Public Health Preparedness
Response Capacity Improving, but Much Remains to Be Accomplished Gao ID: GAO-04-458T February 12, 2004The anthrax incidents in the fall of 2001 and the severe acute respiratory syndrome (SARS) outbreak in 2002-2003 have raised concerns about the nation's ability to respond to a major public health threat, whether naturally occurring or the result of bioterrorism. The anthrax incidents strained the public health system, including laboratory and workforce capacities, at the state and local levels. The SARS outbreak highlighted the challenges of responding to new and emerging infectious disease. The current influenza season has heightened concerns about the nation's ability to handle a pandemic. GAO was asked to examine improvements in state and local preparedness for responding to major public health threats and federal and state efforts to prepare for an influenza pandemic. This testimony is based on GAO's recent report, HHS Bioterrorism Preparedness Programs: States Reported Progress but Fell Short of Program Goals for 2002, GAO-04- 360R (Feb. 10, 2004). This testimony also updates information contained in GAO's report on federal and state planning for an influenza pandemic, Influenza Pandemic: Plan Needed for Federal and State Response, GAO- 01-4 (Oct. 27, 2000).
Although states have further developed many important aspects of public health preparedness, since April 2003, no state is fully prepared to respond to a major public health threat. States have improved their disease surveillance systems, laboratory capacity, communication capacity, and workforce needed to respond to public health threats, but gaps in each remain. Moreover, regional planning between states is lacking, and many states lack surge capacity--the capacity to evaluate, diagnose, and treat the large numbers of patients that would present during a public health emergency. Although states are developing plans for receiving and distributing medical supplies and material for mass vaccinations from the Strategic National Stockpile in the event of a public health emergency, most of these plans are not yet finalized. HHS has not published the federal influenza pandemic plan, and most of the state plans have not been finalized. In 2000, GAO recommended that HHS complete the national plan for responding to an influenza pandemic, but according to HHS, the plan is still under review. Absent a federal plan, key questions about the federal role in the purchase, distribution, and administration of vaccines and antiviral drugs during a pandemic remain unanswered. HHS reports that most states continue to develop their state plans despite the lack of a federal plan.
GAO-04-458T, Public Health Preparedness: Response Capacity Improving, but Much Remains to Be Accomplished
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Testimony:
Before the Committee on Government Reform, House of Representatives:
United States General Accounting Office:
GAO:
For Release on Delivery Expected at 10:00 a.m. EST:
Thursday, February 12, 2004:
Public Health Preparedness:
Response Capacity Improving, but Much Remains to Be Accomplished:
Statement of Janet Heinrich:
Director, Health Care--Public Health Issues:
GAO-04-458T:
GAO Highlights:
Highlights of GAO-04-458T, a testimony before the Committee on
Government Reform, House of Representatives
Why GAO Did This Study:
The anthrax incidents in the fall of 2001 and the severe acute
respiratory syndrome (SARS) outbreak in 2002-2003 have raised concerns
about the nation‘s ability to respond to a major public health threat,
whether naturally occurring or the result of bioterrorism. The anthrax
incidents strained the public health system, including laboratory and
workforce capacities, at the state and local levels. The SARS outbreak
highlighted the challenges of responding to new and emerging
infectious disease. The current influenza season has heightened
concerns about the nation‘s ability to handle a pandemic.
GAO was asked to examine improvements in state and local preparedness
for responding to major public health threats and federal and state
efforts to prepare for an influenza pandemic.
This testimony is based on GAO‘s recent report, HHS Bioterrorism
Preparedness Programs: States Reported Progress but Fell Short of
Program Goals for 2002, GAO-04-360R (Feb. 10, 2004). This testimony
also updates information contained in GAO‘s report on federal and
state planning for an influenza pandemic, Influenza Pandemic: Plan
Needed for Federal and State Response, GAO-01-4 (Oct. 27, 2000).
What GAO Found:
Although states have further developed many important aspects of
public health preparedness, since April 2003, no state is fully
prepared to respond to a major public health threat. States have
improved their disease surveillance systems, laboratory capacity,
communication capacity, and workforce needed to respond to public
health threats, but gaps in each remain. Moreover, regional planning
between states is lacking, and many states lack surge capacity”the
capacity to evaluate, diagnose, and treat the large numbers of
patients that would present during a public health emergency. Although
states are developing plans for receiving and distributing medical
supplies and material for mass vaccinations from the Strategic
National Stockpile in the event of a public health emergency, most of
these plans are not yet finalized.
