Since September 2001 Congress has allocated approximately $3 billion to strengthen the public health infrastructure. To achieve this goal, the U.S. Centers for Disease Control and Prevention (CDC)allocates funding to states, which distribute funds to local jurisdictions. Evidence-based measures to assess public health preparedness are lacking. The authors used an expert-panel process to develop performance measures, based on the ten essential public health services. They developed and conducted tabletop exercises in California to evaluate preparedness to detect and respond to a hypothetical smallpox outbreak based on those measures. There was wide variation of readiness in California. While the sources of variation are often different, common infrastructure gaps need to be addressed.
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