National Health Security Environment and Threat Landscape

HPH systems play a vital role in maintaining national health security. However, shortages of HPH workers, insufficient surge capacity, and availability of training, especially in the nursing field, remain challenges.^[1] Public health emergencies and disasters exacerbate these challenges, which affects overall resiliency of HPH systems. The HPH workforce is susceptible to staffing shortages due to high turnover and burnout.^[2] During COVID-19, the public health and medical workforce also faced heightened personal security concerns, which worsened burnout. Insufficient supply of personal protective equipment (PPE) for essential workers can impede response operations and pose a health risk for emergency, health care, and public health personnel. Workforce shortages, coupled with inequitable patient access to telehealth technologies and limited provider services offered through telehealth, result in deficiencies in critical expertise and disruptions in continuity of care for chronic disease patients, people with disabilities, and underserved communities.

Containment and/or mitigation of a novel disease requires rapid pathogen testing combined with immediate availability of PPE and laboratory supplies. High testing demand, coupled with staffing shortages, challenges with data availability, and regulatory requirements strains public health laboratories and can lead to delays in response.^[3]

Additionally, aging data infrastructure and inconsistent capacity to manage data limits information sharing between the federal government and SLTT authorities.^[4] The lack of interoperable datasets and surveillance systems and technology bottlenecks, including the inadequate linking of electronic health record data and other significant data sources with national syndromic surveillance systems, is a significant challenge that limits situational awareness, delays detection times, and negatively impacts patient care. This challenge leads to an incomplete national picture and slows response activities during public health emergencies and disasters that impact multiple geographic areas.

The public health supply chain^[c] is vulnerable to disruptions during public health emergencies and disasters, leading to shortages in critical supplies and limiting the U.S. health care system's capacity to provide patient care. The United States has inadequate domestic manufacturing capacity and is dependent on foreign sourcing and manufacturing for critical materials and supplies.^[5] Some critical materials are sourced from one geographic location or supplier. Pandemics and increasingly frequent extreme weather events can disrupt production in these areas, resulting in significant supply chain shortages during times of increasing demand. These challenges along with the potential for cyberattacks on the supply chain demonstrate the need for increased domestic production capacity and storage. The public health supply chain is also subject to exploitation by malicious actors who could intentionally surveil and deliberately attack U.S. supply chains, and by counterfeiters who could take advantage of increased consumer demand by selling substandard or non-approved products, putting the nation's health at risk.^[5]

U.S. health security depends on the nation's ability to stop emerging and infectious disease outbreaks at their source, which along with other health threats are exacerbated by climate change. Inadequate global disease monitoring, scarce analytical and diagnostic capabilities to detect and characterize novel infectious disease threats where they occur, and barriers to international sharing data leaves the U.S. at an increased risk from emerging infectious diseases (EIDs). Limited global response governance, lack of clinical research capacity, and fractured resource allocation persist, hindering effective response to global health threats. Crop failures, conflicts over water, and population displacement caused by climate change can increase global migration and accelerate the pace of EIDs, introducing new health security risks to the nation. 

Clear, consistent, timely, and accessible public health information is vital to achieving situational awareness, increasing adoption of public health guidance, and reducing public panic during public health emergencies and disasters. Ineffective, one directional communication strategies can result in misunderstanding and mistrust of public health officials and data and non-compliance with mitigation measures.

Misinformation, disinformation, and malinformation (Mis-Dis-Mal information) disrupts effective risk communication and can be detrimental to health. Mis-Dis-Mal information can rapidly spread, intentionally and unintentionally, to broad audiences through traditional and social media and other online platforms.^[6] During the COVID-19 pandemic, misinformation caused public confusion and led people to reject COVID-19 vaccines, overlook public health measures like masking and social distancing, and use unproven alternative treatments.^[7],[8] Altogether, the proliferation of Mis-Dis-Mal information can prolong response time and diminish the efficacy of recovery operations.^[9]

Community resilience plays a significant role in national health security.^[10] Catastrophic events like pandemics, extreme weather, and mass casualty incidents can test the physical and mental wellbeing of a community. However, communities often face challenges that diminish resilience. Many communities have experienced an increase in substance use disorder in recent years. Public health emergencies and disasters often worsen a community's mental health, giving rise to other disaster-related mental health challenges that require culturally competent^[d] mitigation strategies. In addition, the social determinants of health^[e] affect the health of all communities and contribute to health disparities.

Many underserved communities face barriers to health care access and other resources needed to build and sustain resiliency before, during, and after a disaster. Structural racism, poverty, and other systemic inequities have led to health disparities, which marginalize individuals and increase the risk of morbidity and mortality from disasters, infectious diseases, non-communicable diseases, and the adverse health effects of climate change. Health disparities worsen overall health outcomes and diminish the resiliency of the nation.

The emergence of COVID-19 and other significant health threats showed the need for sufficient and sustained funding of health care, medical research, and public health systems and personnel. Prior to COVID-19, funding for vital programs such as the Public Health Emergency Preparedness program and the Hospital Preparedness Program decreased from 2003 through 2019 (36% and 54% respectively).^[11] State and local health departments continue to struggle with understaffing, antiquated data systems, and inadequate supplies of MCMs.^[12] Since 2020, funding has increased through short-term supplemental appropriations. Increased and sustained investments in HPH infrastructure, staff, and supplies will be critical to further strengthen the nation’s preparedness.

