On October 4, 2001, we confirmed the first bioterrorism-related anthrax case identified in the United States in a resident of Palm Beach County, Florida. Epidemiologic investigation indicated that exposure occurred at the workplace through intentionally contaminated mail. One additional case of inhalational anthrax was identified from the index patient’s workplace. Among 1,076 nasal cultures performed to assess exposure, Bacillus anthracis was isolated from a co-worker later confirmed as being infected, as well as from an asymptomatic mail-handler in the same workplace. Environmental cultures for B. anthracis showed contamination at the workplace and six county postal facilities. Environmental and nasal swab cultures were useful epidemiologic tools that helped direct the investigation towards the infection source and transmission vehicle. We identified 1,114 persons at risk and offered antimicrobial prophylaxis.

The organization of the response to infectious disease outbreaks by public health agencies at the federal, state, and local levels has historically been based on traditional public health functions (e.g., epidemiology, surveillance, laboratory, infection control, and health communications). Federal guidance has established a framework for the management of domestic incidents, including public health emergencies. Therefore, public health agencies have had to find a way to incorporate traditional public health functions into the common response framework of the National Incident Management System. One solution is the development of a Science Section, containing public health functions, that is equivalent to the traditional incident command system sections. Public health agencies experiencing difficulties in developing incident management systems should consider the feasibility and suitability of creating a Science Section to allow a more seamless and effective coordination of a public health response, while remaining consistent with current federal guidance.

Responding to outbreaks is one of the most routine yet most important functions of a public health agency. However, some outbreaks are bigger, more visible, or more complex than others, prompting discussion about when an "outbreak" becomes a "public health emergency." When a public health emergency is identified, resources (eg, funding, staff, space) may need to be redirected from core public health programs to contribute to the public health emergency response. The need to sustain critical public health functions while preparing for public health emergency responses raises a series of operational and resource management questions, including when a public health emergency begins and ends, why additional resources are needed, how long an organization should expect staff to be redirected, and how many staff (or what proportion of the agency's staff ) an organization should anticipate will be needed to conduct a public health emergency response. This article addresses these questions from a national perspective by reviewing events for which the Centers for Disease Control and Prevention redirected staff from core public health functions to respond to a series of public health emergencies. We defined "public health emergency" in both operational and public health terms and found that on average each emergency response lasted approximately 4 months and used approximately 9.5% of our workforce. We also provide reasons why public health agencies should consider the impact of redirecting resources when preparing for public health emergencies.