Infectious Diseases
Gaps Remain in Surveillance Capabilities of State and Local Agencies Gao ID: GAO-03-1176T September 24, 2003Recent challenges, such as the SARS outbreak and the anthrax incidents in the fall of 2001, have raised concerns about the nation's preparedness for a large-scale infectious disease outbreak or bioterrorism event. In order to be adequately prepared for such a major public health threat, state and local public health agencies need to have several basic capabilities, including disease surveillance systems, laboratory facilities, communication systems and a sufficient workforce. GAO was asked to examine the capacity of state and local public health agencies and hospitals to detect and report illnesses or conditions that may result from a large-scale infectious disease outbreak or bioterrorism event. This testimony is based largely on recent work, including a report on state and local preparedness for a bioterrorist attack; preliminary findings from current work on updates of bioterrorism preparedness at the state and local levels; and findings from a survey GAO conducted on hospital emergency department capacity and emergency preparedness.
The efforts of public health agencies and health care organizations to increase their preparedness for infectious disease outbreaks and bioterrorism have improved the nation's ability to recognize such events. However, gaps remain in state and local disease surveillance systems, which are essential to public health efforts to respond to disease outbreaks or bioterrorist attacks. Other essential elements of preparedness include laboratory facilities, workforce, and communication systems. State and local officials report that they are addressing gaps in communication systems. However, there are still significant workforce shortages in state and local health departments. GAO also found that while contingency plans are being developed at the state and local levels, planning for regional coordination for disease outbreaks or bioterrorist events was lacking between states. The disease surveillance capacities of many state and local pubic health systems depend, in part, on the surveillance capabilities of hospitals. Whether a disease outbreak occurs naturally or due to the intentional release of a harmful biological agent by a terrorist, much of the initial response would occur at the local level, particularly at hospitals and their emergency departments. Therefore, hospital personnel would be some of the first healthcare workers with the opportunity to identify an infectious disease outbreak or a bioterrorist event. Most hospitals reported training their staff on biological agents and planning coordination efforts with public health entities; however, preparedness limitations may impact hospitals' ability to conduct disease surveillance. In addition, hospitals still lack the capacity to respond to large-scale infectious disease outbreaks. Also, most emergency departments across the country have experienced some degree of overcrowding, which could be exacerbated during a disease outbreak or bioterrorist event if persons with symptoms go to emergency departments for treatment.
GAO-03-1176T, Infectious Diseases: Gaps Remain in Surveillance Capabilities of State and Local Agencies
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Testimony:
Before the Subcommittee on Emergency Preparedness and Response, Select
Committee on Homeland Security, House of Representatives:
United States General Accounting Office:
GAO:
For Release on Delivery Expected at 2:30 p.m.
Wednesday, September 24, 2003:
INFECTIOUS DISEASES:
Gaps Remain in Surveillance Capabilities of State and Local Agencies:
Statement of Janet Heinrich Director, Health Care--Public Health
Issues:
GAO-03-1176T:
GAO Highlights:
Highlights of GAO-03-1176T, testimony before the Subcommittee on
Emergency Preparedness and Response, Select Committee on Homeland
Security, House of Representatives
Why GAO Did This Study:
Recent challenges, such as the SARS outbreak and the anthrax incidents
in the fall of 2001, have raised concerns about the nation‘s
preparedness for a large-scale infectious disease outbreak or
bioterrorism event. In order to be adequately prepared for such a
major public health threat, state and local public health agencies
need to have several basic capabilities, including disease
surveillance systems, laboratory facilities, communication systems and
a sufficient workforce.
GAO was asked to examine the capacity of state and local public health
agencies and hospitals to detect and report illnesses or conditions
that may result from a large-scale infectious disease outbreak or
bioterrorism event.
This testimony is based largely on recent work, including a report on
state and local preparedness for a bioterrorist attack; preliminary
findings from current work on updates of bioterrorism preparedness at
the state and local levels; and findings from a survey GAO conducted
on hospital emergency department capacity and emergency preparedness.
What GAO Found:
The efforts of public health agencies and health care organizations to
increase their preparedness for infectious disease outbreaks and
bioterrorism have improved the nation‘s ability to recognize such
events. However, gaps remain in state and local disease surveillance
systems, which are essential to public health efforts to respond to
disease outbreaks or bioterrorist attacks. Other essential elements of
preparedness include laboratory facilities, workforce, and
communication systems. State and local officials report that they are
addressing gaps in communication systems. However, there are still
significant workforce shortages in state and local health departments.
