Bioterrorism
Preparedness Varied across State and Local Jurisdictions Gao ID: GAO-03-373 April 7, 2003Much of the response to a bioterrorist attack would occur at the local level. Many local areas and their supporting state agencies, however, may not be adequately prepared to respond to such an attack. In the Public Health Improvement Act that was passed in 2000, Congress directed GAO to examine state and local preparedness for a bioterrorist attack. In this report GAO provides information on state and local preparedness and state and local concerns regarding the federal role in funding and improving preparedness. To gather this information, GAO visited seven cities and their respective state governments, reviewed documents, and interviewed officials. Cities are not identified because of the sensitive nature of this issue.
State and local officials reported varying levels of preparedness to respond to a bioterrorist attack. Officials reported deficiencies in capacity, communication, and coordination elements essential to preparedness and response, such as workforce shortages, inadequacies in disease surveillance and laboratory systems, and a lack of regional coordination and compatible communications systems. Some elements, such as those involving coordination efforts and communication systems, were being addressed more readily, whereas others, such as infrastructure and workforce issues, were more resource-intensive and therefore more difficult to address. Cities with more experience in dealing with public health emergencies were generally better prepared for a bioterrorist attack than other cities, although deficiencies remain in every city. State and local officials reported a lack of adequate guidance from the federal government on what it means to be prepared for bioterrorism. They said they needed specific standards (such as how large an area a response team should be responsible for) to indicate what they should be doing to be adequately prepared. The need for federal guidance has continued to be an issue as states have proceeded in their planning and preparedness activities with funding from HHS. For example, in their progress reports to HHS in late 2002 two states reported that they were seeking guidance from HHS on assessing vulnerabilities for foodborne or waterborne diseases and preparedness steps they should take for these hazards. One of these states has declared that it could not make further efforts on testing for these types of diseases until it receives more guidance. State officials also expressed a desire for more sharing of best practices. Officials stated that, while each jurisdiction might need to adapt procedures to its own circumstances, time could be saved and needless duplication of effort avoided if there were better mechanisms for sharing strategies across jurisdictions. They stated that HHS was better positioned to know about different strategies that states were pursuing and they want information on the best practices.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-03-373, Bioterrorism: Preparedness Varied across State and Local Jurisdictions
This is the accessible text file for GAO report number GAO-03-373
entitled 'Bioterrorism: Preparedness Varied across State and Local
Jurisdictions' which was released on April 07, 2003.
This text file was formatted by the U.S. General Accounting Office
(GAO) to be accessible to users with visual impairments, as part of a
longer term project to improve GAO products‘ accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
Report to Congressional Committees:
United States General Accounting Office:
GAO:
April 2003:
BIOTERRORISM:
Preparedness Varied across State and Local Jurisdictions:
State and Local Bioterrorism Preparedness:
GAO-03-373:
GAO Highlights:
Highlights of GAO-03-373, a report to the Senate Committee on Health,
Education, Labor, and Pensions; the Senate and House Committees on
Appropriations; and the House Committee on Energy and Commerce
Why GAO Did This Study:
Much of the response to a bioterrorist attack would occur at the local
level. Many local areas and their supporting state agencies, however,
may not be adequately prepared to respond to such an attack. In the
Public Health Improvement Act that was passed in 2000, Congress
directed GAO to examine state and local preparedness for a bioterrorist
attack. In this report GAO provides information on state and local
preparedness and state and local concerns regarding the federal role in
funding and improving preparedness. To gather this information, GAO
visited seven cities and their respective state governments, reviewed
documents, and interviewed officials. Cities are not identified because
of the sensitive nature of this issue.
What GAO Found
State and local officials reported varying levels of preparedness to
respond to a bioterrorist attack. Officials reported deficiencies in
capacity, communication, and coordination elements essential to
preparedness and response, such as workforce shortages, inadequacies in
disease surveillance and laboratory systems, and a lack of regional
coordination and compatible communications systems. Some elements, such
as those involving coordination efforts and communication systems, were
being addressed more readily, whereas others, such as infrastructure
and workforce issues, were more resource-intensive and therefore more
difficult to address. Cities with more experience in dealing with
public health emergencies were generally better prepared for a
bioterrorist attack than other cities, although deficiencies remain in
every city.
State and local officials reported a lack of adequate guidance from the
federal government on what it means to be prepared for bioterrorism.
They said they needed specific standards (such as how large an area a
response team should be responsible for) to indicate what they should
be doing to be adequately prepared. The need for federal guidance has
continued to be an issue as states have proceeded in their planning and
preparedness activities with funding from HHS. For example, in their
progress reports to HHS in late 2002 two states reported that they were
seeking guidance from HHS on assessing vulnerabilities for foodborne or
waterborne diseases and preparedness steps they should take for these
hazards. One of these states has declared that it could not make
further efforts on testing for these types of diseases until it
receives more guidance.
State officials also expressed a desire for more sharing of best
practices. Officials stated that, while each jurisdiction might need to
adapt procedures to its own circumstances, time could be saved and
needless duplication of effort avoided if there were better mechanisms
for sharing strategies across jurisdictions. They stated that HHS was
better positioned to know about different strategies that states were
pursuing and they want information on the best practices.
