and Human Services (HHS)
EXPIRED
BUILDING THE EVIDENCE TO PROMOTE BIOTERRORISM AND OTHER PUBLIC HEALTH
EMERGENCY PREPAREDNESS IN HEALTH CARE SYSTEMS
RELEASE DATE: May 30, 2003
PA NUMBER: PAR-03-130 (see Notice of Deactivation NOT-HS-04-008)
CFDA NUMBER: 93.226
Agency for Healthcare Research and Quality, AHRQ
(http://www.ahrq.gov)
APPLICATION RECEIPT DATES: July 17, 2003, January 14, 2004, January 14, 2005,
and January 17, 2006
This Program Announcement expires on August 27, 2004 per Notice of
Deactivation NOT-HS-04-008.
THIS PA CONTAINS THE FOLLOWING INFORMATION:
o Purpose of the PA
o Research Objectives
o Mechanism(s) of Support
o Eligible Institutions
o Individuals Eligible to Become Principal Investigators
o Special Requirements
o Where to Send Inquiries
o Submitting an Application
o Peer Review Process
o Review Criteria
o Receipt and Review Schedule
o Award Criteria
o Required Federal Citations
o References
PURPOSE OF THE PA
The Agency for Healthcare Research and Quality (AHRQ) announces the
availability of 1-2 year (maximum 2 years) research grants that will
examine and promote the health care system's readiness for a
bioterrorist event and other public health emergencies through the
development of new evidence, tools and models. In light of recent
events in the U.S., there is considerable urgency to develop a public
health infrastructure that is prepared to respond to acts of
bioterrorism and other public health emergencies. AHRQ recognizes that
community clinicians, hospitals, and health care systems have essential
roles to play in this infrastructure. To inform and assist these groups
in meeting the health care needs of the U.S. population in the face of
bioterrorist threats and other public health emergencies, AHRQ intends
to support research that emphasizes the following research objectives:
(1) Emergency preparedness of hospitals and health care systems for
bioterrorism and other public health emergencies; (2) Enhanced capacity
needs of ambulatory care, home and long term care, care of psycho-
social consequences, and other related services during and after a
bioterrorist event and other public health emergencies; (3) Information
technology linkages and emerging communication networks to improve the
linkages between the personal health care system, emergency response
networks and public health agencies; (4) Novel uses of health care
system training strategies that can prepare community clinicians to
recognize and manage a bioterrorist event and other public health
emergencies.
RESEARCH OBJECTIVES
The mission of the Agency for Healthcare Research and Quality (AHRQ) is
to support and conduct research that improves the outcomes, quality,
access to, and cost and utilization of health care services. AHRQ
achieves this mission through health services research designed to: (1)
improve clinical practice, (2) improve the health care system's ability
to provide access to and deliver high quality, high-value health care,
(3) provide policymakers with the ability to assess the impact of
payment and organizational changes on outcomes, quality, access, cost
and use of health care services. In doing so, AHRQ seeks to identify
and respond to the information needs of consumers, patients,
clinicians, and other providers, institutions, plans, purchasers, and
Federal and State policy-makers, and to provide them the information
they need to make evidence-based decisions.
AHRQ's investment in bioterrorism and other public health emergencies
preparedness research recognizes that community clinicians, hospitals,
and health care systems have essential roles in the public health
infrastructure. These research investments are intended to complement
the department's investments through the CDC and HRSA programs. The
application of health services research and health system research to
the area of bioterrorism and other public health emergency preparedness
is a relatively new area of inquiry. AHRQ's particular interest in
bioterrorism and other public health emergency preparedness research
focuses on the role of the health care system in preparing for and
responding to bioterrorism other public health emergencies.
Specifically, these projects will highlight issues of health care
system preparedness and coordination between public health and health
care systems. This is an emerging field in need of researchers with
health services research skills that can be applied to bioterrorism
other public health emergency preparedness research. For example, while
health services research has examined hospital capacity and throughput,
there has been limited application of these techniques to surge
capacity as it relates to bioterrorism and other public health
emergency preparedness.
Although the grants will focus broadly upon the emergency preparedness
of health care systems, AHRQ encourages particular attention to the
preparedness of these systems with regard to specific priority
populations. These populations include children, residents of inner-
city areas and rural areas (including frontier areas); low income
groups; minority groups; women; the elderly; and individuals with
special health care needs, including individuals with disabilities and
individuals who need chronic care or end-of-life health care. For many
of these groups, there is limited information about potential
differences in the detection and treatment of bioterrorism-related
illnesses.
AHRQ also recognizes the difficulty in conducting research on actual
bioterrorist events. As a result, many of the proposed projects will
involve theoretical and systemic modeling. However, special emphasis
should also be placed upon the real-world application of these models
through exercises and demonstrations. These research grants will
address pressing national concerns about the health care system's
preparedness for bioterrorism and other public health emergencies. For
that reason, 1-2 year grants will be supported with the expectation of
rapid turnaround and the timely dissemination of results. Insert
language from partnerships grants re: coop agreements and
dissemination? Therefore, the total project period for an application
submitted in response to this PA may not exceed two years. Grants
funded in response to this program announcement will be funded in one
year budget periods.
Background
The anthrax incidents of October 2001 and SARS 2003 quickly illuminated
the challenges that faced our public health and hospital systems and
highlighted the need for a rapid response in building up the public
health infrastructure. Additionally, the need for comprehensive plans
for hospital preparedness, better coordination of communication
systems, and real time information networks between front line
providers and local health departments were apparent and urgent.
Recent studies have demonstrated that the preparedness and
infrastructure of hospitals and the public health system are inadequate
to deal with a bioterrorist attack (Inglesby, Khan, Garrett, Wetter).
One study found that the majority of primary care providers do not feel
prepared to diagnose and manage a bioterrorist event (Chen).
As a result, there has been heightened awareness and responsiveness of
many groups over the recent months. AHRQ has been working with the
Department of Health and Human Services' Office of Public Health and
Emergency Preparedness on activities that capitalize on the unique
expertise and abilities of health services researchers to identify and
evaluate strategies for enhancing the intersection of health care
system needs and resources with public health infrastructure.
AHRQ Evidence-Based Practice Center (EPC) researchers at Johns Hopkins
University have reviewed and reported on the most effective means for
training physicians for bioterrorism and other public health emergency
preparedness. An Integrated Delivery System Research Network partner
at Weill Medical Center designed a model for distributing medications
in response to bioterrorist events that was put into place in New York
City shortly after the anthrax incidents. AHRQ hopes to build upon the
success of these projects by bringing health services research
expertise to the problems of bioterrorism other public health emergency
preparedness, and public health infrastructure.