GAO also found that while contingency plans are being developed at the
state and local levels, planning for regional coordination for disease
outbreaks or bioterrorist events was lacking between states.
The disease surveillance capacities of many state and local pubic
health systems depend, in part, on the surveillance capabilities of
hospitals. Whether a disease outbreak occurs naturally or due to the
intentional release of a harmful biological agent by a terrorist, much
of the initial response would occur at the local level, particularly
at hospitals and their emergency departments. Therefore, hospital
personnel would be some of the first healthcare workers with the
opportunity to identify an infectious disease outbreak or a
bioterrorist event. Most hospitals reported training their staff on
biological agents and planning coordination efforts with public health
entities; however, preparedness limitations may impact hospitals‘
ability to conduct disease surveillance. In addition, hospitals still
lack the capacity to respond to large-scale infectious disease
outbreaks. Also, most emergency departments across the country have
experienced some degree of overcrowding, which could be exacerbated
during a disease outbreak or bioterrorist event if persons with
symptoms go to emergency departments for treatment.
www.gao.gov/cgi-bin/getrpt?GAO-03-1176T.
To view the full testimony, including the scope and methodology, click
on the link above. For more information, contact Janet Heinrich at
(202) 512-7119.
[End of section]
Mr. Chairman and Members of the Subcommittee:
I appreciate the opportunity to be here today to discuss the work we
have done on state and local preparedness to manage outbreaks of
infectious diseases, which may be naturally occurring or the product of
bioterrorism. In order to be adequately prepared for such a major
public health threat, state and local public health agencies need to
have several basic capabilities, including disease surveillance
systems.[Footnote 1] Surveillance is public health officials' most
important tool for detecting and monitoring both existing and emerging
infections. Effective surveillance can facilitate timely action to
control outbreaks and inform allocation of resources to meet changing
disease conditions. Without adequate surveillance, local, state, and
federal officials cannot know the true scope of existing health
problems and may not recognize new diseases until many people have been
affected.
Recent challenges, such as the SARS[Footnote 2] outbreak and the
anthrax incidents in the fall of 2001, have raised concerns about the
nation's preparedness to manage a disease outbreak or a bioterrorist
event should it reach large-scale proportions. Existing surveillance
systems have weaknesses, such as chronic underreporting and outdated
laboratory facilities, which raise concerns about the ability of state
and local agencies to detect emerging diseases or a bioterrorist event.
As a result, state and local response agencies and organizations have
recognized the need to strengthen their public health infrastructure
and capacity. The improvements they are making are intended to
strengthen their ability to identify and respond to major public health
threats, including naturally occurring infectious disease outbreaks and
acts of bioterrorism.
To assist the Subcommittee in its consideration of our nation's
capacity to detect and monitor an outbreak of an infectious disease, my
remarks today will focus on (1) the preparedness of state and local
public health agencies for responding to an infectious disease
outbreak, and (2) the contributions of hospitals to preparedness for an
infectious disease outbreak.
My testimony today is based largely on our recent work, including a
report on state and local preparedness for a bioterrorist
attack.[Footnote 3] For that report, we conducted site visits in
December 2001 through March 2002 to seven cities and their respective
state governments. We also reviewed each state's spring 2002
applications for bioterrorism preparedness funding to the Department of
Health and Human Services' (HHS) Centers for Disease Control and
Prevention (CDC) and Health Resources and Services Administration
(HRSA), and each state's fall 2002 progress report on the use of that
funding. In addition, I will discuss some preliminary findings from our
current work that provides updated information on the preparedness of
state and local public health agencies. For that work, we are reviewing
the summer 2003 applications and progress reports and interviewing
public health officials from 10 states and two major municipalities. I
also will present some findings from a survey we conducted in 2002 on
hospital emergency department capacity and emergency
preparedness.[Footnote 4] We conducted our work in accordance with
generally accepted government auditing standards.
In summary, state and local officials in the cities we visited reported
varying levels of public health preparedness to respond to outbreaks of
emerging infectious diseases such as SARS. They recognized gaps in
preparedness elements that have been difficult to address, including
the disease surveillance and laboratory systems and the response
capacity of the workforce. They also were beginning to address gaps in
preparedness elements such as communication. We found that planning for
regional coordination was lacking between states.
