HHS Bioterrorism Preparedness Programs
States Reported Progress but Fell Short of Program Goals for 2002
Gao ID: GAO-04-360R February 10, 2004
The anthrax incidents during the fall of 2001 raised concerns about the nation's ability to respond to bioterrorist events and other public health threats. The incidents strained the public health system, including surveillance and laboratory workforce capacities, at the state and local levels. Several months after the incidents, the Congress appropriated funds to strengthen state and local bioterrorism preparedness. The Department of Health and Human Services' (HHS) Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA) distributed the funds in 2002 through two cooperative agreement programs with state, municipal, and territorial governments. To strengthen preparedness, the two cooperative agreement programs--CDC's Public Health Preparedness and Response for Bioterrorism Program and HRSA's National Bioterrorism Hospital Preparedness Program--require participants to complete specific activities designed to build public health and health care capacities. The 2002 cooperative agreements for both programs ended on August 30, 2003. For the 2002 cooperative agreements, CDC's and HRSA's programs distributed approximately $918 million and approximately $125 million, respectively. The Public Health Security and Bioterrorism Preparedness and Response Act of 2002 directs us to report on federal programs that support preparedness efforts at the state and local levels. We have previously reported on state and local efforts and hospital preparedness. As agreed with the committees of jurisdiction, for this report, we examined the extent to which states completed 2002 cooperative agreement requirements and whether states identified any factors that hindered implementation of CDC's program and HRSA's program.
States reported progress toward the CDC program's goal of strengthening public health preparedness, but identified factors that hindered them from meeting all of CDC's 2002 cooperative agreement requirements. All states reported progress in developing the capacities CDC considers critical for public health preparedness, but no state completed all program requirements. Some of the 14 requirements that CDC considers critical benchmarks of preparedness were more likely to be completed than others. Four critical benchmarks were met by most of the states. These benchmarks included the establishment of a bioterrorism advisory committee and coverage of 90 percent of the state's population by the Health Alert Network--a nationwide program designed to ensure communication capacity at all state and local health departments. Two critical benchmarks were met by few of the states: development of a statewide response plan and development of a regional response plan. The remaining eight critical benchmarks were met by around half the states. These benchmarks included assessment of emergency preparedness and response capabilities, development of a system that can receive and evaluate urgent disease reports at all times, and development of an interim Strategic National Stockpile plan. In addition, state and local officials reported three main factors that hindered their ability to complete all of CDC's requirements: (1) redirection of resources to the National Smallpox Vaccination Program, (2) difficulties in increasing personnel as a result of state and local budget deficits, and (3) delays caused by state and local management practices, such as contracting and hiring procedures. Similarly, states reported progress toward the HRSA program's goal of strengthening hospital preparedness but identified factors that have hindered their efforts to complete all of HRSA's 2002 program requirements. While no state has completed all of HRSA's requirements--to conduct needs assessments, to meet three critical benchmarks of hospital preparedness, and to address priority issues--states have until March 31, 2004, to complete most of them. No state reported completing all components of its needs assessment. Almost all states reported that they had met two of the three critical benchmarks: designation of a coordinator for hospital preparedness planning and establishment of a hospital preparedness planning committee. No state reported meeting the third benchmark--development of a plan for the hospitals in the state to respond to an epidemic involving at least 500 patients. States reported varying degrees of progress in addressing the priority issues that HRSA required them to address, such as receipt and distribution of medications and vaccines, personal protection of health care workers, quarantine capacity, and communications. State officials expressed concern that HRSA funding was insufficient for states to meet the requirements of the 2002 program. Similarly, hospital representatives reported that redirection of resources to the National Smallpox Vaccination Program and delays caused by lengthy contracting processes for distributing funds from the state to the hospitals hindered efforts to implement the program.
