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2010 Report: Public Health Preparedness

Overview of Preparedness in the U.S. Insular Areas: Territories, Commonwealths, and Freely Associated States

World map highlighting US Insular Areas which include Puerto Rico, US Virgin Islands, Northern Marina Islands, Republic of the Marshall Islands, Guam, Republic of Palau, Federated States of Micronesia and American Samoa

The United States has strategic and economic pacts with two jurisdictions in the Atlantic Ocean and six in the Pacific Basin. Jointly referred to as insular areas, they include territories, commonwealths, and freely associated states. The pacts between the United States and these islands include the provision of federal assistance. CDC’s Public Health Emergency Preparedness (PHEP) cooperative agreement provides funding for preparedness activities to health departments on these islands, many of which face diverse challenges related to their isolated geographical locations and socioeconomic conditions.

Photo: Micronesia residents queue up to receive H1N1 vaccines in fall 2009

Micronesia residents queue up to receive H1N1 vaccines in fall 2009. Public health workers traveled for two weeks by boat to deliver the first vaccine shipments to the dispersed islands.




Photo source: Ministry of Health, Yap, Federated States of Micronesia


The U.S. insular areas receiving PHEP preparedness funding are the territories of American Samoa, Guam, and U.S. Virgin Islands; the commonwealths of the Northern Mariana Islands and Puerto Rico; and the three freely associated states of the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau.47 These areas also received funding specifically for pandemic influenza preparedness through the pandemic influenza supplement in 2006- 2008 and, more recently, through the Public Health Emergency Response grant in response to the 2009 H1N1 influenza pandemic.

Guam Responds to the 2009 H1N1 Influenza Pandemic

Guam Responds to the 2009 H1N1 Influenza Pandemic
The 2009 H1N1 influenza pandemic provided a real world opportunity for Guam to activate its plans to receive medical assets from CDC’s Strategic National Stockpile. Guam has limited laboratory capacity for confirming infectious diseases such as H1N1 pandemic influenza, but plans to increase that capacity. In the future, Guam may be able to serve as a reference laboratory for the broader Pacific region as well as its own growing population. Guam’s population is expected to increase exponentially with the planned relocation of 40,000 U.S. Marines and their dependents from Okinawa to Guam, where the central U.S. military base in the Pacific is located.

Source: CDC, Office of Public Health Preparedness and Response, Division of State and Local Readiness (2009)


Preparedness Challenges and Focus

Public health preparedness efforts in the insular areas differ from the U.S. mainland due to their isolation. Methods for communicating about preparedness range from word of mouth and distributing flyers door-to-door to the use of telephones, cell phones with solar chargers, and HAM radios. Internet connectivity is limited and costly. PHEP funds are used primarily for building and maintaining basic capabilities. The current focus is on obtaining equipment, planning, and exercising emergency response plans, with some emphasis on training.

A Range of Surveillance Systems

Disease surveillance and reporting methods in the islands range from well developed, electronic systems connected to CDC’s secure Epidemic Information Exchange (Epi-X) system and the Health Alert Network (HAN) to more basic, paper-based systems that can be effective in smaller, more remote island communities where electricity may not be available. As of July 2009, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands all responded to HAN test messages within the target time of 30 minutes. The ability of public health staff to receive urgent emerging health information helps ensure that local problems are contained and national events are detected sooner.

Limited Laboratory Capability

Laboratory capability – the ability to analyze biological and chemical specimens – is very limited in the islands. Challenges include large travel distances, slow or little communication between the islands, difficulties in transporting specimens, and lack of training and resources. Another important challenge is the lack of physical infrastructure to support laboratory requirements such as controlled environments and stable power sources. Most of the islands send specimens for confirmatory testing to reference laboratories in the United States and Australia, a practice that is time-consuming; receiving results can take from a week to more than a month.

Improved Planning for Emergencies

PHEP cooperative agreement funding has been instrumental in supporting the development and exercising of emergency response plans for all insular areas. This has resulted in greater preparedness of the public health workforce as well as the communities they serve.

As with states and localities, insular areas receiving PHEP funding are required to report on exercising and improving their response plans. Table 10 presents FY 2008 data submitted by the eight U.S. insular areas. (For a fuller explanation of these data points, see appendix 1.)

Table. Public Health Preparedness Activities in U.S. Insular Areas; 2007-2008
Select to view full-sized version of Table. Public Health Preparedness Activities in U.S. Insular Areas; 2007-2008
View full-sized version of table.

Photo: Preparing Children for Emergencies in Palau

Preparing Children for
Emergencies in Palau

In the Republic of Palau, residents feel strongly that they must pass the skills and culture of their traditional heritage to future generations, and preparing for emergencies is no exception. One of the activities funded by the PHEP cooperative agreement is an annual summer camp conducted by the Ministry of Health called Ak Ready (“Are You Ready”). In this camp, children aged 8-12 are taught how to prepare for public health emergencies that threaten their health and their island. Children learn from elders traditional Palauan resiliency strategies, such as how to make baskets from leaves, how to make spears for fishing, how to build a canoe, and how to catch rainwater for drinking. Learning these skills enhances the children’s confidence in being able to survive during and after a disaster while learning cultural skills that can be handed down to future generations.


Photo source: Ministry of Health, PW (Palau)


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