Because those with symptoms of an infectious disease might go to
emergency departments for treatment, hospital personnel would likely be
some of the first healthcare workers with the opportunity to identify
an infectious disease outbreak. Therefore, the disease surveillance
capacities of many state and local public health systems may depend, in
part, on the surveillance capabilities of hospitals. Most hospitals
reported training their staff and planning coordination efforts with
other public health entities. However, even with these preparations in
place, hospitals lacked the capacity to respond to large-scale
infectious disease outbreaks.
Background:
Infectious diseases include naturally occurring outbreaks, such as
SARS, as well as diseases from biological agents that are intentionally
released by a terrorist, such as smallpox.[Footnote 5] An infectious
disease outbreak, either naturally occurring or from an intentional
release, may not be recognized for a week or more because symptoms may
not appear for several days after the initial exposure, during which
time a communicable disease could be spread to those who were not
initially exposed.
The initial response to an infectious disease of any type, including a
bioterrorist attack, is generally a local responsibility that could
involve multiple jurisdictions in a region, with states providing
additional support when needed. Figure 1 presents the probable series
of responses to a covert release of a biological agent. Just as in a
naturally occurring outbreak, exposed individuals would seek out local
health care providers, such as private physicians or medical staff in
hospital emergency departments or public clinics. Health care providers
would report any illness patterns or diagnostic clues that might
indicate an unusual infectious disease outbreak associated with the
intentional release of a biologic agent to their state or local health
departments.
Figure 1: Local, State, and Federal Entities Involved in Response to
the Covert Release of a Biological Agent:
[See PDF for image]
[A] Health care providers can also contact state entities directly.
[B] Federal departments and agencies can also respond directly to local
and state entities.
[C] The Strategic National Stockpile, formerly the National
Pharmaceutical Stockpile, is a repository of pharmaceuticals,
antidotes, and medical supplies that can be delivered to the site of a
biological (or other) attack.
[End of figure]
In order to be adequately prepared for emerging infectious diseases in
the United States, state and local public health agencies need to have
several basic capabilities, whether they possess them directly or have
access to them through regional agreements. Public health departments
need to have disease surveillance systems and epidemiologists to detect
clusters of suspicious symptoms or diseases in order to facilitate
early detection of disease and treatment of victims. Laboratories need
to have adequate capacity and necessary staff to test clinical and
environmental samples in order to identify an agent promptly so that
proper treatment can be started and infectious diseases prevented from
spreading. All organizations involved in the response must be able to
communicate easily with one another as events unfold and critical
information is acquired, especially in a large-scale infectious disease
outbreak.
In the event of an outbreak, hospitals and their emergency departments
would be on the front line, and their personnel would take on the role
of first responders. Because hospital emergency departments are open 24
hours a day, 7 days a week, exposed individuals would be likely to seek
treatment from the medical staff on duty. Staff would need to be able
to recognize and report any illness patterns or diagnostic clues that
might indicate an unusual infectious disease outbreak to their state or
local health department. Hospitals would need to have the capacity and
staff necessary to treat severely ill patients and limit the spread of
infectious disease.
The federal government also has a role in preparedness for and response
to major public health threats. It becomes involved in investigating
the cause of a disease, as it did with SARS. In addition, the federal
government provides funding and resources to state and local entities
to support preparedness and response efforts. CDC's Public Health
Preparedness and Response for Bioterrorism program provided funding
through cooperative agreements in fiscal year 2002 totaling $918
million to states and municipalities to improve bioterrorism
preparedness and response, as well as other public health emergency
preparedness activities. The funding supported development and
improvements in a number of areas CDC considers critical to
preparedness and response, including surveillance capacity to rapidly
detect outbreaks of illness that may be the result of bioterrorism or
other public health threats.
HRSA's Bioterrorism Hospital Preparedness Program provided funding
through cooperative agreements in fiscal year 2002 of approximately
$125 million to states and municipalities to enhance the capacity of
hospitals and associated health care entities to respond to
bioterrorist attacks. Earlier this month, HHS announced that
approximately $870 million and $498 million have been provided for
fiscal year 2003 through the CDC and HRSA programs, respectively, to
states and municipalities to continue these efforts.