What GAO Recommends:
GAO recommends that the Department of Health and Human Services (HHS),
in consultation with the Department of Homeland Security,
* develop specific benchmarks that define adequate preparedness for a
bioterrorist attack and can be used by jurisdictions to guide their
preparedness efforts; and
* develop a mechanism for evaluating and sharing useful solutions to
problems among jurisdictions.
HHS and the Department of Homeland Security concurred with the
recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-03-373.
To view the full report, including the scope and methodology, click on
the link above. For more information, contact Janet Heinrich at (202)
512-7119.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
State and Local Officials Reported Varying Levels of Bioterrorism
Preparedness:
State and Local Jurisdictions and Response Organizations Made Progress
in Developing Preparedness Plans, but Regional Plans Remained
Undeveloped:
State and Local Officials Expressed Concerns regarding Federal Funding
and Lack of Guidance:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Bioterrorism Preparedness in Seven Case Cities:
Appendix II: Scope and Methodology:
Appendix III: Comments from the Department of Health and
Human Services:
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Acknowledgments:
Related GAO Products:
Table:
Table 1: Bioterrorism Preparedness Elements for the Seven Cities We
Visited, December 2001 through March 2002:
Figure:
Figure 1: Local, State, and Federal Entities Involved in Response to
the Covert Release of a Biological Agent:
Abbreviations:
CDC: Centers for Disease Control and Prevention:
DOJ: Department of Justice:
Epi-X: Epidemic Information Exchange:
FEMA: Federal Emergency Management Agency:
HAN: Health Alert Network:
HHS: Department of Health and Human Services:
HRSA: Health Resources and Services Administration:
MMRS: Metropolitan Medical Response System:
OER: Office of Emergency Response:
This is a work of the U.S. Government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. It may contain
copyrighted graphics, images or other materials. Permission from the
copyright holder may be necessary should you wish to reproduce
copyrighted materials separately from GAO‘s product.
United States General Accounting Office:
Washington, DC 20548:
April 7, 2003:
Congressional Committees:
Since the terrorist attacks of September 11, 2001, and the subsequent
anthrax incidents, there has been great concern about
bioterrorism[Footnote 1] in the United States. With this concern, there
is growing recognition that the unique characteristics of a
bioterrorist attack, in contrast to a conventional attack, would
require additional response preparation and coordination. Much of the
response to a bioterrorist attack would occur at the local level. The
intentional release of a biological agent by a terrorist might not be
recognized for several days, during which time a communicable disease
could be spread to those who were not initially exposed. Hospitals and
their emergency departments, as well as private physicians and nurses,
would most likely be the first responders, as victims began to seek
treatment of their symptoms.
In order to be adequately prepared for a bioterrorist attack, state and
local response organizations[Footnote 2] need to have several basic
capabilities, whether they possess them directly or have access to them
through regional agreements. Health care providers, including emergency
medical personnel, need to be trained to recognize symptoms of diseases
caused by biological agents likely to be used in a bioterrorist attack
(such as anthrax and smallpox). Public health departments need to have
the appropriate infrastructure,[Footnote 3] including disease
surveillance systems,[Footnote 4] in place at the state and local
levels to detect clusters of suspicious symptoms or diseases in order
to
facilitate early detection of an attack 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. Hospitals need to have adequate facilities and necessary
staff to appropriately treat patients. All organizations involved in
the response must be able to communicate easily with one another as
events unfold and critical information is acquired. In addition, plans
that describe how state and local officials would manage and coordinate
an emergency response need to be in place and to have been tested in an
exercise, both at the state and local levels and at the regional level.
It has been suggested, however, that many state and local areas may not
be adequately prepared to respond to and manage a bioterrorist
attack.[Footnote 5] For example, it has been reported that there is an
ongoing shortage of intensive care unit beds and isolation rooms, where
infectious disease patients are treated.[Footnote 6] In addition, a
recent report has identified problems with the public health
infrastructure, particularly at the local level, and stated that public
health departments have generally been poorly funded.[Footnote 7]
The Department of Health and Human Services (HHS), the Federal
Emergency Management Agency (FEMA), and the Department of Justice (DOJ)
provide assistance to state and local governments in enhancing
preparedness for bioterrorism and for emergencies of all
types.[Footnote 8] In November 2002, the President signed the Homeland
Security Act of 2002, which established the Department of Homeland
Security. As a result of this legislation, FEMA and certain DOJ and HHS
programs with preparedness and response functions have been transferred
to the new department.
The Public Health Improvement Act directed that we examine state and
local levels of preparedness for a bioterrorist attack.[Footnote 9] We
have previously reported on activities by federal agencies to prepare
for and respond to a bioterrorist attack.[Footnote 10] In this report,
we are providing information on the preparedness of state and local
jurisdictions for responding to such an attack, state and local
bioterrorism response planning efforts, and state and local concerns
regarding the federal role in funding and improving state and local
preparedness.