At the same time, emphasis is being placed upon 'dual use'
technologies. 'Dual use' refers to systems of care, tools, or
technologies that, while offering proven benefit in bioterrorism and
other public health emergency preparedness, are also utilized in the
everyday delivery of health care. Examples include the use of a pre-
existing asthma surveillance system to help detect bioterrorist events,
or the enhancement of current natural disaster warning systems to
improve communication between clinicians and the public health system.
Objectives and Scope of Activity:
AHRQ seeks bioterrorism and other public health emergency preparedness
projects that address these specific priority research areas: (1)
Emergency preparedness of hospitals and health care systems for
bioterrorism and other public health emergencies; (2) Enhanced capacity
needs of ambulatory care, home and long term care, care of psycho-
social consequences, and other related services during and after a
bioterrorist event and other public health emergencies; (3) Information
technology linkages and emerging communication networks to improve the
linkages between the personal health care system, emergency response
networks and public health agencies; (4) Novel uses of health care
system training strategies that can prepare community clinicians to
recognize and manage a bioterrorist event and other public health
emergencies.
(1) Emergency preparedness of hospitals and health care systems for
bioterrorist events and other public health emergencies.
The national health care system's ability to mobilize resources for
surge capacity has become increasingly important since the anthrax
cases in fall of 2001 and the recent advent of SARS. Readiness to
respond to mass casualties expected from a large-scale bioterrorist
attack and other public health emergencies is unique in its
intersection of public health, clinical medicine and emergency
management planning. It is critical that we examine the outcomes and
cost of models of hospitals, hospital emergency departments, and health
system readiness, including any proposed models of regional care. The
lack of surge capacity in our current health care system is the primary
issue for any locale dealing with casualties from a bioterrorist attack
and other public health emergencies. In selected areas, the
availability of nurses, pharmacists and other members of the health
care team have been described in crisis, leaving some systems of care
with little to no capacity to respond to bioterrorist events and other
public health emergencies. Currently, little evidenced-based guidance
has been available to assist metropolitan and non-metropolitan areas in
planning for the provision of such expanded capacity. Given the
current financial constraints confronting health care institutions and
the current shortage of health care personnel, there is an enormous
need for creative model development to address these looming problems.
Surge capacity has three major aspects: facilities, equipment, and most
importantly personnel. As issues of capacity are examined, there is a
need to study the collaborative role of current systems not typically
connected to networks of care such as the DoD and VA facilities and in
some regions for-profit and not-for-profit institutions. Studies are
needed to examine the impact of market forces on capacity and its
effects on regional models of health care system preparedness. Staffing
issues of surge capacity also need to be examined for various health
care settings including hospital inpatient systems, emergency
departments, primary care practices, alternative care sites, home care
and long term care.
In addition to the issues around surge capacity, adequate risk
communication is vital for an effective response to bioterrorism and
other public health emergencies. Risk communication is a science-based
approach for communicating effectively in high-concern situations.
There is a need for studies and models of good risk communication that
are designed to meet the needs of diverse audiences in the event of a
bioterrorist attack and other public health emergencies. For example,
the health care workforce and first responders involved in a
bioterrorist event and other public health emergencies need customized,
well-organized information. Similarly, effective communication between
designated spokespersons and the general public must be studied and
implemented.
Illustrative questions of interest under this priority area include:
o What are the effects and costs of system readiness efforts on
hospitals, hospital emergency departments and health systems?
o Which indicators in regional care models are suggestive of
preparedness?
o How have regional care models improved public health preparedness
and at what cost?
o What staffing and personnel models can be employed to meet the
requirements of surge capacity in the event of a bioterrorist event and
other public health emergencies?
o How can models of mass prophylaxis and vaccination be adapted for
special populations such as children, elderly, and the homebound,
homeless, disabled?
o How does the health care system communicate risk to providers and
the public? How can the effectiveness of that communication be
measured?
o What are the best means for risk communication? How will these
models differ for the general public and health care provider
communities?
o How can current public health emergency communication systems be
utilized for bioterrorism response?
o What kind of intelligence would be most helpful pre , during and
post event? and for what audience?
o How would providers use that information?o What is the best vehicle
for communication and with what groups are the various models most
effective?
(2) Enhanced capacity needs of a broad range of health care settings,
including hospitals, emergency departments, ambulatory care, home and
long term care, care of psycho-social consequences, and other related
services during and after a bioterrorist event and other public health
emergencies.
Most preparedness activities to date have focused on the immediate
needs for mass casualty events within emergency departments and
hospitals. However, surge capacity issues impact all health care
settings, including ambulatory care, home and long term care. In
addition, many of the settings most in need of study are already
affected by shortages and financial constraints. For example,
ambulatory care settings may experience increased volume during the be
involved initially in the mass casualty event, as well as a significant
n increases in post event visits for both medical and psycho social
evaluationssurge capacity. The problem of increased volume of
individuals that must be accommodated when current capacity is exceeded
at the emergent level is compounded by the post event care needs of
those victims that will stress an overburdened segments of the system.
Similarly, home care and long term care settings, which are already
under strain, may be called upon to provide extended medical and psycho
social care to persons affected by bioterrorism and other public health
emergencies. Staffing issues and personnel demands, as well as cost
implications, including reimbursement, need to be critically examined
in variouswill be vital to these settings as enhanced capacity is
requiredneeded.
In the event of a bioterrorist attack and other public health
emergencies, health care workers will be taxed to stretch their time
and expertise and will most likely assume a heightened level of risk
for themselves and their families. The psycho-social consequences of a
bioterrorist event and other public health emergencies upon mental
health care resources, health care utilization, and cost modeling, have
not been studied. The redeployment of adequately trained mental health
personnel in the case of a bioterrorist event or other public health
emergencies will be vital, in addition to the role of cross trained
personnel who are prepared to substitute and augment services for
limited qualified mental health personnel. Examination and development
of models for training, mobilization and management of individuals
experiencing bioterrorism-related, or other public health emergencies
will be critical.