HHS has not published the federal influenza pandemic plan, and most of
the state plans have not been finalized. In 2000, GAO recommended that
HHS complete the national plan for responding to an influenza
pandemic, but according to HHS, the plan is still under review. Absent
a federal plan, key questions about the federal role in the purchase,
distribution, and administration of vaccines and antiviral drugs
during a pandemic remain unanswered. HHS reports that most states
continue to develop their state plans despite the lack of a federal
plan.
What GAO Recommends:
www.gao.gov/cgi-bin/getrpt?GAO-04-458T.
To view the full product, 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 Committee:
I appreciate the opportunity to be here today to discuss the work we
have done pertaining to the nation's preparedness to manage major
public health threats. The anthrax incidents in the fall of 2001, the
SARS[Footnote 1] outbreak in 2002-2003, and the recent incidents
involving ricin have raised concerns about the nation's ability to
respond to a major public health threat, whether naturally occurring or
the result of bioterrorism. The anthrax incidents strained the public
health system, including surveillance[Footnote 2] and laboratory
capacities as well as the workforce, at the state and local
levels.[Footnote 3] The SARS outbreak highlighted the challenges in
responding to new and emerging infectious disease--especially when the
ability to identify the disease and a vaccine for preventing it are
lacking.[Footnote 4] The current influenza season has heightened
concerns about our nation's ability to handle a pandemic.[Footnote 5]
The Congress has recognized the need to strengthen the nation's ability
to respond to such threats and has increased appropriations for
federal, state, and local public health preparedness efforts. The
Department of Health and Human Services (HHS) has been developing a
national plan for responding to an influenza pandemic.
As you requested, to assist the Committee in its consideration of our
nation's ability to respond to a major public health threat, whether
naturally occurring or the result of bioterrorism, my remarks today
will focus on (1) state and local preparedness for responding to major
public health threats and (2) federal and state efforts to prepare for
an influenza pandemic.
My testimony today updates testimony that we provided to you in April
2003[Footnote 6] and is based largely on work we conducted for our
recently released report on HHS's programs that support state and local
preparedness for bioterrorism and other public health threats.[Footnote
7] For that report, we reviewed each state's progress report[Footnote
8] on the use of bioterrorism preparedness funding distributed in 2002
by HHS's Centers for Disease Control and Prevention (CDC) and Health
Resources and Services Administration (HRSA). The progress reports
covered the period through August 30, 2003, for CDC's program and
through July 1, 2003, for HRSA's program. For that report 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. My testimony today also updates information provided in
our October 2000 report on federal and state planning for an influenza
pandemic.[Footnote 9] To update that information, in February 2004, we
spoke with officials from CDC and HHS's National Vaccine Program
Office. We conducted our work in accordance with generally accepted
government auditing standards.
In summary, although states have further developed many important
aspects of public health preparedness, since I testified before you in
April 2003, no state is fully prepared to respond to a major public
health threat. States have improved their disease surveillance systems,
laboratory capacity, communication capacity, and workforce needed to
respond to public health threats, but gaps in each remain. Moreover,
regional planning between states is lacking, and many states lack surge
capacity--the capacity to evaluate, diagnose, and treat the large
numbers of patients that would present during a public health
emergency. Although states are developing plans for receiving and
distributing medical supplies and material for mass vaccinations from
the Strategic National Stockpile in the event of a public, most of
these plans are not yet finalized.
HHS has not published the federal influenza pandemic plan, and most of
the state plans for influenza have not been finalized. In 2000, we
recommended that HHS complete the national plan for responding to an
influenza pandemic, but according to HHS, the plan is still under
review. Absent a federal plan, key questions about the federal role in
the purchase, distribution, and administration of vaccines and
antiviral drugs during a pandemic remain unanswered. HHS reports that
most states continue to develop their state plans despite the lack of a
federal plan.