GAO-04-360R, HHS Bioterrorism Preparedness Programs: States Reported Progress but Fell Short of Program Goals for 2002
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February 10, 2004:
Congressional Committees:
Subject: HHS Bioterrorism Preparedness Programs: States Reported
Progress but Fell Short of Program Goals for 2002:
The anthrax incidents during the fall of 2001 raised concerns about the
nation's ability to respond to bioterrorist events and other public
health threats. The incidents strained the public health system,
including surveillance[Footnote 1] and laboratory workforce
capacities, at the state and local levels.[Footnote 2] Several months
after the incidents, the Congress appropriated funds to strengthen
state and local bioterrorism preparedness.[Footnote 3] The Department
of Health and Human Services' (HHS) Centers for Disease Control and
Prevention (CDC) and Health Resources and Services Administration
(HRSA) distributed the funds in 2002 through two cooperative agreement
programs with state, municipal, and territorial governments.[Footnote
4]
To strengthen preparedness, the two cooperative agreement programs--
CDC's Public Health Preparedness and Response for Bioterrorism Program
and HRSA's National Bioterrorism Hospital Preparedness Program--
require participants to complete specific activities designed to build
public health and health care capacities. The 2002 cooperative
agreements for both programs ended on August 30, 2003. For the 2002
cooperative agreements, CDC's and HRSA's programs distributed
approximately $918 million and approximately $125 million,
respectively.[Footnote 5]
The Public Health Security and Bioterrorism Preparedness and Response
Act of 2002 directs us to report on federal programs that support
preparedness efforts at the state and local levels.[Footnote 6] We have
previously reported on state and local efforts and hospital
preparedness.[Footnote 7] As agreed with the committees of
jurisdiction, for this report, we examined the extent to which states
completed 2002 cooperative agreement requirements and whether states
identified any factors that hindered implementation of CDC's program
and HRSA's program. In this report, we use the term "state" to refer to
the 50 states, the District of Columbia, New York City, Chicago, and
Los Angeles County. Enclosure I contains the information we provided
during our January 14, 2004 briefing of your staff.
To determine the extent to which states had completed program
requirements, we relied primarily on the cooperative agreement progress
reports that CDC and HRSA required the states to submit. We checked the
data for internal consistency as well as consistency with other sources
and determined that they were adequate for our purposes. We reviewed
semi-annual progress reports submitted by the states, covering the
period through August 30, 2003, for CDC's program and through July 1,
2003, for HRSA's program.[Footnote 8] For a number of reasons, we use
broad categories to describe the degree of progress states have made in
completing requirements. These reasons include: CDC and HRSA changed
the reporting formats over the course of the agreements, states had
varying interpretations of what constituted completion of the
requirements, and the final reports do not reflect follow-up by CDC and
HRSA to clarify states' responses. We also interviewed officials and
reviewed relevant documents from CDC, HRSA, and HHS's Office of the
Assistant Secretary for Public Health Emergency Preparedness. We also
interviewed officials from 10 states, 1 local health department within
each of these states, and 2 major metropolitan areas directly funded by
CDC and HRSA.[Footnote 9] The program participants are not identified
in this report because of the sensitive nature of the issue. In
addition, we interviewed representatives and reviewed documents from
the Association of State and Territorial Health Officials and the
American Hospital Association and its affiliates. We reviewed documents
from the National Association of County and City Health Officials, the
Council of State and Territorial Epidemiologists, and the Association
of Public Health Laboratories. We performed our work from June 2003
through February 2004 in accordance with generally accepted government
auditing standards.
Results:
States reported progress toward the CDC program's goal of strengthening
public health preparedness, but identified factors that hindered them
from meeting all of CDC's 2002 cooperative agreement requirements. All
states reported progress in developing the capacities CDC considers
critical for public health preparedness, but no state completed all
program requirements. Some of the 14 requirements that CDC considers
critical benchmarks of preparedness were more likely to be completed
than others. Four critical benchmarks were met by most of the states.
These benchmarks included the establishment of a bioterrorism advisory
committee and coverage of 90 percent of the state's population by the
Health Alert Network--a nationwide program designed to ensure
communication capacity at all state and local health departments. Two
critical benchmarks were met by few of the states: development of a
statewide response plan and development of a regional response plan.
The remaining eight critical benchmarks were met by around half the
states. These benchmarks included assessment of emergency preparedness
and response capabilities, development of a system that can receive and
evaluate urgent disease reports at all times, and development of an
interim Strategic National Stockpile[Footnote 10] plan. In addition,
state and local officials reported three main factors that hindered
their ability to complete all of CDC's requirements: (1) redirection of
resources to the National Smallpox Vaccination Program,[Footnote 11]
(2) difficulties in increasing personnel as a result of state and local
budget deficits, and (3) delays caused by state and local management
practices, such as contracting and hiring procedures.
Similarly, states reported progress toward the HRSA program's goal of
strengthening hospital preparedness but identified factors that have
hindered their efforts to complete all of HRSA's 2002 program
requirements. While no state has completed all of HRSA's requirements-
-to conduct needs assessments, to meet three critical benchmarks of
hospital preparedness, and to address priority issues--states have
until March 31, 2004, to complete most of them. No state reported
completing all components of its needs assessment. Almost all states
reported that they had met two of the three critical benchmarks:
designation of a coordinator for hospital preparedness planning and
establishment of a hospital preparedness planning
committee. No state reported meeting the third benchmark--development
of a plan for the hospitals in the state to respond to an epidemic
involving at least 500 patients. States reported varying degrees of
progress in addressing the priority issues that HRSA required them to
address, such as receipt and distribution of medications and vaccines,
personal protection of health care workers, quarantine capacity, and
communications. State officials expressed concern that HRSA funding was
insufficient for states to meet the requirements of the 2002 program.