Illustrative questions of interest under this priority area include:
o What is the role of various elements of the health care system in
meeting the surge capacity demands in a regional model of care?
o What are the barriers and demands for surge capacity on home care
and long term care in a post event scenario of mass casualties?
o What are the economic implications to rural health care systems in
finances, personnel, and equipment in a bioterrorist event with mass
casualties and other public health emergencies?
o What models for cooperation are effective in regional models that
may include school, hotels, and community health centers as alternate
sites to care for victims of a bioterrorist event?
o What is the capacity of existing special care systems to be enhanced
and redesigned for use in the case of a bioterrorist event and other
public health emergencies, such as poison control and, burn teams?,
neonatal networks etc.
o What models can be developed to deploy adequately trained mental
health professionals to areas of need in the event of a bioterrorist or
mass casualty event?
o What are the financial and regulatory incentives for efficient
models of regionalized health care services for care following a
bioterrorist event and other public health emergencies?
(3) Information technology linkages and emerging communication
networks to improve the linkages between the personal health care
system, emergency response networks and public health agencies.
A key issue in the Nation's capacity to respond to the threat of
bioterrorism and other public health emergencies will depend on the
ability of clinicians, health care facilities, and public health
officials to collect, analyze, manage, and communicate information
rapidly, accurately, and effectively. Information and communication
technologies (IT) can play a vital role in assisting clinicians and
public health officials to detect and respond effectively to
bioterrorism threats and other public health emergencies. These
investments in IT are ultimately intended to assure a vital public
health information network or to assure that such a network includes
effective linkages with clinicians and health care settings.
Unfortunately, the lack of a national interconnected health information
infrastructure presents a significant barrier to realizing many of the
potential benefits offered by IT.
There are a number of IT systems currently in use in the clinical and
public health sector in the United States. However, the majority of
them were not designed for detecting or managing bioterrorism events or
other emerging public health emergencies. In the recent study by the
University of California San Francisco-Stanford Evidence-Based Practice
Center (EPC), the investigators identified 217 IT systems of potential
use by clinicians and public health officials in the event of a
bioterrorist attack. They included 90 surveillance systems, 55
detection systems, 26 communication systems, 23 diagnostic systems, 18
management systems, and 7 systems that integrate surveillance,
communication, and command and control functions. The investigators
found that most of these systems were not designed specifically for
bioterrorism, but instead were created for detecting and managing
naturally occurring illnesses such as influenza. In addition, many of
the systems had not been evaluated rigorously for their effectiveness
in dealing with bioterrorism. In fact, many had not even been evaluated
for their originally intended purpose. Most of the evaluations that
did exist were limited in scope - they looked at the usefulness of the
systems for their intended purpose, but they did not provide
information about their effects on important outcomes. Despite these
limitations, many of the systems were thought to be potentially useful
for responding to bioterrorism threats, especially if they provided
"dual use" functionality - i.e. they were designed to serve clinical or
public health purposes, but they could also be adapted to respond to
bioterrorism threats.
IT can play a central role in the development of communication systems
for providing bidirectional information flow in real-time between
front-line clinicians and local, state, regional and national public
health departments. The ability to collect, analyze and communicate
this information is crucial for early detection of possible
bioterrorist threats and other public health emergencies and can help
facilitate the rapid mobilization of appropriate personnel and
resources in response to such a bioterrorist event and other public
health emergencies. The use of clinical decision support systems can
also help clinicians, public health officials, and the public respond
to perceived or actual threats by improving their knowledge, decision-
making, and management abilities.
Although IT offers immense potential as a key component of the Nation's
armamentarium for dealing with the threat of bioterrorism and other
public health emergencies, large gaps exist in current technologies and
the application of these technologies to maximize the benefits of IT to
improve public health preparedness. As demonstrated by the EPC report,
further research is needed to learn the most effective and efficient
ways to use IT to improve our Nation's capacity to respond to the
threat of bioterrorism. IT applications that are designed to assist in
the detection, diagnosis, reporting, treatment, communication, and
overall management of potential and real bioterrorism events and other
public health emergencies must be developed and evaluated with respect
to their impact on important outcomes.
Areas for further research include: evaluation of current systems to
determine the best ways to leverage existing technology for
bioterrorism and other public health emergency preparedness;
development and evaluation of systems to improve surveillance and
detection of possible threats; development and evaluation of diagnostic
and treatment decision support systems to assist front-line clinicians,
health care facilities, and public health officials, including
innovative ways to provide fast and dependable communication links
between local, state, regional, and national entities; use of automated
systems that can gather important information from existing information
sources; use of handheld devices to assist clinicians and public health
officials respond to bioterrorism and other public health emergences;
and the use of smart IT systems with analytical capabilities that are
integrated into the clinical workflow and do not require redundant data
input.
Illustrative questions of interest under this priority area include:
o How can existing IT systems such as hospital bed and emergency
department monitoring systems be enhanced to and identify surge
capacity and regional assets in the event of a bioterrorist attack and
other public health emergencies?
o What are the most effective models of communication networks that
enhance the health care teams ability to be involved in early
recognition, diagnosis and treatment of victims of a bioterrorist event
and other public health emergencies.
o What models can be designed that are effective at linking providers
across the healthcare system with public health and the private health
care system?
4) Novel uses of health care system training strategies that can
prepare community clinicians to recognize and manage a bioterrorist
event and other public health emergencies.
Healthcare providers primary care clinicians in the community are a
vital part of the health care system's response to bioterrorism and
other public health emergencies. In particular, primary care and other
community clinicians are important elements in the front-line response
to those types of events. While there are data that suggest that
primary care providers do not feel adequately prepared to deal with
bioterrorist events, there is little information about effective
training strategies that can prepare clinicians for such events. There
is also limited information about other training issues relate to
effective models of cross training of specialty physicians and
specialty trained nurses for care of mass casualties in a bioterrorist
event and other public health emergencies. There is a need for research
on effective models of training and data systems to track the trained
workforce are needed. In addition, further research is needed on how
to and address issues of mobilizeing this healthcare workforce in the
event of an attack. AHRQ is not seeking specific educational curricula
but rather novel models and demonstrated strategies for training that
can be implemented by health care systems.
Illustrative questions of interest under this priority area include:
o What training models are most effective in preparing healthcare
personnel to care for rare public health events and bioterrorist
agents?
o What models of workforce tracking and mobilizations can be employed
within a region or state level?
o What are the lessons learned from disaster drills, table top
exercises, formal classes, simulated events, that inform our effective
planning for essential health care personnel and first responders? Are
these exercises cost-effective?
o Are computer simulations a cost-effective method for bioterrorism
and other public health preparedness?
o What information technologies and decision support tools are
effective in training and enhancing the knowledge and skills of health
care providers and first responders?