Background:
The initial response to a public health emergency--for instance an
outbreak of an infectious disease--generally occurs at the local and
state levels and could involve disease surveillance, laboratory
testing, epidemiologic investigation,[Footnote 10] communication, and
health care treatment. As a public health emergency develops, each
plays a critical role in an effective response. Local and state health
departments collect and monitor data, such as reports from clinicians,
for disease trends and evidence of an outbreak. Laboratory personnel
test clinical and environmental samples for possible exposures and
identification of illnesses. Epidemiologists in the health departments
use disease surveillance systems to detect clusters of suspicious
symptoms or diseases in order to facilitate early detection of disease
and treatment of victims. Public health officials provide needed
information to the clinical community, other responders, and the public
and implement control measures to prevent additional cases from
occurring. Health care providers treat patients and limit the spread of
infectious disease. All these response activities require a workforce
that is sufficiently skilled and adequate in number.
The federal government provides funding and resources to state and
local entities to support preparedness and response efforts. For
example, in fiscal year 2002 CDC's Public Health Preparedness and
Response for Bioterrorism cooperative agreement[Footnote 11] program
provided approximately $918 million to states to improve bioterrorism
preparedness and response as well as other public health emergency
preparedness capacities. Similarly, HRSA's Bioterrorism Hospital
Preparedness cooperative agreement program provided approximately $125
million to states in fiscal year 2002 to enhance the capacity of
hospitals and associated health care entities to respond to
bioterrorist attacks. HHS renewed these cooperative agreements for the
period of August 31, 2003 through August 30, 2004. For these renewed
agreements, CDC's program and HRSA's program distributed about $870
million and about $498 million, respectively. Among the other resources
that the federal government provides is the Strategic National
Stockpile, which contains pharmaceuticals and medical supplies that can
be delivered to the site of a public health emergency anywhere in the
United States within 12 hours of the decision to deploy them.
The federal government also supports preparedness efforts for an
influenza pandemic. HHS's National Vaccine Program Office is
responsible for the development of federal plans for vaccine and
immunization activities and coordinating these efforts among federal
agencies. To foster state and local planning, HHS issued interim
planning guidance for the states in 1997 that outlined general federal
and state responsibilities during an influenza pandemic. HHS expects
that if a pandemic occurs, both the vaccines that are used to prevent
influenza and the antiviral drugs that are used to treat influenza will
be in short supply.[Footnote 12] The guidance discussed certain key
issues related to limited supplies of the influenza vaccine and
antiviral drugs--for instance the amount of vaccine and antiviral drugs
that will be purchased at the federal level; the division of
responsibility between the public and private sectors for the purchase,
distribution, and administration of these supplies during a pandemic;
and priorities for vaccinating population groups, such as health
workers and public health personnel involved in the pandemic response,
and persons traditionally considered to be at increased risk of severe
influenza illness and mortality.
States Have Further Developed Important Aspects of Public Health
Preparedness, but Additional Work Is Needed:
States reported that as of the summer of 2003 they have made
improvements in their preparedness to respond to major public health
threats, but no aspect of preparedness has been fully addressed by all
of the states.[Footnote 13] Specifically, although states have
strengthened their disease surveillance systems, laboratory capacity,
communications, workforce, surge capacity, regional coordination
across state borders, and readiness to utilize the Strategic National
Stockpile, all of these important aspects of preparedness require
additional work.
Disease Surveillance Systems:
Although some states have made improvements to their disease
surveillance systems, the nation's ability to detect and report a
disease outbreak is not uniformly strong across all states. For
example, about half of the states reported that their health
departments are capable of receiving and evaluating urgent disease
reports on a 24-hour-per-day, 7-day-per-week basis; however, few states
reported having the ability to rapidly detect an outbreak of an
influenza-like illness in the state. Similarly, few states reported
efforts to strengthen links between their public health and animal
surveillance systems[Footnote 14] and the veterinary community in order
to monitor diseases in animals that may be spread to humans, such as
the West Nile virus.[Footnote 15]
Laboratory Capacity:
States have increased their capacity to test and identify specimens and
improve laboratory security, although laboratory capacity is not
uniformly robust in all states. All states participate in CDC's
Laboratory Response Network, a network of local, state, federal, and
international laboratories that are equipped to respond to biological
and chemical terrorism, emerging infectious diseases and other public
health threats. However, only about half of the states reported that
they have at least one public health laboratory within the state that
has the appropriate instrumentation and appropriately trained staff to
conduct certain tests for rapidly detecting and correctly identifying
biological agents. About half of the states reported that they had a
facility with a biosafety level sufficient to handle such agents as
anthrax.[Footnote 16] About half the states also reported that
laboratory security within the state is consistent with HHS guidelines,
which include recommendations for protecting laboratory personnel and
preventing the unauthorized removal of dangerous biologic agents from
the laboratory.
