This study was limited by the small number of hospitals and the modest number of observer pairs. Because only 6 of 17 hospitals agreed to participate, there is a possibility the hospitals were not representative.

Because the reported barriers might be different from those observed during outbreaks, they should be regarded as a proxy for reality.

The EH and EPR administrators recognize many barriers to direct community engagement in general.EH professionals feel disconnected from preparedness planning and see themselves as too busy conducting feefor-service activities

Due to the small study sample size, these findings may not begeneralizable to all preparedness-focused HCCs.While participants were very forthcoming in their responses to the interview questions, response bias is often inherent in self-report interviews.

Operational feasibility of these guidelines has not yet been tested nor established

It is necessary to discuss the generalizability and validity of the findings internationally.

CASPER trainings are successful in increasing disaster epidemiology skills. CASPER can be used by Public Health Emergency Preparedness program awardees to help build and sustain preparedness and response capabilities.CASPER is an effective and frequently employed tool for public health emergency managementThe use of CASPER as a public health emergency preparedness and response tool can increase state and local public health emergency response capacities.Although originally designed for disaster response, CASPERs can be used throughout the disaster life cycle and in nondisaster situations, and they can can contribute to informing jurisdictional

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assessmentsSome areas have been indentified for future improvementThe majority (80.0%) of CASPERs did not document implementation of recommendations based on CASPER findings.Disseminating CASPER findings and sharing lessons learned with the wider public health community are important to highlight common problems and opportunities for improvement that exist across many communities

However, this procedure for reconstructing roofs has problems if there are many flat roofs and many outliers in the data.

We were unable to gather more information about these possible causes.

According to the authors, further work is required to validate some of the assessment tools so that they can be used to document proficiency.