MECHANISM OF SUPPORT
This PA will use the cooperative agreement (U01) award mechanism, with
this assistance mechanism, substantial AHRQ programmatic involvement
with the awardees is anticipated during performance of the activity.
The dominant role and prime responsibility for the activity resides
with awardee(s) for the project as a whole, although specific tasks and
activities in carrying out the studies will be shared among the
awardees and the AHRQ Program Official(s). Details of the
responsibilities, relationships and governance of the study to be
funded under cooperative agreement(s) are discussed later in this
document under the section describing awardee and AHRQ rights and
responsibilities. The anticipated award date is September 2003.
AHRQ does not use the Modular Grant Application and Award Process.
ELIGIBLE INSTITUTIONS
You may submit (an) application (s) if your institution has any of the
following characteristics:
o For Profit or Non-profit organizations
o Domestic and foreign
o Public and private non-profit institutions, such as universities,
clinics, colleges, hospitals, and professional associations
o Units of State and local governments
o Faith-based and community-based organizations
o Tribes and Tribal Organizations
Practice-based networks, such as Integrated Delivery System Research
Networks or PBRN, are encouraged to apply.
Organizations described in section 501(c) 4 of the Internal Revenue
Code that engage in lobbying are not eligible.
Important Note: Under recent enacted reauthorization legislation, AHRQ
is authorized to enter into cooperative agreements with for-profit
organizations as well as with public and not- for profit entities.
Thus, for-profit organizations are eligible to respond to this notice
with applications for cooperative agreements. Such applications will be
administered in accordance with Subpart E of 45 CFR Part 74 and 42 CFR
part 67 Subpart A. This latter regulation has not yet been amended to
reflect these changes in Agency name and authority. (See December 6,
1999, AHRQ reauthorization at http://www.ahrq.gov.
Applicants are required to seek approval from AHRQ staff at least 3
weeks prior to the anticipated submission of any application requesting
$500,000 or more in direct costs for any year. If staff is contacted
less than 3 weeks before submission, there may be insufficient time to
make a determination about assignment prior to the intended submission
date. Applicants proposing grants for $500,000 or more for any year
should read the "Advanced Approval of Unsolicited Applications That
Request More Than $500,000 Direct Costs in Any One Year," published in
the NIH Guide for Grants and Contracts on August 22,1997
http://www.ahrq.gov (under Funding Opportunities).
INDIVIDUALS ELIGIBLE TO BECOME PRINCIPAL INVESTIGATORS
Any individual with the skills, knowledge, and resources necessary to
carry out the proposed research is invited to work with their
institution or organization to develop an application for support.
Individuals from under represented racial and ethnic groups as well as
individuals with disabilities are always encouraged to apply for AHRQ
programs.
SPECIAL REQUIREMENTS
Studies under this PA are expected to produce evidence, tools, and
models that can be integrated into preparedness initiatives at the
national, state, and local level. Applicants should be concrete in
describing 1) decision making audiences most interested in the proposed
research and 2) how applicants anticipate their results being used and
by what audiences. The Agency recognizes that rural communities, which
historically have had limited public health infrastructure, small
numbers of providers and volunteer emergency medical services ( EMS),
are considered most vulnerable and least able to respond. The ability
of local first responders, public health agencies and providers to
respond to an event is critical. Therefore, AHRQ recognizes the unique
burden preparedness activities and expectations place on rural
communities and will strongly encourage researchers to address rural
considerations in all proposal as appropriate. Dissemination and
implementation strategies should not be limited to publication in peer-
reviewed journals, but should address mechanisms and vehicles to
disseminate, implement, and communicate evidence, tools and models with
appropriate national, state, and local entities, professional
associations and other parties engaged in bioterrorism preparedness
activities.
TERMS AND CONDITIONS OF AWARD
These special Terms of Award are in addition to and not in lieu of
otherwise applicable OMB administrative guidelines, HHS grant
administration regulations at 45 CFR Parts 74 and 92, 42 CFR Part 67
Subpart A, and other HHS, PHS grants administration policy statements.
Applicants should be familiar with the Agency's grant regulations, 42
CFR Part 67 Subpart A, and particularly sections 67.18-67.22. [Part
92 applies when State and local governments are eligible to apply as a
"domestic organization."]
Consistent with the U01 concept defined under Mechanism of Support, the
dominant role and prime responsibility for the activity resides with
the awardee(s) for the project as a whole, although specific tasks and
activities in carrying out the studies will be shared among the
awardees and the AHRQ Program Official(s).
Awardee Rights and Responsibilities
Awardees have primary authorities and responsibilities to define
objectives and approaches, and to plan, conduct, analyze, and publish
results, interpretations, and conclusions of their studies.
Awardees will retain custody of and have primary rights to the data
developed under these awards, subject to Government rights of access
consistent with current HHS, PHS, and AHRQ policies.
AHRQ Staff Responsibilities
The AHRQ Program Official(s) will have substantial scientific
programmatic involvement in directing the grant activities to address
priority issues of AHRQ and the U.S. Department of Health and Human
Services regarding bioterrorism and other public health emergency
preparedness initiatives. AHRQ staff will coordinate grantee activities
with the Health Resources Services Administration Hospital Preparedness
Program staff and other relevant DHHS agencies and provide technical
assistance to the grantees on identifying key mechanisms, vehicles, and
partners to disseminate, implement, and communicate the evidence, tools
and models from these projects. The dominant role and prime
responsibility for the activity resides with the awardee(s) for the
project as a whole, although specific tasks and activities in carrying
out the studies will be shared among the awardees and the AHRQ Program
Official(s). AHRQ program official(s) will also facilitate the
acquisition of appropriate data sets as needed. AHRQ reserves the
right to terminate or curtail the study (or an individual award) in the
event of any major delays or failure to adhere to the overall study
design that may result in the failure to successfully produce the
models, tools, or reports intended, or any human subject ethical issues
that may dictate a premature termination.
Collaborative Responsibilities
When appropriate, AHRQ expects award recipients to work with each other
to identify collaborative activities that contribute toward enhanced
preparedness initiatives.