Communication:
Although improving, communication, both among those involved in
responding to a major public health threat--such as public health
officials, health care providers, and emergency management agencies--
and with the public, remains a challenge. CDC's Health Alert Network
has been expanded--most of the states reported that the local health
departments that cover at least 90 percent of their populations are
involved in this network.[Footnote 17] However, many states reported
that they were still in the process of assessing their communication
needs. Although about half the states have a plan for educating the
public about the risks posed by bioterrorism and other public health
threats, few states have mechanisms in place for communicating with the
general public during an incident about such issues as when it is
necessary to go to the hospital.
Workforce:
States have increased the number of personnel essential to public
health preparedness, but concerns about workforce shortages remain.
Most of the states reported that the bioterrorism preparedness funding
from CDC allowed each to appoint an executive director of its
bioterrorism preparedness and response program, to designate a response
coordinator, and to hire at least one epidemiologist for each
metropolitan area with a population greater than 500,000. However, most
states continue to have staffing concerns. As we have reported
previously,[Footnote 18] some state and local health officials have had
difficulty finding and hiring epidemiologists and laboratory personnel.
The ability to hire and retain personnel in these areas is still a
concern for state and local health officials, who identify workforce
shortages as a long-term challenge to their preparedness efforts.
Surge Capacity:
Most states lack surge capacity--that is, the capacity to respond to
the large influx of patients that could occur during a public health
emergency. For example, few states reported that they had the capacity
to evaluate, diagnose, and treat 500 or more patients involved in a
single incident. Furthermore, no state reported having protocols in
place for augmenting personnel in response to large influxes of
patients, and few states reported having plans for sharing clinical
personnel among hospitals. In addition, few states reported having the
capacity to rapidly establish clinics to immunize or provide treatment
to large numbers of patients.
Regional Planning:
Few states have regional plans in place that would coordinate the
response among states during a public health emergency, and state
officials remain concerned about a lack of regional planning across
state borders. Few states have completed regional response plans for
incidents of bioterrorism and other public health threats and
emergencies. Most of the states that do have such plans have not
established training programs to support their plans or mechanisms to
test their plans.
Strategic National Stockpile:
Most state plans for using the Strategic National Stockpile in the
event of a public health emergency have not been fully developed. All
states have prepared preliminary plans for the receipt and management
of stockpile materials, but only about a third of the states have plans
that outline how they would distribute antibiotics, chemical/nerve
agent antidotes, and other materials to areas within the state.
The Federal Influenza Plan Has Not Been Finalized, but State Planning
and Other Efforts Continue:
Federal officials have not finalized plans for responding to an
influenza pandemic, and state influenza pandemic response plans are in
various stages of completion.
As we have reported previously,[Footnote 19] federal officials have
drafted but not finalized the federal influenza pandemic plan. In 2000,
we recommended that HHS complete the national plan for responding to an
influenza pandemic, but HHS reported recently that the plan was still
under review within HHS. However, HHS is taking other steps to prepare
for an influenza pandemic. For example, CDC has increased the supply of
ventilators and added an antiviral drug to the Strategic National
Stockpile. HHS is also coordinating with other federal partners, such
as the Department of Agriculture, to improve the nation's ability to
respond to public health emergencies involving the veterinary and
agricultural sectors.
Despite the absence of a finalized, federal response plan for an
influenza pandemic, states are developing their own response plans.