EIDs, especially those with pandemic potential, are a significant threat to the United States, and outbreaks anywhere in the world may have the potential to become global pandemics. As demonstrated by SARS-CoV-2, pandemic pathogens can spread quickly, upend daily life, and have cascading health, social, economic, and political consequences. Zoonoses, diseases spreading from animals to people, are the origin of 3 out of every 4 infectious diseases in humans.^[14]  Zoonotic coronavirus outbreaks like Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and SARS-CoV-2, demonstrate the ever-present risk of zoonotic pathogens to human health and underscores the need for integrated surveillance, global and domestic clinical research networks, and international coordination. Vector-borne diseases like malaria and Zika virus are also an increasing global concern as vector territory changes due to climate change and urbanization.^[15]  In addition, climate change can increase the prevalence and geographic range of waterborne, airborne, and food-borne disease outbreaks, further threatening national health security.^[16]  Globalization and misuse of antibiotics in livestock further increase the risk of infectious disease spreading from animal and food sources to humans and becoming epidemics or pandemics.^[17]  

Antimicrobial resistance (AMR) continues to threaten human, animal, and environmental health as pathogens adapt to evade the current repertoire of drugs used to combat them. More than 2.8 million antibiotic-resistant infections occur in Americans each year which result in over 35,000 deaths.^[18]  While deaths due to antibiotic resistant infections have decreased by 18% since 2013, AMR is a sustained and growing threat. The Centers for Disease Control and Prevention (CDC) lists 18 urgent, serious, or concerning pathogens that pose significant risks to U.S. health security.^[16] A 2022 CDC report shows antimicrobial-resistant infections and antibiotic use increased in hospitals during the first year of the COVID-19 pandemic. Data show significant surges in human antibiotic use, difficulty in following infection prevention and control guidance (like limited personal protective equipment, or PPE), and a resulting increase in health care-associated, antimicrobial-resistant infections in U.S. hospitals.^[19]  Treating AMR infections also carries a significant economic burden. In 2021, CDC estimated that treating six antibiotic resistance threats contributes to more than $4.6 billion in health care costs annually in the U.S.^[20]  At any given time in the country, 1 in 31 hospitalized patients has a health care-associated infection (HAI), including AMR infections.^[21]  HAIs significantly impact hospitalized patients, therefore an incident that increases the rate of hospitalization will also increase the risk of HAIs and associated AMR infections.^[22]  For example, the incidence of ventilator-associated HAIs increased in 2020, coinciding with increased ventilator use as part of the COVID-19 response.^[23] 

Extreme weather events driven by climate change such as hurricanes, wildfires, droughts, winter storms, floods, and thunderstorms have increased in frequency and intensity in recent years. In 2020, multiple heat waves resulted in hundreds of recurrent wildfires on the U.S. west coast, burning twice as many acres as compared to 2019.^[24] Moreover, the 2020 Atlantic hurricane season included a historic 30 named storms and seven major hurricanes.^[25] In 2021, the United States saw unprecedented winter storms hit South-Central Texas and dangerous heat waves across the Pacific Northwest.^[26],[27]

Extreme weather events directly affect HPH and other critical infrastructure and disrupt public health supply chains.^[28] They also exacerbate chronic health conditions, mental health conditions, and health disparities, reducing community resilience and worsening health outcomes.^[29] In addition, concurrent extreme weather events challenge response and recovery operations, strain surge capacity, and lead to competition for resources. The intersection of the physical impacts of climate change like rising temperatures and changing precipitation patterns with environmental degradation and pollution will create future challenges with food and water security and threaten health.

Figure 1: Impact of Climate Change on Human Health^[30]

The risk from intentional CBRN incidents has increased due to continued capability expansion, modernization, low yield weapons development, eroding international norms, information proliferation, emerging drone concerns, and increasing threat actor awareness. An uptick in the available information on and use of chemical weapons globally could pose greater risk to U.S. health security.^[31] Additionally, non-state actors acquiring radiological and nuclear materials remains a risk.

Advancements in biotechnology, genomics and gene-editing platforms, and other legitimate-use technologies could be used deliberately to create biological weapons. The United States must also be prepared against malicious use novel technologies like artificial intelligence and machine learning that could enable the development of new bioweapons that complicate detection. Malicious actors have already shown interest in and some capacity to develop biological weapons.^[32] Additionally, as use of biotechnologies to study high consequence pathogens increases, so too does the risk of accidental biological incidents and the risk of laboratory-acquired infections.^[33]

Cyberattacks from threat actors at home and abroad continue to threaten national health security and disrupt patient care. Cyber threats can disrupt federal and SLTT emergency response activities and exploit vulnerabilities in critical infrastructure systems.^[34] Threat actors can target pharmaceutical, biologic, and medical device manufacturing and supply chains. Additionally, health care data breaches are increasing, putting electronic patient data at risk. In 2020, the health care sector experienced a 51% increase in the total volume of records exposed when compared with 2019.^[35] Cyberattacks have resulted in cancelled or delayed surgeries and cancer treatments, closure of COVID-19 test collection sites, and disruption of electronic communications between hospitals.^[36]

The United States needs to prepare for and respond to simultaneous health security threats. For example, an extreme weather event causing mass population displacement is further complicated during a pandemic. Response to an extreme weather event is significantly complicated by physical infrastructure damage, migration, and mitigation efforts aimed at limiting the spread of infectious diseases. Concurrent incidents with negative health consequences strain the public health supply chain and response personnel, leading to economic instability and adverse impacts on patient care. Communities with chronic health disparities are especially vulnerable to compounding climate risks, such as a hurricane during an extreme heat wave.

Health care and public health emergency response operations can be further complicated by a concurrent threat such as a cyberattack or geopolitical conflict that disrupts critical infrastructure supply chains, and health care facilities.^[37] 

The nation must also be prepared to respond to unknown threats to national health security. The need for threat-agnostic, rapidly deployable MCMs is clear. In addition to MCM development, unknown threats require a well-equipped and well-trained HPH workforce that can readily respond to new threats. Applying evidence-based practices from previous health security events will allow for a more adaptable and flexible response.