To address our objectives, we conducted multiday site visits to seven
cities and their respective state governments from December 2001
through March 2002, at a time when states were intensively planning for
their response to a future potential bioterrorist attack following the
anthrax incidents of the previous fall. Cities were selected to provide
wide variation in geographic location, population size, and experience
with natural disasters and large exercises. (See app. I for an overview
of each city we visited, including comparisons across several elements
of preparedness.) We do not identify these cities in this report
because of the sensitive nature of this issue. During the site visits,
we interviewed officials from state and local public health
departments, local emergency medical services, state and local
emergency management agencies, local fire and law enforcement agencies,
and hospitals. For each city we visited, we also reviewed copies of the
state‘s spring 2002 application for bioterrorism-related funding
through cooperative agreements with HHS‘s Centers for Disease Control
and Prevention (CDC) and Health Resources and Services Administration
(HRSA). In addition, we reviewed the progress reports on the CDC and
HRSA cooperative agreements that were submitted to HHS in late 2002
from the relevant states, covering the period through October 31, 2002.
Because of the events of the fall of 2001, and the subsequent federal
preparedness funding, changes were occurring at the state and local
levels with regard to bioterrorism preparedness during our site visits
and subsequent data collection. Changes have continued to occur since
our visits, and this report may not reflect all these changes. In
addition to making the state and local site visits and reviewing the
pertinent documents, we interviewed officials from federal agencies and
representatives from national public health associations, and we
reviewed reports, including reports of the Advisory Panel to Assess
Domestic Response Capabilities for Terrorism Involving Weapons of Mass
Destruction,[Footnote 11] concerning state and local preparedness for
bioterrorism. Because our focus was on the public health and medical
consequences of a bioterrorist event, we do not report on preparedness
activities funded by DOJ and FEMA in this study. (See app. II for
details regarding our scope and methodology.) We conducted our work
from November 2001 through April 2003 in accordance with generally
accepted government auditing standards.
Results in Brief:
Officials in the states and cities we visited reported varying levels
of preparedness to respond to a bioterrorist attack. They recognized
deficiencies in preparedness and were beginning to address these gaps
and weaknesses. The states and cities we visited were generally better
prepared in certain elements than in others. Some elements, such as
those involving coordination efforts and communication systems, were
being addressed more readily, whereas others, such as infrastructure
and workforce issues, were more resource-intensive and therefore more
difficult to address. Officials in the seven cities we visited told us
of gaps and weaknesses in capacity elements essential to preparedness
and response, such as workforce shortages and inadequate laboratory
facilities. The level of preparedness varied by city as well as by
element. Those cities that had multiple prior experiences with public
health emergencies caused by natural disasters and with preparation for
special events, such as political conventions, were generally more
prepared than the other cities, which had little or no such experience
prior to our site visits.
State and local jurisdictions and response organizations we visited
were engaged in planning efforts to address problems in bioterrorism
preparedness at the state and local levels, but regional planning
between states was generally lacking. Most of the cities and states we
visited had emergency operation plans for coordinating the response to
emergencies. At the time of our site visits, many of these plans had
not specifically addressed the unique requirements of response to a
bioterrorist attack, but many officials were beginning to incorporate a
bioterrorism response component. Preparing the application plans for
the CDC and HRSA funding helped states to identify problems on which to
focus their efforts, including the need for increased participation of
hospitals in local preparedness and the development of regional plans.
Although progress was made on local planning, regional planning
involving multiple municipalities, counties, or jurisdictions in
neighboring states or a neighboring country lagged. A regional response
to a bioterrorist attack could require participation of officials from
neighboring states or a neighboring country, yet some states lacked
sufficient coordination with their neighboring states and country and
had not participated in joint response planning.
State and local officials had concerns regarding the distribution and
sustainability of federal funding for improving state and local
bioterrorism preparedness programs and the lack of specific standards
for determining adequacy of preparedness. State and local officials
disagreed as to whether federal funding should flow through the state
or go directly to the local jurisdictions, with each group wanting to
control the funds. In addition, hospital officials reported that
federal funding intended to enhance emergency preparedness in their
cities had not always been shared with them in the past. Further, state
and local officials stressed that sustained funding is a key factor in
maintaining the effectiveness of federal funds. Officials requested
more federal guidance and sharing of best practices to assist them in
addressing the remaining deficiencies. All types of response
organizations were asking for federal guidance on what it means to be
adequately prepared for bioterrorism. State and local officials told us
that specific benchmarks would help them determine whether they were
adequately prepared to respond to a bioterrorist attack. State
officials also requested that federal agencies do more to identify and
share best practices to assist in preparedness and avoid duplication of
effort.
We are recommending that HHS, in consultation with the Department of
Homeland Security, help state and local jurisdictions better prepare
for a bioterrorist attack by developing specific benchmarks that define
adequate preparedness for a bioterrorist attack and can be used by
state and local jurisdictions to assess and guide their preparedness
efforts. We are also recommending that HHS, in consultation with the
Department of Homeland Security, develop a mechanism by which solutions
to problems that have been used in one jurisdiction can be evaluated by
HHS and, if appropriate, shared with other jurisdictions.
We provided a draft of this report to HHS and the Department of
Homeland Security for their review. HHS concurred with our
recommendations and provided information on measures it is taking to
address the concerns we identified. The liaison from the Department of
Homeland Security provided oral comments noting the department‘s
concurrence with the draft report and the recommendations.