Despite Improvements, Gaps Remain in Disease Surveillance Capabilities
of State and Local Public Health Agencies:
In the cities we visited, state and local officials reported varying
levels of public health preparedness to respond to outbreaks of
emerging infectious diseases such as SARS. They recognized gaps in
preparedness elements that have been difficult to address, including
the disease surveillance and laboratory systems and the response
capacity of the workforce. They also were beginning to address gaps in
preparedness elements such as communication. We found that planning for
regional coordination was lacking between states.
Progress Has Been Made in Elements of Public Health Preparedness, but
Gaps Remain:
States and local areas had weaknesses in some public health
preparedness elements, including the disease surveillance and
laboratory systems and the response capacity of the workforce. Gaps in
capacity often are not amenable to solution in the short term because
either they require additional resources or the solution takes time to
implement. States and local areas were addressing gaps in
communication.
Surveillance Systems:
State and local officials for the cities we visited in early 2002
recognized and were attempting to address inadequacies in their
surveillance systems. Local officials were concerned that their
surveillance systems were inadequate to detect a bioterrorist event,
and all of the states we visited were making efforts to improve their
disease surveillance systems. Six of the cities we visited used a
passive surveillance system[Footnote 6] to detect infectious disease
outbreaks.[Footnote 7] However, passive systems may be inadequate to
identify a rapidly spreading outbreak in its earliest and most
manageable stage because, as officials in three states noted, there is
chronic underreporting and a time lag between diagnosis of a condition
and the health department's receipt of the report. To improve disease
surveillance, six of the states and two of the cities we visited were
developing surveillance systems using electronic databases. Several
cities were also evaluating the use of nontraditional data sources,
such as pharmacy sales, to conduct surveillance.[Footnote 8] Three of
the cities we visited were attempting to improve their surveillance
capabilities by incorporating active surveillance components into their
systems. For our ongoing work, state and local officials told us that
their surveillance systems had improved somewhat. The officials
reported that CDC funds have enabled them make some of these
improvements in their surveillance systems, including the development
of Web-based disease reporting and active surveillance systems.
Laboratory Facilities:
Officials from all of the states we visited in early 2002 reported
problems with their public health laboratory systems and said that they
needed to be upgraded. All states were planning to purchase the
equipment necessary for rapidly identifying a biological agent. State
and local officials in most of the areas that we visited told us that
the public health laboratory systems in their states were stressed, in
some cases severely, by the sudden and significant increases in
workload during the anthrax incidents in the fall of 2001. During these
incidents, the demand for laboratory testing was significant even in
states where no anthrax was found and affected the ability of the
laboratories to perform their routine public health functions.
Following the incidents, over 70,000 suspected anthrax samples were
tested in laboratories across the country. According to preliminary
data from our interviews and review of 2003 progress reports, officials
reported that CDC funds enabled them to make improvements to their
laboratory infrastructure, including upgrading their laboratory
facilities, purchasing reagents and equipment, and improving their
capability to test for select biologic agents.
Officials in the states we visited in 2002 were working on other
solutions to their laboratory problems. States were examining various
ways to manage peak loads, including entering into agreements with
other states to provide surge capacity, incorporating clinical
laboratories into cooperative laboratory systems, and purchasing new
equipment. One state was working to alleviate its laboratory problems
by upgrading two local public health laboratories to enable them to
process samples of more dangerous pathogens and by establishing
agreements with other states to provide backup capacity. Another state
reported that it was using the funding from CDC to increase the number
of pathogens the state laboratory could diagnose. The state also
reported that it has worked to identify laboratories in adjacent states
that are capable of being reached within 3 hours over surface roads. In
addition, all of the states reported that their laboratory response
plans had been revised to cover reporting and sharing laboratory
results with local public health and law enforcement agencies.
Workforce:
At the time of our early 2002 site visits, shortages in personnel
existed in state and local public health departments and laboratories
and were difficult to remedy. Officials from state and local health
departments told us that staffing shortages were a major concern. Two
of the states and cities that we visited were particularly concerned
that they did not have enough epidemiologists to do the appropriate
investigations in an emergency. Officials at one state department of
public health we visited said that the department had lost
approximately one-third of its staff because of budget cuts over the
past decade. This department had been attempting to hire more
epidemiologists. Barriers to finding and hiring epidemiologists
included noncompetitive salaries and a general shortage of people with
the necessary skills.