Similarly, hospital representatives reported that redirection of
resources to the National Smallpox Vaccination Program and delays
caused by lengthy contracting processes for distributing funds from the
state to the hospitals hindered efforts to implement the program.
In summary, although the states' progress fell short of 2002 program
goals, CDC's and HRSA's cooperative agreement programs have enabled
states to make much needed improvements in the public health and health
care capacities critical for preparedness. States are more prepared now
than they were prior to these programs, but much remains to be
accomplished.
Agency Comments:
We provided a draft of this report to HHS. HHS informed us that it had
no comment on the draft report but provided technical comments, which
we incorporated where appropriate.
We are sending copies of this report to the Secretary of HHS, the
Director of CDC, the Administrator of HRSA, and other interested
officials. We will also provide copies to others upon request. In
addition, the report will be available at no charge on the GAO Web site
at http://www.gao.gov.
If you or your staff have any questions or need additional information,
please contact me at (202) 512-7119. Another contact and key
contributors are listed in enclosure III.
Janet Heinrich:
Director, Health Care--Public Health Issues:
Signed by Janet Heinrich:
Enclosures - 3:
List of Committees:
The Honorable Judd Gregg:
Chairman:
The Honorable Edward M. Kennedy:
Ranking Minority Member:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
The Honorable Ted Stevens:
Chairman:
The Honorable Robert C. Byrd:
Ranking Minority Member:
Committee on Appropriations:
United States Senate:
The Honorable W.J. "Billy" Tauzin:
Chairman:
The Honorable John D. Dingell:
Ranking Minority Member:
Committee on Energy and Commerce:
House of Representatives:
The Honorable C.W. Bill Young:
Chairman:
The Honorable David R. Obey:
Ranking Minority Member:
Committee on Appropriations:
House of Representatives:
Enclosure 1:
[See PDF for slideshow]
[End of slideshow]
CDC Focus Areas, Critical Capacities, and Critical Benchmarks (2002):
To strengthen public health preparedness, CDC identified focus areas
for states to improve their public health capacity. Within each focus
area, CDC identified the specific capacities that are critical for
states to be prepared to respond to a bioterrorist event or other
public health emergency. To guide states in building these critical
capacities, CDC specified a number of requirements for the 2002
cooperative agreements, and designated some of them as critical
benchmarks. Table 1 lists the focus areas and their associated critical
capacities and critical benchmarks.
Table 1: CDC Focus Areas, Critical Capacities, and Critical Benchmarks
for the 2002 Cooperative Agreements:
Focus area: Focus area A; Critical capacity: Preparedness Planning and
Readiness Assessment;
Critical capacity #1: To establish a process for strategic leadership,
direction, coordination, and assessment of activities to ensure state
and local readiness, interagency collaboration, and preparedness for
bioterrorism, other outbreaks of infectious disease, and other public
health threats and emergencies; Critical benchmark: Critical benchmark
#1: Designate an executive director of the bioterrorism preparedness
and response program; Critical benchmark #2: Establish a bioterrorism
advisory committee.
Critical capacity #2: To conduct integrated assessments of public
health system capacities related to bioterrorism, other infectious
disease outbreaks, and other public health threats and emergencies to
aid and improve planning, coordination, and implementation; Critical
benchmark: Critical benchmark #3: Assessment of emergency preparedness
and response capabilities; Critical benchmark #4: Assessment of
statutes, regulations, and ordinances that provide for credentialing,
licensure, and delegation of authority for executing emergency public
health measures.
Critical capacity #3: To respond to emergencies caused by bioterrorism,
other infectious disease outbreaks, and other public health threats and
emergencies through the development and exercise of a comprehensive
public health emergency preparedness and response plan; Critical
benchmark: Critical benchmark #5: Development of a statewide response
plan and provisions for exercising the plan; Critical benchmark #6:
Development of regional response plans.
Critical capacity #4: To ensure that state, local, and regional
preparedness for and response to bioterrorism, other infectious
outbreaks, and other public health threats and emergencies are
effectively coordinated with federal response assets; Critical
benchmark: Critical benchmark #7: Develop an interim plan to receive
and manage items from the Strategic National Stockpile (SNS).