According to HHS officials, as of February 2004, 15 states have final
or draft plans, and 34 states are actively working on plans. In these
plans, states have had to make assumptions about what the federal role
during an influenza pandemic will be. It is still unclear whether the
private sector, the public sector, or both will have responsibility for
purchasing and distributing vaccines and antiviral drugs. Some states
have assumed that vaccine supply will be under the control of the
federal government, while others have assumed that it will not. States
have also made different assumptions about who will pay for vaccines,
antiviral medications, and related supplies.
Concluding Observations:
States have taken many actions to improve their ability to respond to a
major public health threat, but no state has reported being fully
prepared. Federal plans for the purchase, distribution, and
administration of vaccines and drugs in response to an influenza
pandemic still have not been finalized, complicating the efforts of
states to develop their state plans and heightening concern about our
nation's ability to respond effectively to an influenza pandemic.
States are more prepared now, but much remains to be accomplished.
Mr. Chairman, this completes my prepared statement. I would be happy to
respond to any questions you or other Members of the Committee may have
at this time.
Contact and Acknowledgments:
For further information about this testimony, please contact Janet
Heinrich at (202) 512-7119. Angela Choy, Maria Hewitt, Krister Friday,
Nkeruka Okonmah, and Michele Orza also made key contributions to this
statement.
FOOTNOTES
[1] SARS is the abbreviation for severe acute respiratory syndrome.
[2] Public health surveillance uses systems that provide for the
ongoing collection, analysis, and dissemination of health-related data
to identify, prevent, and control disease.
[3] See U.S. General Accounting Office, Bioterrorism: Public Health
Response to Anthrax Incidents of 2001, GAO-04-152 (Washington, D.C.:
Oct. 15, 2003).
[4] See U.S. General Accounting Office, 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).
[5] Pandemics are worldwide epidemics. Influenza pandemics can have
successive "waves" of disease and last for up to 3 years. Three
pandemics occurred in the 20th century: the "Spanish flu" of 1918,
which killed at least 20 million people worldwide; the "Asian flu" of
1957; and the "Hong Kong flu" of 1968.
[6] U.S. General Accounting Office, Infectious Disease Outbreaks:
Bioterrorism Preparedness Efforts Have Improved Public Health Response
Capacity, but Gaps Remain, GAO-03-654T (Washington, D.C.: Apr. 9,
2003).
[7] U.S. General Accounting Office, HHS Bioterrorism Preparedness
Programs: States Reported Progress but Fell Short of Program Goals for
2002, GAO-04-360R (Washington, D.C.: Feb. 10, 2004).
[8] The progress reports were for the 50 states, the District of
Columbia, and the nation's three largest municipalities (New York City,
Chicago, and Los Angeles County).
[9] U.S. General Accounting Office, Influenza Pandemic: Plan Needed for
Federal and State Response, GAO-01-4 (Washington, D.C.: Oct. 27, 2000).
[10] Epidemiology is the study of how disease is distributed in
populations and the factors that influence or determine this
distribution.
[11] A cooperative agreement is used as a mechanism to provide
financial support for a particular activity when substantial
interaction is expected between the executive agency and a state, local
government, or other recipient carrying out the funded activity.
[12] These shortages are expected because demand would exceed current
rates of production and because manufacturers report that increasing
the production capacity of antiviral drugs can take at least 6 to 9
months.
[13] In this section, "state" refers to the 50 states, the District of
Columbia, New York City, Chicago and Los Angeles County.
[14] Animal health surveillance involves the collection, evaluation,
and interpretation of data to provide timely and accurate detection,
diagnosis, prevention, and control of diseases in animals.
[15] For more information, see U.S. General Accounting Office, West
Nile Virus Outbreak: Lessons for Public Health Preparedness, GAO/
HEHS-00-180 (Washington, D.C.: Sept. 11, 2000).
[16] Biosafety measures the degree of protection a laboratory offers to
personnel, the environment, and the community.
[17] The Health Alert Network is a nationwide program designed to
ensure communication capacity at all state and local health
departments. This network enables local health departments to receive
health alerts and other information from CDC and state health
departments.
[18] U.S. General Accounting Office, Bioterrorism: Preparedness Varied
across State and Local Jurisdictions, GAO-03-373 (Washington, D.C.:
Apr. 7, 2003); GAO-04-360R; GAO-03-654T.
[19] GAO-01-4; GAO-03-654T.