Workforce capacity issues may also hinder implementation of infectious
disease control measures. For example, the shortage of epidemiologists
could grow worse if, in the event of a severe outbreak, existing health
care workers became infected as a result of their more frequent
exposure to a contaminated environment or became exhausted working
longer hours. Workforce shortages could be further exacerbated because
of the need to conduct contact tracing.[Footnote 9] According to World
Health Organization officials, an individual infected with SARS came in
contact with, on average, 30 to 40 people in Asian countries--all of
whom had to be contacted and informed of their possible exposure.
During our site visits in early 2002, shortages in laboratory personnel
were also cited. Officials in one city noted that they had difficulty
filling and maintaining laboratory positions and that people that
accepted the positions often left the health department for better-
paying positions. Increased funding for hiring staff cannot necessarily
solve these shortages in the near term because for many types of
laboratory positions there are not enough trained individuals in the
workforce. According to the Association of Public Health Laboratories,
training laboratory personnel to provide them with the necessary skills
will take time and require a strategy for building the needed
workforce.[Footnote 10] For our current work updating these findings,
many of the state and local officials we interviewed cited shortages in
trained epidemiologists or laboratory personnel as persistent.
In 2002, state and local officials told us that sustained funding would
be necessary to address one important need--hiring and retaining needed
staff. They told us they would be reluctant to hire additional staff
unless they were confident that the funding would be sustained and
staff could be retained. These statements are consistent with the
findings of the Advisory Panel to Assess Domestic Response Capabilities
for Terrorism Involving Weapons of Mass Destruction, which recommended
that federal support for state and local public health preparedness and
infrastructure building be sustained at an annual rate of $1 billion
for the next 5 years to have a material impact on state and local
governments' preparedness for a bioterrorist event.[Footnote 11] We
have noted previously that federal, state, and local governments have a
shared responsibility in preparing for terrorist attacks and other
disasters.[Footnote 12] However, prior to the infusion of federal
funds, few states were investing in their public health infrastructure.
Communication:
We found that officials were beginning to address communication
problems. For example, six of the seven cities we visited in early 2002
were examining how communication would take place in a public health
emergency. Many cities had purchased communication systems that allow
officials from different organizations to communicate with one another
in real time. In addition, state and local health agencies were working
with CDC to build the Health Alert Network (HAN), an information and
communication system. The nationwide HAN program has provided funding
to establish infrastructure at the local level to improve the
collection and transmission of information related to public health
preparedness. Goals of the HAN program include providing high-speed
Internet connectivity, broadcast capacity for emergency communication,
and distance-learning infrastructure for training. For our current
work, our preliminary review of the 2003 progress reports from 12
jurisdictions shows that 11 reported that over 90 percent of their
population was covered by HAN.
Some State and Local Contingency Planning Underway, but Regional
Coordination Is Lacking:
As part of the effort to prepare for a possible outbreak of an
infectious disease, there is contingency planning at the state and
local levels. Health departments, for instance, are in the process of
developing contingency response plans for SARS. The SARS preparations
have been modeled after a checklist designed for pandemic influenza. To
facilitate these preparations, the Association of State and Territorial
Health Officials and the National Association of County and City Health
Officials, in collaboration with CDC, published a checklist for state
and local health officials to use in the event of a SARS resurgence.
The checklist encompasses a broad spectrum of preparedness activities,
such as legal issues related to isolation and quarantine, strategies
for communicating information to health care providers, and suggestions
for ensuring other community partners such as law enforcement and
school officials are prepared.
During our 2002 site visits, however, we found that response
organization officials were concerned about a lack of planning for
regional coordination between states during an infectious disease
outbreak. As called for by the guidance for the CDC and HRSA funding,
all of the states we visited in 2002 organized their planning on the
basis of regions within their states, assigning local areas to
particular regions for planning purposes. A concern for response
organization officials was the lack of planning for regional
coordination between states. A hospital official in one city we visited
said that state lines presented a "real wall" for planning purposes.
Hospital officials in one state reported that they had no agreements
with other states to share physicians. However, one local official
reported that he had been discussing these issues and had drafted
mutual aid agreements for hospitals and emergency medical services.
Public health officials from several states reported developing working
relationships with officials from other states to provide backup
laboratory capacity.