Critical capacity #5: To effectively manage the CDC SNS, should it be
deployed--translating SNS plans into firm preparations, periodic
testing of SNS preparedness, and periodic training for entities and
individuals that are part of SNS preparedness; Critical benchmark: No
critical benchmarks were identified for 2002 cooperative agreements.
Focus area: Focus area B; Critical capacity: Surveillance and
Epidemiology Capacity;
Critical capacity #6: To rapidly detect a terrorist event through a
highly functioning, mandatory reportable disease surveillance system,
as evidenced by ongoing timely and complete reporting by providers and
laboratories, especially of illnesses and conditions possibly resulting
from bioterrorism, other infectious disease outbreaks, and other public
health threats and emergencies; Critical benchmark: Critical benchmark
#8: Develop a system to receive and evaluate urgent disease reports on
a 24-hour-per-day, 7-day-per-week basis.
Critical capacity #7: To rapidly and effectively investigate and
respond to a potential terrorist event as evidenced by a comprehensive
and exercised epidemiologic response plan that addresses surge
capacity, delivery of mass prophylaxis and immunizations, and pre-event
development of specific epidemiologic investigation and response needs;
Critical benchmark: Critical benchmark #9: Assess current epidemiologic
capacity and achieve the goal of at least one epidemiologist for each
metropolitan statistical area.
Critical capacity #8: To rapidly and effectively investigate and
respond to a potential terrorist event, as evidenced by ongoing
effective state and local response to naturally occurring individual
cases of urgent public health importance, outbreaks of disease, and
emergency public health interventions such as emergency
chemoprophylaxis or immunization activities; Critical benchmark: No
critical benchmarks were identified for 2002 cooperative agreements.
Focus area: Focus area C; Critical capacity: Laboratory Capacity--
Biologic Agents;
Critical capacity #9: To develop and implement a statewide program to
provide rapid and effective laboratory services in support of the
response to bioterrorism, other infectious disease outbreaks, and other
public health threats and emergencies; Critical benchmark: Critical
benchmark #10: Develop a plan to improve working relationships and
communication between clinical labs and higher level Laboratory
Response Network (LRN)[A] labs.
Critical capacity #10: As an LRN member, to ensure adequate and secure
laboratory facilities, reagents, and equipment to rapidly detect and
correctly identify biological agents likely to be used in a
bioterrorist incident; Critical benchmark: No critical benchmarks were
identified for 2002 cooperative agreements.
Focus area: Focus area D; Critical capacity: Laboratory Capacity--
Chemical Agents;
Critical capacity: No critical capacities/benchmarks were identified
for 2002 cooperative agreements; Critical benchmark:
Focus area: Focus area E; Critical capacity: Health Alert Network/
Communications and Information Technology.
Critical capacity #11: To ensure effective communications connectivity
among public health departments, health care organizations, law
enforcement organizations, public officials, and others by: (a)
continuous, high-speed connectivity to the Internet; (b) routine use of
e-mail for notification of alerts and other critical communication; and
(c) a directory of public health participants (including primary
clinical personnel), their roles, and contact information covering all
jurisdictions; Critical benchmark: Critical benchmark #11: Ensure that
90 percent of the population is covered by the Health Alert Network;
Critical benchmark #12: Develop a communications system that provides a
24-hour-per-day, 7-day-per-week flow of critical health information.
Critical capacity #12: To ensure a method of emergency communication
for participants in public health emergency response that is fully
redundant with e-mail; Critical benchmark: No critical benchmarks were
identified for 2002 cooperative agreements.
Critical capacity #13: To ensure the ongoing protection of critical
data and information systems and capabilities for continuity of
operations; Critical benchmark: No critical benchmarks were identified
for 2002 cooperative agreements.
Critical capacity #14: To ensure secure electronic exchange of
clinical, laboratory, environmental, and other public health
information in standard formats between the computer systems of public
health partners; Critical benchmark: No critical benchmarks were
identified for 2002 cooperative agreements.
Focus area: Focus area F; Critical capacity: Risk Communication and
Health Information Dissemination.
Critical capacity #15: To provide needed health/risk information to the
public and key partners during a terrorism event by establishing
critical baseline information about the current communication needs and
barriers within individual communities, and identifying effective
channels of communication for reaching the general public and special
populations during public health threats and emergencies; Critical
benchmark: Critical benchmark #13: Develop an interim plan for risk
communication and information dissemination.