Background:
Initial response to a public health emergency 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. The federal government could also
become involved in investigating or responding to an incident. In
addition, the federal government provides funding and resources to
state and local entities to support preparedness and response efforts.
Response to a Bioterrorist Incident:
Response to a release of a biological agent, whether covert or overt,
would generally begin at the local level, with the federal government
becoming involved as needed.[Footnote 12] Having the necessary
resources immediately available at the local level to respond to an
emergency can minimize the magnitude of the event and the cost of
remediation. In the case of a covert release of a biological agent, it
could be hours or days before exposed people start exhibiting signs and
symptoms of the disease. Figure 1 presents the probable series of
responses to such a bioterrorist incident. 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]
Local and state health departments would collect and monitor data, such
as reports from health care providers, for disease trends and
outbreaks. Clinical samples would be collected for
laboratorians[Footnote 13] to test for identification of illnesses.
Epidemiologists[Footnote 14] in the health departments would use the
disease surveillance systems to provide for the ongoing collection,
analysis, and dissemination of data to identify unusual patterns of
disease.
The federal government could also become involved, as needed, in
investigating or responding to an incident. For certain high-risk
diseases, such as the Ebola virus, sample testing would be done at a
federal Biosafety Level 4 laboratory[Footnote 15] equipped to handle
dangerous and exotic biological agents. CDC has one such laboratory for
testing of these dangerous agents. CDC also provides state and local
jurisdictions with assistance on epidemiological investigations and
treatment advice. Other federal agencies may also assist state and
local jurisdictions in the investigation of and response to
bioterrorism and other public health emergencies.
HHS Funding for State and Local Bioterrorism Preparedness:
Prior to January 2002, HHS distributed funds for bioterrorism
preparedness through two main programs. From 1999 to through 2001 it
funded state and local health departments through CDC‘s Bioterrorism
Preparedness and Response Program. From 1996 through 2001 it provided
funding to local jurisdictions, targeting police, firefighters,
emergency medical responders, hospitals, and public health agencies
through the Metropolitan Medical Response System (MMRS)[Footnote 16] of
the Office of Emergency Response (OER), formerly the Office of
Emergency Preparedness, which was transferred to the Department of
Homeland Security on March 1, 2003.[Footnote 17] CDC and HRSA are
expanding or developing programs to help state and local governments,
as well as hospitals and other health care entities, improve
preparedness for and response to bioterrorism and other emergencies.
In January 2002, HHS announced the allocation of $1.1 billion through
CDC, HRSA, and OER for state and local bioterrorism
preparedness.[Footnote 18] This funding supports three separate but
related efforts--CDC‘s Public Health Preparedness and Response for
Bioterrorism program, HRSA‘s Bioterrorism Hospital Preparedness
Program, and OER‘s MMRS program. States applying for funding through
cooperative agreements under CDC‘s Public Health Preparedness and
Response for Bioterrorism program and HRSA‘s Bioterrorism Hospital
Preparedness Program were required to submit bioterrorism preparedness
plans to HHS by April 15, 2002. All 50 states and four major
municipalities [Footnote 19] applied for and received funding through
these cooperative agreements.[Footnote 20] The noncompetitive
cooperative agreements provide that CDC and HRSA funds must be used to
supplement and not supplant any current federal, state, and local funds
that would otherwise be used for bioterrorism and other public health
preparedness activities and that these activities should be coordinated
with any MMRS programs in the jurisdiction. Also in 2002, additional
funding was appropriated for expanding the National Pharmaceutical
Stockpile, renamed the Strategic National Stockpile,[Footnote 21] and
supporting bioterrorism-related research at the National Institutes of
Health‘s National Institute of Allergy and Infectious
Diseases.[Footnote 22]
Of the $1.1 billion, the CDC 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.[Footnote 23],[Footnote 24] The HRSA 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.[Footnote 25] The department released the first 20
percent of these funds to states and the municipalities within weeks of
the January announcement. HHS identified 17 ’critical benchmarks“ (14
for the CDC funding and 3 for the HRSA funding) that officials were
required to address in their application plans. HHS used the critical
benchmarks to screen application plans for approval before it released
the remaining 80 percent of the CDC and HRSA funding. The benchmarks
for the CDC program included such activities as designating an
executive director of the state bioterrorism preparedness and response
program, developing an interim plan to receive and manage items from
the Strategic National Stockpile, and preparing a time line for the
development of regional plans to respond to bioterrorism. In addition,
CDC is allowing states to use this funding to address preparedness
efforts between states and in regions that border a foreign country.
The benchmarks for the HRSA program included development of a timeline
for developing and implementing a regional hospital plan for dealing
with a potential epidemic involving at least 500 patients. HHS requires
progress reports from the states at approximately 6-month intervals to
provide oversight of CDC and HRSA programs and to determine future
funding.[Footnote 26] The remaining funds that were allocated for state
and local preparedness in January 2002 supported OER‘s MMRS
program.[Footnote 27]
State and Local Officials Reported Varying Levels of Bioterrorism
Preparedness:
State and local officials reported varying levels of preparedness to
respond to a bioterrorist attack. They recognized deficiencies in
preparedness and were beginning to address them. We found that the
states and cities we visited were making greater progress in certain
elements of preparedness than in others. Some elements, such as those
involving coordination efforts and communication systems, were being
addressed more readily, whereas others, such as infrastructure and
workforce issues, were more resource-intensive and therefore more
difficult to address. The level of preparedness varied across the
cities, with jurisdictions that had multiple prior experiences with
public health emergencies generally being more prepared than the other
cities, which had little or no such experience prior to our site
visits.