Arbitration
Any disagreement that may arise on scientific/programmatic matters
(within the scope of the award), between award recipients and AHRQ may
be brought to arbitration. An arbitration panel will be composed of
three members one selected by the individual awardee in the event of an
individual disagreement, a second member selected by AHRQ, and the
third member selected by the two prior selected members. This special
arbitration procedure in no way affects the awardee's right to appeal
an adverse action that is otherwise appealable in accordance with the
PHS regulations at 42 CFR Part 50, Subpart D and HHS regulation at 45
CFR Part 16.
o Priority Populations
The Agency's authorizing legislation (refer to http://www.ahrq.gov
(Under Funding Opportunties) directs special attention in Agency
programs to populations of inner-city areas and rural areas (including
frontier areas); low income groups; minority groups; women; children;
the elderly; and individuals with special health care needs, including
individuals with disabilities and individuals who need chronic care or
end-of-life health care. Applications under this RFA should address
attention to and potential benefits for these priority populations.
o Publication Transmittal: General AHRQ Requirements
In keeping with the Agency's efforts to translate the results of AHRQ-
funded research into practice and policy, grantees and/or contractors
are to inform the Office of Health Care Information (OHCI) when
articles from their studies are accepted for publication in the
professional literature. Grantees and contractors should also discuss
any ideas about other dissemination and marketing efforts with OHCI
staff. The goal is to ensure that efforts to disseminate research
findings are coordinated with other Agency activities to maximize
awareness and application of the research by potential users, including
clinicians, patients, health care systems and purchasers and
policymakers. This is critical when outreach to the general and trade
press is involved. Contact with the media will take place in close
coordination with OHCI and the press offices of the grantee's or
contractor's institutions. In cases when products are created (such as
annual or final reports, Web-based tools, CD-ROMs), grantees and
contractors will be asked to submit to OHCI a brief plan describing how
the product will be publicized. An OHCI staff person will be assigned
to each product and will coordinate the implementation of the plan,
especially issues related to printing and electronic dissemination, and
outreach to the media.
WHERE TO SEND INQUIRIES
We encourage your inquiries concerning this PA and welcome the
opportunity to answer questions from potential applicants. Inquiries
may fall into three areas: scientific/research, peer review, and
financial or grants management issues:
o Direct your questions regarding programmatic issues, including
information on the inclusion of women, minorities, and children in
study populations to:
Sally Phillips, RN, PhD
Center for Primary Care Research
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
Telephone: 301-427-1571
FAX: 301-427-1595
Email: sphillip@ahrq.gov
o Direct your questions about peer review issues to:
Carl Ohata, PhD
Office of Research Review, Education, and Policy
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
Telephone: (301) 427-1549
FAX: (301) 427-1561
Email: cohata@AHRQ.gov
Direct your questions about financial or grant management matters to:
George Gardner
Grants Management Specialist
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
Telephone: (301) 427-1453
FAX: (301) 427-1464
Email: ggardner@ahrq.gov
SUBMITTING AN APPLICATION
Applications must be prepared using the PHS 398 research grant
application instructions and form (rev. 5/2001). The PHS 398 is
available at http://grants.nih.gov/grants/funding/phs398/phs398.html in
an interactive format. For further assistance contact GrantsInfo,
Telephone 301-710-0267, Email: GrantsInfo@nih.gov.
The PA title and number must be typed on line 2 of the face page of the
application form and the YES box must be marked.
APPLICATION RECEIPT DATES: Applications submitted in response to this
program announcement will be accepted at the following application
deadlines: July 17, 2003, January 14, 2004, January 14, 2005, and
January 17, 2006.
This Program Announcement expires on July 17, 2007 unless reissued.
SUPPLEMENTAL INSTRUCTIONS:
Applicants are encouraged to make use of AHRQ'S Healthcare Cost and
Utilization Program (HCUP). The HCUP includes databases covering 1988-
1997, with 1998 and 1999 data available in 2001. These all-payer
databases were created through a Federal-State-industry partnership to
build a multistate healthcare data system. The main HCUP databases
contain discharge-level information for inpatient hospital stays in a
uniform format with privacy protections. The Nationwide Inpatient
Sample (NIS) is a nationwide probability sample of about 1000
hospitals. The State Inpatient Databases (SID) contain inpatient
records for all community hospitals in 22 states. Other HCUP databases
contain ambulatory surgery data from nine states. These databases can
be directly linked to county-level data form the Health Resources and
Services Administration's Area Resource File and to hospital-level data
from the Annual Survey of the American Hospital Association.
This does not preclude the use of secondary data sources or primary
data collection.
SPECIFIC INSTRUCTIONS FOR MODULAR GRANT APPLICATIONS:
AHRQ is not using the Modular Grant Application and Award Process.
Applicants for funding from AHRQ should ignore application instructions
concerning the Modular Grant Application and Award Process, and prepare
applications according to instructions provided in form PHS 398 .
Applications submitted in the Modular format will be returned without
review.
SENDING AN APPLICATION TO THE NIH and AHRQ:
Submit a signed, typewritten original of the application, including the
checklist, and three signed photocopies in one package to:
Center for Scientific Review
National Institutes of Health
6701 Rockledge Drive, Room 1040 - MSC 7710
Bethesda, MD 20892-7710
(20817 for express/courier service)
At the time of submission, two additional copies of the application,
labeled "Advanced Copy (s)" must also be sent to:
Sally Phillips, RN, PhD
Center for Primary Care Research
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
Telephone: 301-427-1571
FAX: 301-427-1595
Email: sphillip@ahrq.gov
SPECIAL APPLICATION REQUIREMENTS:
Application Preparations:
1) Biographical Sketches: In addition to general biographical
information, applicants should describe the relevant experience and
activity of the researchers to this specific research area of study.
2) Research Plan: In addition to the overall elements of the research
plan, applicants should address:
o how the researcher/s have direct experience in the field of study
described in this project or how their previous experience will
transfer to this new area of research?
o the decision making audiences most interested in the proposed
research.
o how applicants anticipate their results being used and by what
audience?
o a detailed plan for the mechanisms and vehicles to disseminate,
implement, and communicate evidence, models, and tools with
appropriate national, State, and local entities, professional
associations, and other parties engaged in bioterrorism and other
public health preparedness activities.
APPLICATION PROCESSING: Applications must be received by the receipt
dates listed in the heading of this PA. If an application is received
after that date, it will be returned to the applicant without review.