Focus area: Focus area G; Critical capacity: Education and Training;
Critical capacity #16: To ensure the delivery of appropriate education
and training to key public health professionals, infectious disease
specialists, emergency department personnel, and other health care
providers in preparedness for and response to bioterrorism, other
infectious disease outbreaks, and other public health threats and
emergencies, either directly or through the use (where possible) of
existing curricula and other sources, including schools of public
health and medicine, academic health centers, CDC training networks,
and other providers; Critical capacity #16: To ensure the delivery of
appropriate education and training to key public health professionals,
infectious disease specialists, emergency department personnel, and
other health care providers in preparedness for and response to
bioterrorism, other infectious disease outbreaks, and other public
health threats and emergencies, either directly or through the use
(where possible) of existing curricula and other sources, including
schools of public health and medicine, academic health centers, CDC
training networks, and other providers; Critical benchmark: Critical
benchmark #14: Prepare a timeline to assess training needs.
Source: CDC.
[A] CDC established the LRN to maintain state-of-the-art capabilities
for biological agent identification and characterization. The LRN is a
multilevel system designed to link state and local public health
laboratories with advanced capacity clinical, military, veterinary,
agricultural, water, and food-testing laboratories.
[End of table]
Enclosure III:
GAO Contact and Staff Acknowledgments:
GAO Contact:
Michele Orza, (202) 512-6970:
Acknowledgments:
The following staff members made important contributions to this work:
Angela:
Choy, Chad Davenport, Maria Hewitt, Krister Friday, and Nkeruka
Okonmah.
(290293):
FOOTNOTES
[1] Public health surveillance uses systems that provide for the
ongoing collection, analysis, and dissemination of health-related data
to identify, prevent, and control disease.
[2] See U.S. General Accounting Office, Bioterrorism: Public Health
Response to Anthrax Incidents of 2001, GAO-04-152 (Washington, D.C.:
Oct. 15, 2003).
[3] Department of Defense and Emergency Supplemental Appropriations for
Recovery from and Response to Terrorist Attacks on the United States
Act, Pub. L. No. 107-117, 115 Stat. 2230, 2314 (2002), and the
Departments of Labor, Health and Human Services and Education, and
Related Agencies Appropriations Act of Fiscal Year 2002, Pub. L. No.
107-116, 115 Stat. 2186, 2198.
[4] A cooperative agreement is used as a mechanism to provide financial
support when substantial interaction is expected between the executive
agency and a state, local government, or other recipient carrying out
the funded activity. Under their programs, CDC and HRSA made funding
available to the following: all 50 states; the District of Columbia;
the country's three largest municipalities (New York City, Chicago, and
Los Angeles County); the territories of American Samoa, Guam, and the
U.S. Virgin Islands; and the commonwealths of the Northern Mariana
Islands and Puerto Rico. CDC also made funding available to the
republics of Palau and the Marshall Islands and the Federated States of
Micronesia.
[5] In 2003, the Congress appropriated additional funds for
bioterrorism preparedness. Consolidated Appropriations Resolution,
2003, Pub. L. No. 108-7, Division G, Title II, 117 Stat. 11, 322. HHS
renewed the cooperative agreements for the period of August 31, 2003
through August 30, 2004. CDC's and HRSA's programs distributed about
$870 million and about $498 million, respectively.
[6] Pub. L. No. 107-188, § 157, 116 Stat. 594, 633 (2002).
[7] U.S. General Accounting Office, Bioterrorism: Preparedness Varied
across State and Local Jurisdictions, GAO-03-373 (Washington, D.C.:
Apr. 7, 2003), and Hospital Preparedness: Most Urban Hospitals Have
Emergency Plans but Lack Certain Capacities for Bioterrorism Response,
GAO-03-924 (Washington, D.C.: Aug. 6, 2003).
[8] The final progress report for one state was missing for the CDC
program. HRSA did not require states to complete some of the
requirements until March 31, 2004.
[9] We selected these program participants in order to provide a range
of population sizes, geographic locations, and experience with
responding to disasters and conducting large drills and exercises. Each
of the 10 local health departments in our sample serves a major
metropolitan area within a state.
[10] The Strategic National Stockpile, formerly the National
Pharmaceutical Stockpile, is a repository of pharmaceuticals and
medical supplies that can be delivered to the site of a biological or
other attack.
[11] In December 2002, HHS directed states to offer smallpox
vaccination to public health and health care workers; however,
additional funds ($100 million) were not made available to carry out
the vaccinations until May 2003. For more information on the National
Smallpox Vaccination Program, see U.S. General Accounting Office,
Smallpox Vaccination: Implementation of National Program Faces
Challenges, GAO-03-578 (Washington, D.C.: Apr. 30, 2003).