Progress Was Made in Elements of Preparedness Related to Coordination
and Communication:
The cities we visited generally made greater progress in coordination
and communication preparedness than in other elements of preparedness.
Coordination efforts where progress was made included participation by
relevant government and private sector officials in meetings to discuss
how to work together in an emergency and participation in joint
training exercises. Communication efforts included the purchase and
implementation of new communication systems and development of
procedures for communicating with the public and the media. Despite
these advances, deficiencies in coordination and communication
remained.
Most of the cities we visited had made efforts to improve coordination
among the response organizations. Experience from public health
emergencies, especially the terrorist attacks of September 11, 2001,
and the subsequent anthrax incidents, provided momentum for local
response organizations--including fire departments, emergency medical
services, law enforcement, public health departments, emergency
management agencies, and hospitals--to improve coordination.
Organizations, such as hospitals, that previously were not
substantially involved increased their participation in preparedness
meetings and agreements. Further, most of the states we visited
reported having established better links between the public health
departments and the hospitals since the September 11, 2001, terrorist
attacks and the subsequent anthrax incidents than had previously
existed. For example, after September 11, 2001, a hospital in one of
the cities reported that the public health department had given it a
telephone number to reach public health officials 24 hours a day, 7
days a week.
In many aspects, the anthrax incidents in October 2001 were exercises
in cooperation between the health care community and traditional first
responders. Many cities were inundated with calls about suspicious
packages and powders. In several of the cities we visited, public
health officials reported working with police and fire officials to
create a system to determine which specimens were most suspicious.
These triage systems greatly reduced the number of costly full-
emergency responses. For example, during the height of the public‘s
concern about anthrax, one city, which was experiencing as many as 75
to 90 reports of a white powder per day, decided against sending out a
complete hazardous materials unit for every report. Instead it sent a
team consisting of a fire official, a hazardous materials official, a
police official, and a public health official and this team made an
initial assessment of whether the full team was needed to respond.
Coordination improved not only horizontally, that is, across different
entities within jurisdictions, but also vertically, that is, between
local and state agencies. According to their progress reports, all of
the states we visited used the 2002 federal funding in part to identify
needs and coordinate and integrate information technology systems. In
all of these states, emergency management communication systems were
integrated both vertically between state and local agencies and
horizontally between local government and hospitals. Only one of these
states reported in its progress report to HHS that it continued to have
major difficulties in improving coordination across different
governmental levels because its communication system was not capable of
sending and receiving critical health information.
In addition, we found that officials were beginning to address
communication problems. For example, six of the seven cities we visited
were examining how communication would take place in an emergency. Many
cities have purchased communication systems that allow officials from
different organizations to communicate with one another in real time.
Officials in one area told us that the fire and police departments in
their area had incompatible radio systems and, consequently, were
unable to communicate directly. This locality intended to install a
compatible radio system. It was also considering purchasing wireless
communication and messaging devices because of their success in other
jurisdictions on September 11, 2001.
State officials reported that they were beginning to make progress in
developing procedures for communication. Responding to the anthrax
incidents revealed a number of communication issues. For example, state
and local agency officials identified problems with how information
about the anthrax incidents was given to the public. These problems
included not always getting facts about anthrax out quickly, not
explaining what was occurring, and releasing inconsistent messages.
Officials in one city told us that they set up an advisory group of
retired media personnel to help them examine how they could use the
media to help convey their message. Following a chemical exercise,
public health officials in the same city realized that better lines of
communication were needed. In response, members of the core
bioterrorism team were issued pagers so that they could be contacted
more easily. In addition, two states we visited reported to HHS that
the outbreaks of West Nile virus in summer 2002 provided successful
tests of their communication capabilities.
In addition to these improvements, the 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 a
bioterrorism incident as well as other emergency health events and
disease surveillance. Goals of the HAN program include providing high-
speed Internet connectivity, broadcast capacity for emergency
communication, and distance-learning infrastructure for training.
Despite these improvements, deficiencies in communication and
coordination remained. For example, while four of the states we visited
said in their progress reports that they had completed integrating all
of their jurisdictions into HAN, two states had not yet achieved CDC‘s
goal to cover 90 percent of the state‘s population.[Footnote 28] One of
these states reported that, although it had developed a plan for
emergency communication with the public, local needs were still being
assessed. This state reported that coordination across multiple
governmental levels was problematic and time-consuming, and progress in
meeting goals for planning was slow. In addition, as of November 2002,
only two of the states we visited reported that they had conducted
preparedness exercises that encompassed all jurisdictions in the state.
According to the states‘ progress reports, all states we visited
intended to conduct exercises on at least some portion of their various
preparedness plans, such as the plan for receiving and distributing the
Strategic National Stockpile, in 2003.