The CSR and AHRQ will not accept any application in response to this PA
that is essentially the same as one currently pending initial review
unless the applicant withdraws the pending application. The CSR and
AHRQ will not accept any application that is essentially the same as
one already reviewed. This does not preclude the submission of
substantial revisions of applications already reviewed, but such
applications must include an Introduction addressing the previous
critique.
Although there is no immediate acknowledgment of the receipt of an
application, applicants are generally notified of the review and
funding assignment within 8 weeks.
Applicants are encourage to read all PHS Forms 398 instructions prior
to preparing an application in response to this PA. The PHS 398 type
size requirements (p.6) will be enforced rigorously and non-compliant
applications will be returned. It is very important to note that
limitations on number of pages and size of font must be observed;
applications violating these requirements will be returned without
review.
Institutional Review Board (IRB) approval of human subjects is not
required prior to peer review of an AHRQ application. The "AHRQ
Revised Policy for IRB Review of Human Subjects Protocols in Grant
Applications" was published in the NIH Guide on September 27, 2000.
(http://grants.nih.gov/grants/guide/notice-files/NOT-HS-00-003.html)
The PA is also available on AHRQ's Web site, http://www.AHRQ.gov, (see
under Funding Opportunities) and through AHRQ InstantFAX at (301) 594-
2800. To use InstantFAX, you must call from a facsimile (FAX) machine
with a telephone handset. Follow the voice prompt to obtain a copy of
the table of contents, which has the document order number (not the
same as the PA number). The PA will be sent at the end of the ordering
process. AHRQ InstantFAX operates 24 hours a day, 7 days a week. For
comments or problems concerning AHRQ InstantFax, please call (301) 594-6344.
TECHNICAL ASSISTANCE:
AHRQ encourages applicants to take advantage of a technical assistance
conference call sponsored by AHRQ program staff. This conference call
will be held on July 2, 2003, 1-3 p.m. Please contact Kelly Morgan
kmorgan@ahrq.gov or 301-427-1570, 2 working days prior to the
conference call.
Projects will ordinarily not use CMS (Medicare or Medicaid) data
involving individual identifiers. Purchase of CMS public-use data, if
required, should be discussed in the application narrative and included
in the budget.
Application Preparation (for Using CMS Data)
For applications that propose to use Medicare or Medicaid data that are
individually identifiable, applicants should state explicitly in the
"Research Design and Methods" section of the Research Plan (form 398)
the specific files, time periods, and cohorts proposed for the
research. In consultation with Center for Medicare and Medicaid
Services (CMS), previously called Health Care Financing Administration
(HCFA), AHRQ will use this information to develop a cost estimate for
obtaining the data. This estimate will be included in the estimated
total cost of the grant at the time funding decisions are made.
Applicants should be aware that for individually identifiable Medicare
and Medicaid data, Principal Investigators and their grantee
institutions will be required to enter into a Data Use Agreement (DUA)
with CMS to protect the confidentiality of data in accordance with
AHRQ's confidentiality statue, 42 USC 299c3(c), the Privacy rules at 45
CFR Part 164, if applicable, and standards set out in OMB Circular A-
130, Appendix III Security of Federal Automated Information Systems.
The use of the data will be restricted to the purposes and time period
specified in the DUA. At the end of this time period, the grantee will
be required to return the data to CMS or certify that the data have
been destroyed.
Unless AHRQ is able to negotiate exceptional arrangements, for the sole
purpose of assuring that data confidentiality is maintained, included
in the DUA is the requirement that the User agrees to submit to CMS, a
copy of all findings within 30 days of making such findings. The user
further agrees not to submit these findings to any third party
(including but not limited to any manuscript to be submitted for
publication) until receiving CMS's approval to do so.
In developing research plans, applicants should allow time for
refining, approving, and processing any CMS data requests. Requests
may take 6 months from the time they are submitted to complete.
Applications proposing to contact beneficiaries or their providers
require the approval of the CMS Director and may require meeting(s)
with CMS staff.
CMS data are provided on IBM mainframe tapes using the record and data
formats commonly employed on these computers. Applicants should either
have the capability to process these tapes and formats or plan to make
arrangements to securely convert them to other media and formats.
Questions regarding CMS data should be directed to the AHRQ program
official listed under INQUIRIES.
In carrying out its stewardship of research programs, the AHRQ, at some
point in the future, may begin requesting information essential to an
assessment of the effectiveness of Agency research programs.
Accordingly, grant recipients are hereby notified that they may be
contacted after the completion of awards for periodic updates on
publications resulting from AHRQ grant awards, and other information
helpful in evaluating the impact of AHRQ-sponsored research.
AHRQ expects grant recipients to keep the Agency informed of
publications as well as the known uses and impact of their Agency-
sponsored research. Applicants are to agree to notify AHRQ immediately
when a manuscript based on research supported by the grant is accepted
for publication, and to provide the expected date of publication as
soon as it is known, regardless of whether or not the grant award is
still active.
To receive an award, applicants must agree to submit an original and 2
copies of an abstract, executive summary, and full report of the
research results in the format prescribed by AHRQ no later than 90 days
after the end of the project period. The executive summary should be
sent at the same time on a computer disk which specifies on the label
the format used (WP5.1 or WP6.0 is preferable).
PEER REVIEW PROCESS
Upon receipt, applications will be reviewed for completeness and
responsiveness by the Agency Referral Officer, program staff, and
grants management staff. Incomplete and/or non-responsive applications
or applications not following instructions given in this PA will be
returned to the applicant by the Agency Referral Officer without
further consideration. Applications that are complete and responsive
to the PA will be evaluated for scientific and technical merit by an
appropriate peer review group convened in accordance with standard AHRQ
peer review procedures.
As part of the merit review, all applications will:
o Receive a written critique
o Undergo a process in which only those applications deemed to have
the highest scientific merit will be discussed and assigned a priority
score.
REVIEW CRITERIA
In the written comments, reviewers will be asked to discuss the
following aspects of your application in order to judge the likelihood
that the proposed research will have a substantial impact on the
pursuit of these goals:
o Significance
o Approach
o Investigator
o Environment
o Budget
The scientific review group will address and consider each of these
criteria in assigning your application's overall score, weighting them
as appropriate for each application. Your application does not need to
be strong in all categories to be judged likely to have a major
scientific impact and thus deserve a high priority score.
(1) SIGNIFICANCE: Does your study address an important problem? If
the aims of your application are achieved, is the proposed work likely
to result in enhanced preparedness for a significant sector of the
health care system? Will this project provide federal, state and local
policy makers, and others participating in the formulation of plans and
policies for bioterrorism and other public health emergency
preparedness, with the evidence, models, and tools that will enhance
preparedness activities?