Hospital Preparedness Improved, but Limitations in Response Capacity
Remain:
Because those with symptoms of an infectious disease might go to
emergency departments for treatment, hospital personnel would likely be
some of the first healthcare workers with the opportunity to identify
an emerging infectious disease outbreak. Therefore, the disease
surveillance capacities of many state and local public health systems
may depend, in part, on the surveillance capabilities of hospitals.
Most hospitals reported training their staff and planning coordination
efforts with other public health entities. However, even with these
preparations in place, hospitals lacked the capacity to respond to
large-scale infectious disease outbreaks.
Hospitals Provide Vital Disease Surveillance Capacity:
The disease surveillance capacities of many state and local public
health systems may depend, in part, on the surveillance capabilities of
hospitals. During the recent SARS outbreak in North America, for
instance, hospital emergency rooms played an important role in
identifying those who had the disease. According to hospital officials
in California and New York, hospital emergency room or other waiting
room staff routinely used questionnaires to screen incoming patients
for fever, cough, and travel to a country with active cases of SARS.
They said that hospitals' signs in various locations generally used by
incoming patients and visitors also asked individuals to identify
themselves to hospital staff if they met these criteria. In Toronto,
which experienced a much greater prevalence of SARS than the United
States, everyone entering a hospital was required to answer screening
questions and to have their temperature checked before they were
allowed to enter.
Most Hospitals Reported Planning and Training Efforts, but Fewer Than
Half Have Participated in Drills or Exercises:
In our survey of over 2,000 metropolitan hospitals,[Footnote 13] most
reported that they have provided training to staff on biological
agents, but fewer than half have participated in drills or exercises
related to bioterrorism. Most hospitals we surveyed reported providing
training about identifying and diagnosing symptoms for the six
biological agents identified by the CDC as most likely to be used in a
bioterrorist attack. At least 90 percent of hospitals reported
providing training for two of these agents--smallpox and anthrax--and
approximately three-fourths of hospitals reported providing training
about the other four--plague, botulism, tularemia, and hemorrhagic
fever viruses.
Our hospital survey found that 4 out of 5 hospitals reported having a
written emergency response plan for large-scale infectious disease
outbreaks. Of the hospitals with emergency response plans, most include
a description of how to achieve surge capacity for obtaining additional
pharmaceuticals, other supplies, and staff. In addition, almost all
hospitals reported participating in community interagency disaster
preparedness committees.
At the time of our site visits between December 2001 and March 2002, we
found that hospitals were beginning to coordinate with other local
response organizations and collaborate with each other in local
planning efforts. Hospital officials in one city we visited told us
that until September 11, 2001, hospitals were not seen as part of a
response to a terrorist event but that city officials had come to
realize that the first responders to a bioterrorism incident could be a
hospital's medical staff. Officials from the state began to emphasize
the need for a local approach to hospital preparedness. They said,
however, that it was difficult to impress the importance of cooperation
on hospitals because hospitals had not seen themselves as part of a
local response system. The local government officials were asking them
to create plans that integrated the city's hospitals and addressed such
issues as off-site triage of patients and off-site acute care.
Most Emergency Departments Have Experienced Some Degree of Crowding:
Our survey of metropolitan hospitals found that most emergency
departments have experienced some degree of overcrowding.[Footnote 14]
Persons with symptoms of infectious disease would potentially go to
emergency departments for treatment, further stressing these
facilities. The problem of overcrowding is much more pronounced in some
hospitals and areas than in others. In general, hospitals that reported
the most problems with crowding were in the largest metropolitan
statistical areas (MSA) and in the MSAs with high population growth.
For example, in fiscal year 2001, hospitals in MSAs with populations of
2.5 million or more had about 162 hours of diversion (an indicator of
crowding),[Footnote 15] compared with about 9 hours for hospitals in
MSAs with populations of less than 1 million. Also, the median number
of hours of diversion in fiscal year 2001 for hospitals in MSAs with a
high percentage population growth was about five times that for
hospitals in MSAs with lower percentage population growth.
Hospitals in the largest MSAs and in MSAs with high population growth
that have reported crowding in emergency departments may have
difficulty handling a large influx of patients during a potential
infectious disease outbreak, especially if this outbreak occurred in
the winter months when the incidence of influenza is quite high. For
example, public health officials with whom we spoke said that in the
event of a large-scale SARS outbreak, entire hospital wards may need to
be used as separate SARS isolation facilities. Moreover, certain
hospitals within a community may need to be designated as SARS
hospitals.