Progress in Improving Preparedness Capacity Lagged:
In contrast to the improvements made in coordination and communication,
progress related to the response capacity of the workforce, the
surveillance and laboratory systems, and hospitals generally lagged.
Deficiencies 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.
Workforce:
At the time of our site visits, shortages in personnel existed in state
and local public health departments, laboratories, and hospitals and
were difficult to remedy. Officials from state and local health
departments told us that staffing shortages were a major concern. One
official from a state health department said that local health
departments in his state were able to handle the additional work
generated by the anthrax incidents only by putting aside their normal
daily workload. Local officials also stated that their normal daily
workload suffered when staff were diverted from their usual
responsibilities to work on bioterrorism response planning. Local
officials recognized that diverting staff from their usual duties is
appropriate in a time of crisis but were concerned about the impact on
their other public health responsibilities over the longer term. 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. One state department of public health
we visited 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.
Shortages in laboratory and hospital personnel were also cited.
Officials in one city noted that they had difficulty filling and
maintaining laboratory positions. People that accepted the positions
often left the health department for better-paying positions. Five of
the states we visited reported shortages of hospital medical staff,
including nurses and physicians, necessary to increase response
capacity in an emergency. Increased funding for hiring staff cannot
necessarily solve these shortages because for many types of positions,
such as laboratorians, there are not enough trained individuals in the
workforce. According to the Association of Public Health Laboratories,
training laboratorians to provide them with the necessary skills will
take time and require a strategy for building the needed
workforce.[Footnote 29]
Three states cited ongoing shortages of personnel, which they were
addressing in their progress reports. Two states had reported that they
plan to hire veterinarians[Footnote 30] to assist in their preparedness
efforts. One of these two states also noted difficulties in recruiting
personnel when there was no guarantee of funding beyond the current
year, meaning that prospective employees may not be offered permanent
positions. Another state, however, has had success in hiring
epidemiologists.
Surveillance Systems and Laboratory Facilities:
State and local officials for the cities we visited recognized and were
attempting to address inadequacies in their surveillance systems and
laboratory facilities. Local officials were concerned that their
surveillance systems were inadequate to detect a bioterrorist event.
Six of the cities we visited used a passive surveillance
system[Footnote 31] to detect infectious disease outbreaks.[Footnote
32] 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 electronic
surveillance systems. In one city we visited, the public health
department received clinical information electronically from existing
hospital databases, which required no additional work by the hospitals.
Several cities were also evaluating the use of nontraditional data
sources, such as pharmacy sales, to conduct surveillance. Three of the
cities we visited were attempting to improve their surveillance
capabilities by incorporating active surveillance components into their
systems.[Footnote 33] For example, one city asked six hospitals to
participate in a type of active system in which the public health
department obtains information from the hospitals and conducts ongoing
analysis of the data to search for certain combinations of signs and
symptoms.[Footnote 34] The city also had an active surveillance system
for influenza.
However, work to improve surveillance systems has proved challenging.
For example, despite initiatives to develop active surveillance
systems, the officials in one city considered event detection to be a
weakness in their system, in part because they did not have authority
to access hospital information systems. In addition, various local
public health officials in other cities reported that they lacked the
resources to sustain active surveillance.
Officials from all of the states we visited 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. 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. Public health laboratories in some areas quickly ran out of
space for testing and storing samples. State and local officials had to
rely on laboratory assistance at the federal level, and CDC received
over 6,000 anthrax-related samples and had to operate its anthrax-
testing laboratory 24 hours a day, 7 days a week and open an additional
laboratory to test all the samples. Eighty-five percent of state and
territorial public health laboratories reported that the need to
perform bioterrorism testing during the anthrax incidents had a
negative impact on their ability to do routine work, delaying testing
for tuberculosis, sexually transmitted diseases, and other infectious
diseases.[Footnote 35]
Further, public health laboratories have a minimal association with
private laboratories (that is, laboratories that are associated with
private hospitals or are independent) or sometimes lack ties to
laboratories in other states that could serve as a backup to ensure
timely testing of samples. One state we visited had one state public
health laboratory, no backup laboratory, and no written agreements with
neighboring states to provide support. A task force of the Association
of Public Health Laboratories has written that a lack of close ties can
lead to a lack of communication and a lack of coordination of
laboratory testing, both of which are needed to support public health
interventions.[Footnote 36] All states we visited recognized these
problems and, in their progress reports to HHS, reported that they were
using the funds to improve the Laboratory Response Network.[Footnote
37]
According to their progress reports, officials in the states we visited
were working on solutions to their laboratory problems. States were
examining various ways to manage peak loads, including training
additional staff in the newest bioterrorism response methods, 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 providing training on protocols
for handling bioterrorist agents, upgrading two local public health
laboratories to Biosafety Level 3 laboratories,[Footnote 38] and
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 were revised to cover reporting and sharing
laboratory results with local public health and law enforcement
agencies.
Hospitals:
Federal, state, and local officials were concerned that hospitals might
not have the capacity to accept and treat sudden, large increases in
the number of patients, as might be seen in a bioterrorist attack.
Hospital, state, and local officials reported that hospitals needed
additional equipment and capital improvements--including medical
stockpiles, personal protective equipment, decontamination facilities,
quarantine and isolation facilities, and air handling and filtering
equipment--to enhance preparedness.