(2) APPROACH: Are the rationale, preliminary plans, interventions,
model or tool development methodologies, testing, evaluation and
disseminations or preliminary plans adequately described, suitably
evidence-based, technically sound, well integrated, and appropriate to
the aims of the project? Does the application acknowledge potential
problem areas and consider alternative tactics? Will the proposed
evidence, tools and/or models be relevant to bioterrorism and other
public health emergency preparedness activities at the national, state,
and local level?
(3) INVESTIGATOR: Are you appropriately trained and well suited to
carry out this work? Is the work proposed appropriate to your
experience level as the principal investigator and to that of other
researchers? Does the proposed study team reflect an appropriate array
of skills for the aims and evaluation and dissemination? Are the time
commitment sufficient to accomplish the aims? Are roles clearly
delineated and complementary?
(4) ENVIRONMENT: Does the scientific environment in which your work
will be done contribute to the probability of success? Is there
evidence of institutional support? Is there any affiliation or a plan
for affiliation of the organization or research team members with
national, State, or local bioterrorism and other public health
emergency preparedness partners that can enhance the likelihood of
successful dissemination of the evidence, models, or tools developed?
(6) BUDGET: The proposed project budget and the requested period of
support in relation to the proposed research questions:?
ADDITIONAL REVIEW CRITERIA: In addition to the above criteria, your
application will also be reviewed with respect to the following:
o PROTECTIONS: The adequacy of the proposed protection for humans or
the environment, to the extent they may be adversely affected by the
project proposed in the application.
o INCLUSION: The adequacy of plans to address the need of both
genders, all racial and ethnic groups (and subgroups), and children as
appropriate for the aims of the project. Adequacy of attention to
other populations of special priority to AHRQ (see discussion on
Priority Populations in the section on Special Requirements, above, and
Inclusion Criteria included in the section on Agency policies and
Requirements, below.)
DATA SHARING:
Data Confidentiality
Pursuant to section 924(c) of the Public Health Service Act [42 USC
299c-3(c)], information obtained in the course of any AHRQ supported-
study that identifies an individual or entity must be treated as
confidential in accordance with any explicit or implicit promises made
regarding the possible uses and disclosures of such data. There are now
civil monetary penalties for violation of this confidentiality statute.
[42 U.S.C.299c-3(d)] In the Human Subjects section of the application,
applicants must describe procedures for ensuring the confidentiality of
the identifying information to be collected. The description of the
procedures should include a discussion of who will be permitted access
to the information, both raw data and machine readable files, and how
personal identifiers and other identifying or identifiable data will be
restricted and safeguarded. Identifiable patient health information
collected by grantees under this PA will also be managed in accordance
with 42 CFR Parts 160 and 164, federal regulations pertaining to the
privacy of patient-related health information. These privacy
regulations, developed by the Department of Health and Human Services
pursuant to the Health Insurance Portability and Accountability Act of
1996 (HIPAA), are scheduled to be effective and enforceable in April
2003. These regulations serve to limit the disclosure of personally
identifiable patient information and define when and how such
information can be disclosed. Thus, for example, health care plans and
providers will require either patient authorization of disclosures of
identifiable information to be made to researchers who are not their
health care providers or waivers of such authorizations obtained from
an IRB or Privacy Board (defined in the regulations) upon being
satisfied that any identifiable health information will be
appropriately safeguarded by the investigators.
The awardee should ensure that computer systems containing confidential
data have a level and scope of security that equals or exceeds those
established by the Office of Management and Budget (OMB) in OMB
Circular No. A-130, Appendix III - Security of Federal Automated
Information Systems. The National Institute of Standards and Technology
(NIST) has published several implementation guides for this circular.
They are: An Introduction to Computer Security: The NIST Handbook;
Generally Accepted Principals and Practices for Securing Information
Technology Systems; and Guide for Developing Security Plans for
Information Technology Systems. The circular and guides are available
on the web at http://csrc.nist.gov/publications/nistpubs/800-12/. The
applicability and intended means of applying these confidentiality and
security standards to subcontractors and vendors, if any, should be
addressed in the application.
Rights in Data
AHRQ grantees may copyright unless otherwise provided in grant awards,
or seek patents, as appropriate, for final and interim products and
materials including, but not limited to, methodological tools,
measures, software with documentation, literature searches, and
analyses, which are developed in whole or in part with AHRQ funds. Such
copyrights and patents are subject to a worldwide irrevocable Federal
government license to use and permit others to use these products and
materials for government purposes. In accordance with its legislative
dissemination mandate, AHRQ purposes may include, subject to statutory
confidentiality protections, making project materials, data bases,
results, and algorithms available for verification or replication by
other researchers; and subject to AHRQ budget constraints, final
products may be made available to the health care community and the
public by AHRQ or its agents, if such distribution would significantly
increase access to a product and thereby produce public health
benefits. Ordinarily, to accomplish distribution, AHRQ publicizes
research findings but relies on grantees to publish research results in
peer-reviewed journals and to market grant-supported products.
AHRQ's Office of Health Care Information wishes to be consulted in
advance of publication in order to coordinate these issuances with
other AHRQ dissemination activities. Important legal rights and
requirements applicable to AHRQ grantees are set out or referenced in
the AHRQ's grants regulation at 42 CFR Part 67, Subpart A (Available in
libraries and from the GPO's website
http://www.access.gpo.gov/nara/cfr/index.html).
RECEIPT AND REVIEW SCHEDULE
Technical Assistance Conference Call: July 2, 2003
Application Receipt Dates: July 17, 2003
January 14, 2004
January 14, 2005
January 17, 2006
(This Program Announcement expires on July 17, 2007 unless reissued.)
Peer Review Date: August 2003
Earliest Anticipated Start Date: September 2003
AWARD CRITERIA
Award criteria that will be used to make award decisions include:
o Scientific merit (as determined by peer review)
o Availability of funds
o Programmatic priorities
REQUIRED FEDERAL CITATIONS
INCLUSION OF WOMEN, MINORITIES, AND CHILDREN IN RESEARCH STUDY
POPULATIONS: It is the policy of AHRQ that women and members of
minority groups be included in all AHRQ-supported research projects
involving human subjects, unless a clear and compelling rationale and
justification are provided that inclusion is inappropriate with respect
to the health of the subjects or the purpose of the research.
