we want people to be creative, we want them to control themselves and not take on responsibilities they can't handle.

As one of our experts said, "Know what you know, know what you don't know, and know who to call."

Beyond knowing the chain of command, it's critical that a clear and consistent message is given to the public. You have to know where to send people for the right resources. In the anthrax cases last year, a lack of coordination among different health agencies in getting information out was part of the problem.

Also, every staff member at an agency remains a public health expert when they go home after a shift. Everyone needs to be kept up to date. No one should leave work from a public health agency in an emergency without the latest fact sheet to take home.

How will the competencies be used?

Jurisdictions are now scrambling to make plans for bioterrorism events. The competencies complement these plans and with both, the agencies will be able to assure their communities that they're ready to go.

The Public Health Ready project—a collaboration of our center, the CDC, and the National Association of County and City Health Officials—will undertake the next stage and get the entire local public health agency staff trained in these competencies. The project's advisory board is currently developing criteria for certifying each state and local public health agency and we're hoping to test a few agencies this winter and make it available to everyone by next fall.

Lately, news has focused on smallpox and when and whom to vaccinate. What are your thoughts on the subject?

I may be living in a dream world, but I think we may be worrying about bioterrorism so much the rest of public health will deteriorate and kids won't be immunized with routine vaccines. I don't want us to be distracted from the basics.

Thanks to the television show "ER," I think people have an exaggerated sense of smallpox transmissibility. Not everyone who walks by an infected person will come down with a case. Even if an outbreak began when we had not immunized every single person, post-exposure vaccination is a realistic mechanism of controlling an outbreak of smallpox. It is less than perfect, especially in a densely populated city, but it would minimize the size of the outbreak. We have immunized large numbers of people in New York City in a very short time before. It worked well and we can do that again. The city is hard at work setting up a plan for vaccination centers.

How would a public health agency respond to an attack today?

If a bioterrorist launched an attack today before all the competency training were put in place, public health agencies would figure out what to do. There may be a lot of confusion on the first day. I think the New York City department responded well last year, but some people lacked confidence about what they were doing. Competency training should get rid of the first-day confusion.