The resources that hospitals would require for responding to a
bioterrorist attack with mass casualties are far greater than what are
needed for everyday performance. Meeting these needs fully would be
extremely difficult because bioterrorism preparedness is expensive and
hospitals are reluctant to create capacity that is not needed on a
routine basis and may never be utilized at a particular facility.
Although hospitals may not be able to fully meet all preparedness
needs, they can take action to increase their preparedness by
developing plans for their internal emergency response operations, and
some hospital officials reported taking these initial actions. For
example, officials at one hospital we visited appointed a bioterrorism
coordinator and developed plans for taking care of the families of
hospital staff, transporting patients to the hospital, and
communicating during an emergency. However, from its assessments of
hospital capacity, one of the states we visited reported that only 11
percent of its hospitals could readily increase their capacity for
treating patients with communicable diseases requiring isolation, such
as smallpox. Another state reported that most of its hospitals have
little or no capacity for isolating patients diagnosed with or being
tested for communicable diseases. A third state was working with the
state hospital association to provide every hospital in the state with
portable decontamination units.
Efforts have been made to assist hospitals in preparing for
bioterrorism. For example, the hospital association in one city we
visited was developing a set of recommendations, based on the American
Hospital Association checklist,[Footnote 39] along with cost estimates,
for health care facilities to improve their preparedness. The
association‘s recommendations included that each hospital have a 3-day
supply of basic personal protective equipment (such as gloves, gowns,
and shoe covers) on hand for staff, a 3-day supply of specified
pharmaceuticals, emergency power, a loud speaker or other mechanism to
communicate with a large group of converging casualties outside of the
hospital entrance, and an external decontamination facility capable of
handling 50 victims per hour. These guidelines give hospitals criteria
by which they can measure their preparedness and, in turn, improve
their internal emergency response operation plans.
In their progress reports to HHS, all the states we visited discussed a
number of activities they were undertaking with the HRSA funding to
increase hospital preparedness. These included hiring state hospital
bioterrorism program coordinators and medical directors, exploring the
feasibility of coordinating hospitals‘ bioterrorism emergency planning
across states, and supplying selected hospitals with biohazard suits
and decontamination systems.
Level of Preparedness Varied across Cities We Visited:
We found that the overall level of bioterrorism preparedness varied by
city. In the cities we visited, we observed that those cities that had
recurring experience with public health emergencies, including those
resulting from natural disasters, or with preparation for National
Security Special Events, such as political conventions,[Footnote 40]
were generally more prepared than cities with little or no such
experience. Cities that had dealt with multiple public health
emergencies in the past might have been further along because they had
learned which organizations and officials need to be involved in
preparedness and response efforts and moved to include all pertinent
parties in the efforts. Experience with natural disasters raised the
awareness of local officials regarding the level of public health
emergency preparedness in their cities and the kinds of preparedness
problems they needed to address. For example, in one city we visited,
officials found that emergency operations center personnel became
separated from one another during earthquakes and had trouble staying
in contact. These problems made decision making difficult. The
officials told us that the personnel needed to learn how to use their
radio system more effectively. (See app. I for details concerning
preparedness by city.):
All the cities we visited had to respond to suspected anthrax incidents
in fall 2001; however, each city found different deficiencies in its
capabilities. The anthrax incidents presented challenges for
jurisdictions across the country, not just in the communities where
anthrax was found. Among the problems that surfaced during the anthrax
incidents, for example, were several dealing with coordination across
agencies and communication among departments and jurisdictions and with
the public. A local official reported that there was no mechanism to
coordinate the public information, medical recommendations, and
epidemiologic assessments throughout the state and neighboring areas
and that this created considerable confusion and frustration for the
public and medical community.[Footnote 41] In addition, officials in
several states became aware of different types of limitations in their
state and local communication capabilities during the anthrax
incidents. For example, in one rural state, which had no confirmed
anthrax cases but numerous false alarms, the state public health
department faxed messages containing critical information to hospitals
throughout the state. Officials in the department realized that this
one-way system was insufficient because they also needed to be able to
receive communications rapidly. They were able to increase their
communication capabilities by setting up a 24-hour toll-free telephone
number staffed by officials, who could respond to questions from
hospitals. In another state, public health laboratory officials found
that it was difficult for many facilities to print files received from
CDC because their Internet connections were inadequate. Ultimately, the
state created CD-ROMs containing the protocols describing how to deal
with suspected anthrax samples, and a state public health official
drove more than 500 miles across the state to deliver them.
One of the cities we visited, which had experienced a large natural
disaster in the late 1990s, was in the early stages of bioterrorism
preparedness. This city is in a predominantly rural state, which
started receiving funds for establishing a HAN system for public health
information in fiscal year 2002. There were five epidemiologists at the
state level and none at the local level, so the city depended on the
state to determine when a disease investigation was warranted. The
state had a limited passive surveillance system, with plans for a more
elaborate, active surveillance system.
In contrast, another city we visited was much further along in
bioterrorism preparedness. In addition to dealing with natural
disasters and other public health emergencies, the city had also
prepared for and hosted a National Security Special Event. The state
had been receiving funding for HAN since 1999. Epidemiologists were
employed at the state and local levels. The city had a passive
surveillance system, and it also had an active surveillance system for
influenza, which has symptoms similar to those of the early stages of
diseases attributable to several likely bioterrorist agents, such as
anthrax.