All investigators proposing research involving human subjects should
read the UPDATED "NIH Guidelines on the Inclusion of Women and
Minorities as Subjects in Clinical Research," published in the NIH
Guide for Grants and Contracts on August 2, 2000
(http://grants.nih.gov/grants/guide/notice-files/not-od-00-048.html).
A complete copy of the updated Guidelines is available at
http://grants.nih.gov/grants/funding/women_min/guidelines_update.htm.
To the extent possible, AHRQ requires adherence to these NIH
Guidelines.
Investigators may obtain copies from the above sources or from the AHRQ
Publications Clearinghouse, listed under INQUIRIES, or from the NIH
Guide Web site http://grants.nih.gov/grants/guide/index.html. AHRQ
Program staff may also provide additional information concerning these
policies (see INQUIRIES).
AHRQ also encourages investigators to consider including children in
study populations, as appropriate.
PUBLIC ACCESS TO RESEARCH DATA THROUGH THE FREEDOM OF INFORMATION ACT:
The Office of Management and Budget (OMB) Circular A-110 has been
revised to provide public access to research data through the Freedom
of Information Act (FAIA) under some circumstances. Data that are (1)
first produced in a project that is supported in whole or in part with
Federal funds and (2) cited publicly and officially by a Federal agency
in support of an action that has the force and effect of law (i.e., a
regulation) may be accessed through FAIA. If no Federal act is taken,
having the force and effect of law, in reliance upon an AHRQ supported
research project, the underlying data is not subject to this disclosure
requirement and under FAIA, 5 USC 552(b), disclosure of identifiable
data from such study is exempted from disclosure under "the (b)(3)
exemption." It is important for applicants to understand the scope of
this requirement and its limited potential impact on data collected
with AHRQ support. Proprietary data might also be exempted from FAIA
disclosure requirements under "the (b)(4) exemption", for example, if
it constituted trade secrets or commercial information. However, courts
have generally not regarded a researcher's interest in "his" data as
proprietary. NIH has provided guidance at
http://grants.nih.gov/grants/policy/a110/a110_guidance_dec1999.htm.
Should applicants wish to place data collected under this PA in a
public archive, which can provide protections for the data (e.g., as
required by the confidentiality statute applicable to AHRQ supported
projects, 42 U.S.C. 299c-3(c)) and manage the distribution of non-
identifiable data for an indefinite period of time, they may. The
application should include a description of any archiving plan in the
study design and include information about this in the budget
justification section of the application. In addition, applicants
should think about how to structure informed consent statements and
other human subjects procedures given the potential for wider use of
data collected under this award.
STANDARDS FOR PRIVACY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION:
The Department of Health and Human Services (DHHS) issued final
modification to the "Standards for Privacy of Individually Identifiable
Health Information", the "Privacy Rule," on August 14, 2002. The
Privacy Rule is a federal regulation under the Health Insurance
Portability and Accountability Act (HIPAA) of 1996 that governs the
protection of individually identifiable health information, and is
administered and enforced by the DHHS Office for Civil Rights (OCR).
Those who must comply with the Privacy Rule (classified under the Rule
as "covered entities") must do so by April 14, 2003 (with the
exception of small health plans which have an extra year to comply).
Decisions about applicability and implementation of the Privacy Rule
reside with the researcher and his/her institution. The OCR website
(http://www.hhs.gov/ocr/) provides information on the Privacy Rule,
including a complete Regulation Text and a set of decision tools on "Am
I a covered entity?" Information on the impact of the HIPAA Privacy
Rule on NIH processes involving the review, funding, and progress
monitoring of grants, cooperative agreements, and research contracts
can be found at http://grants.nih.gov/grants/guide/notice-files/
NOT-OD-03-025.html.
HEALTHY PEOPLE 2010: The Public Health Service (PHS) is committed to
achieving the health promotion and disease prevention objectives of
"Healthy People 2010," a PHS-led national activity for setting health
improvement priorities for the United States. AHRQ encourages
applicants to submit grant applications with relevance to the specific
objectives of this initiative. Potential applicants may obtain a copy
of "Healthy People 2010" at http://www.health.gov/healthypeople.
AUTHORITY AND REGULATIONS: This program is described in the Catalog of
Federal Domestic Assistance, Number 93.226. Awards are made under
Title IX of the Public Health Service Act (42 USC 299-299c-7) as
amended by P.L. 106-129 (1999). Awards are administered under the PHS
Grants Policy Statement and Federal Regulations 42 CFR 67, Subpart A,
and 45 CFR Parts 74 or 92. This program is not subject to the
intergovernmental review requirements of Executive Order 12372 or
Health Systems Agency review.
The PHS strongly encourages all grant and contract recipients to
provide a smoke-free workplace and promote the non-use of all tobacco
products. In addition, Public Law 103-227, the Pro-Children Act of
1994, prohibits smoking in certain facilities (or in some cases, any
portion of a facility) in which regular or routine education, library,
day care, health care or early childhood development services are
provided to children. This is consistent with the PHS mission to
protect and advance the physical and mental health of the American
people.
REFERENCES
1. Bravata DM, McDonald K, Owens DK. Bioterrorism: use of information
technologies and decision support system. AHRQ Clearinghouse. 2001.
2. Catlett C, Perl T, Jenckes MW, Robinson KA, Mitchell D, Hage J,
Fuererstein CJ, Chuang S, Bass E. Evidence report on training
clinicians for public health events relevant to bioterrorism
preparedness. AHRQ Clearinghouse. 2001.
3. Chen FM, Hickner J, Fink KS, Galliher JM, Burstin, H. On the front
lines: family physician's preparedness for bioterrorism. J. Fam Pract
2002;51:745-50.
4. Garrett LC,. Magruder C, Molgard CA. Taking the terror out of
bioterrorism: planning for a bioterrorist event from a local
perspective. J Public Health Manag Pract. 2000;6(4):1-7.
5. Khan AS, Morse S, Lillibridge S. Public-health preparedness for
biological terrorism in the USA. Lancet. 2000;356(9236):1179-1182.
6. Khan AS, Ashford DA. Ready or not preparedness for bioterrorism. N
Engl J Med. 2001; 345(4):287-289.
7. Wetter DC, Daniell WE, Tesser DC. Hospital preparedness for
victims of chemical and biological terrorism. Am J Public Health.
2001;91(5):710-716.
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NIH Funding Opportunities and Notices
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