Concluding Observations:
Efforts at the state and local level have improved the ability to
identify and respond to infectious disease outbreaks and bioterrorism.
These improvements have included upgrades to laboratory facilities and
communication systems. Hospitals have also begun planning and training
efforts to respond to large-scale infectious disease outbreaks. Despite
these improvements, gaps in preparedness remain. We found that some
disease surveillance systems may be inadequate, that there are
shortages of key personnel in some localities, and that most hospital
emergency departments across the country have experienced some degree
of overcrowding, which could be exacerbated during a disease outbreak.
Mr. Chairman, this completes my prepared statement. I would be happy to
respond to any questions you or other Members of the Subcommittee may
have at this time.
Contact and Staff Acknowledgments:
For further information about this testimony, please contact Janet
Heinrich at (202) 512-7119. Angela Choy, Krister Friday, Martin T.
Gahart, Gay Hee Lee, and Deborah Miller also made key contributions to
this statement.
[End of section]
Related GAO Products:
Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but
Lack Certain Capacities for Bioterrorism Response. GAO-03-924.
Washington, D.C.: August 6, 2003.
Severe Acute Respiratory Syndrome: Established Infectious Disease
Control Measures Helped Contain Spread, But a Large-Scale Resurgence
May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003.
Bioterrorism: Information Technology Strategy Could Strengthen Federal
Agencies' Abilities to Respond to Public Health Emergencies. GAO-03-
139. Washington, D.C.: May 30, 2003.
SARS Outbreak: Improvements to Public Health Capacity are Needed for
Responding to Bioterrorism and Emerging Infectious Diseases. GAO-03-
769T. Washington, D.C.: May 7, 2003.
Smallpox Vaccination: Implementation of National Program Faces
Challenges. GAO-03-578. Washington, D.C.: April 30, 2003.
Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have
Improved Public Health Response Capacity, but Gaps Remain. GAO-03-654T.
Washington, D.C.: April 9, 2003.
Bioterrorism: Preparedness Varied across State and Local Jurisdictions.
GAO-03-373. Washington, D.C.: April 7, 2003.
Hospital Emergency Departments: Crowded Conditions Vary among Hospitals
and Communities. GAO-03-460. Washington, D.C.: March 14, 2003.
Homeland Security: New Department Could Improve Coordination but
Transferring Control of Certain Public Health Programs Raises Concerns.
GAO-02-954T. Washington, D.C.: July 16, 2002.
Homeland Security: New Department Could Improve Biomedical R&D
Coordination but May Disrupt Dual-Purpose Efforts. GAO-02-924T.
Washington, D.C.: July 9, 2002.
Homeland Security: New Department Could Improve Coordination but May
Complicate Priority Setting. GAO-02-893T. Washington, D.C.: June 28,
2002.
Homeland Security: New Department Could Improve Coordination but May
Complicate Public Health Priority Setting. GAO-02-883T. Washington,
D.C.: June 25, 2002.
Bioterrorism: The Centers for Disease Control and Prevention's Role in
Public Health Protection. GAO-02-235T. Washington, D.C.: November 15,
2001.
Bioterrorism: Review of Public Health Preparedness Programs. GAO-02-
149T. Washington, D.C.: October 10, 2001.
Bioterrorism: Public Health and Medical Preparedness. GAO-02-141T.
Washington, D.C.: October 9, 2001.
Bioterrorism: Coordination and Preparedness. GAO-02-129T. Washington,
D.C.: October 5, 2001.
Bioterrorism: Federal Research and Preparedness Activities. GAO-01-
915. Washington, D.C.: September 28, 2001.
West Nile Virus Outbreak: Lessons for Public Health Preparedness. GAO/
HEHS-00-180. Washington, D.C.: September 11, 2000.
Combating Terrorism: Need for Comprehensive Threat and Risk Assessments
of Chemical and Biological Attacks. GAO/NSIAD-99-163. Washington, D.C.:
September 14, 1999.
Combating Terrorism: Observations on Biological Terrorism and Public
Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16,
1999.
FOOTNOTES
[1] Disease surveillance uses systems that provide for the ongoing
collection, analysis, and dissemination of health-related data to
identify, prevent, and control disease.
[2] SARS is the abbreviation for severe acute respiratory syndrome.
[3] U.S. General Accounting Office, Bioterrorism: Preparedness Varied
across State and Local Jurisdictions, GAO-03-373 (Washington, D.C.:
Apr. 7, 2003).
[4] Findings from the survey include those related to emergency
department capacity, which we reported in U.S. General Accounting
Office, Hospital Emergency Departments: Crowded Conditions Vary among
Hospitals and Communities, GAO-03-460 (Washington, D.C.: Mar. 14, 2003)
and to hospital emergency preparedness for mass casualty incidents,
which we reported in U.S. General Accounting Office, Hospital
Preparedness: Most Urban Hospitals Have Emergency Plans but Lack
Certain Capacities for Bioterrorism Response, GAO-03-924 (Washington,
D.C.: Aug. 6, 2003).
[5] CDC developed a critical agent list that focuses on the biological
agents that would have the greatest impact on public health. This list
includes a category of agents identified by CDC as most likely to be
used in a bioterrorist attack and includes communicable diseases such
as smallpox and pneumonic plague.
[6] Passive surveillance systems rely on laboratory and hospital staff,
physicians, and other relevant sources to take the initiative to
provide data on illnesses to the health department, where officials
analyze and interpret the information as it arrives. In contrast, in an
active disease surveillance system, public health officials contact
sources, such as laboratories, hospitals, and physicians, to obtain
information on conditions or diseases in order to identify cases.
Active surveillance can provide more complete detection of disease
patterns than a system that is wholly dependent on voluntary reporting.
[7] Officials in one city told us that although it had no local disease
surveillance, its state maintained a passive disease surveillance
system.
[8] This type of active surveillance system in which the public health
department obtains information from such sources as hospitals and
pharmacies and conducts ongoing analysis of the data to search for
certain combinations of signs and symptoms, is sometimes referred to as
a syndromic surveillance system. A senior HHS official stated that
research examining the usefulness of syndromic surveillance needs to
continue. See S. Lillibridge, Disease Surveillance, Bioterrorism, and
Homeland Security, Conference Summary and Proceedings Prepared by the
Annapolis Center for Science-Based Public Policy (Annapolis, Md.: U.S.
Medicine Institute for Health Studies, Dec. 4, 2001).
[9] Contact tracing is the identification and tracking of individuals
who may have been exposed to a person with a specific disease.
[10] Association of Public Health Laboratories, "State Public Health
Laboratory Bioterrorism Capacity," Public Health Laboratory Issues in
Brief: Bioterrorism Capacity (Washington, D.C.: October 2002).
[11] Advisory Panel to Assess Domestic Response Capabilities for
Terrorism Involving Weapons of Mass Destruction, Fourth Annual Report
to the President and the Congress of the Advisory Panel to Assess
Domestic Response Capabilities for Terrorism Involving Weapons of Mass
Destruction (Arlington, Va.: RAND, Dec. 15, 2002). The Advisory Panel
was established to assess federal agency efforts to enhance domestic
preparedness, the progress of federal training programs for local
emergency responses, and deficiencies in federal programs for response
to incidents involving weapons of mass destruction; to recommend
strategies for ensuring effective coordination of federal agency
response efforts and for ensuring fully effective local response
capabilities for weapons of mass destruction incidents; and to assess
appropriate state and local roles in funding effective local response
capabilities. The Advisory Panel issues annual reports to the President
and to the Congress and has submitted four annuals reports to date.
[12] See U.S. General Accounting Office, Homeland Security: Effective
Intergovernmental Coordination Is Key to Success, GAO-02-1013T
(Washington, D.C.: Aug. 23, 2002).
[13] Between May and September 2002, we surveyed over 2,000 short-term,
nonfederal general medical and surgical hospitals with emergency
departments located in metropolitan statistical areas. (See U.S.
General Accounting Office, Hospital Emergency Departments: Crowded
Conditions Vary among Hospitals and Communities, GAO-03-460
(Washington, D.C.: Mar. 14, 2003) for information on the survey
universe and development of the survey.) For the part of the survey
that specifically addressed hospital preparedness for mass casualty
incidents, we obtained responses from 1,482 hospitals, a response rate
of about 73 percent.
[14] GAO-03-460.
[15] Diversions occur when hospitals request that en route ambulances
bypass their emergency departments and transport patients that would
have otherwise been taken to those emergency departments to other
medical facilities.