Even the cities that were better prepared were not strong in all
elements. For example, one city had successfully developed an
integrated approach to preparedness in which multiple organizations,
both governmental and nongovernmental, examined where terrorist attacks
are likely to occur, how they could be mitigated, and what resources
were necessary. City officials also reported that communications had
been effective during public health emergencies and that the city had
an active disease surveillance system. However, officials also reported
deficiencies in laboratory capacity and said that hospitals had not
received sufficient bioterrorism response training. Another one of the
better-prepared cities was connected to HAN and the Epidemic
Information Exchange (Epi-X),[Footnote 42] and all county emergency
management agencies in the state were linked. However, the state did
not have written agreements with its neighboring states for responding
to an emergency, and a major hospital in the city we visited lacked
sufficient equipment for a bioterrorism response.
State and Local Jurisdictions and Response Organizations Made Progress
in Developing Preparedness Plans, but Regional Plans Remained
Undeveloped:
State and local jurisdictions and response organizations made progress
in developing plans to improve their preparedness. They had begun to
include bioterrorism in their agencies‘ overall emergency operation
plans, and preparing the application plans for HHS funding helped
states focus their planning efforts. In addition, hospitals, which were
beginning to be seen as part of a local response system, were starting
to participate in local response planning. While progress was made in
local planning, regional planning between states lagged. A regional
response to a bioterrorist attack would potentially require the mutual
participation of officials from neighboring states or, in several
instances, a neighboring country, yet some states lacked such
coordination with their neighboring states and country and had not
participated in joint response planning.
State and Local Jurisdictions Had Increased Bioterrorism Planning
Efforts:
At the time of our site visits, although most of the cities and states
we visited had emergency operation plans, many of these plans did not
specifically address the unique requirements of response to a
bioterrorist attack. However, many of the response organizations in
these cities and states had begun to develop emergency operation plans
that include bioterrorism response. Officials from all of these
response organizations stated that planning for a bioterrorist incident
is difficult because they do not know what it means to be prepared and
therefore are not sure if their plans will be adequate.
At the time of our site visits, all seven states were in the stage of
’planning to plan“ for bioterrorism. While all of these states had
previously taken steps to assess the readiness levels of their
localities, they continued to need further assessments. For example,
most were doing some assessments of capacity, such as assessments of
hospital capacity and equipment. Although some of these efforts were
time-consuming because of the need to develop assessment tools, such as
surveys, the information on needs and current status is essential for
the states to be able to plan.
Preparing the application plans for HHS helped states to identify
problems in bioterrorism preparedness by requiring them to address
specified preparedness focus areas. In the application process, states
were required to assess their capabilities in the focus areas and
discuss how they planned to address their deficiencies. For example,
under the surveillance and epidemiologic capacity focus area in its
application plan for CDC funding, one state we visited identified a
lack of adequate staffing, expertise, and resources. Officials reported
in the plan that the department of public health was developing
regional medical epidemiology teams, each of which would include a
part-time practicing physician and a full-time epidemiologist, with
enough teams to cover all the regions in the state. These teams would
establish ongoing relationships with area hospital infection control
programs, emergency departments, and other health care providers.
Another state reported in its HRSA application plan that it did not
have the capability to track resources, supplies, and the distribution
of patients at the regional level. It planned to expand an existing
electronic tracking system to track each hospital‘s capacity,
resources, and patient distribution on a real-time basis.
Hospitals Were Beginning to Recognize Need for Inclusion in Local
Planning:
At the time of our site visits, 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 the city
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.
Government officials, health care association representatives, and
hospital officials in many of the areas that we visited stated that
hospitals had become more interested in these issues and more involved
in planning efforts than prior to September 11, 2001. They noted that
health care providers in hospitals gained an awareness of the
seriousness of the threat of bioterrorism and began to ask for
information, lectures, and presentations of their cities‘ emergency
plans. Hospital representatives, as well as state and local officials,
told us that hospital personnel were more interested in attending
training on biological agents and that hospitals had formed better
connections with local public health departments in many areas. We also
found that some hospitals were starting to collaborate with one another
on planning efforts.
Regional Planning Was Lacking between States:
Response organization officials were concerned about a lack of planning
for regional coordination between states. As called for by the guidance
for the cooperative agreements, all of the states we visited organized
their planning on a regional basis, assigning local areas to particular
regions for planning purposes. However, the state-defined regions
encompassed areas within the state only. A concern for response
organization officials was the lack of planning for regional
coordination between states and with a neighboring country of the
public health response to a bioterrorist attack. With regard to
coordination efforts 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 border 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.
States varied with regard to the intensity of their coordination
efforts with a neighboring country. Officials in one state told us that
the state lacked the needed coordination with the foreign country that
it borders, but they reported in the state‘s CDC application plan that
workforce plans and infectious disease surveillance and reporting are
the two priorities for the state with the neighboring country. The
emergency management officials in the city we visited in that state
reported that the border guards knew and informally coordinated with
one another. Officials in this state reported in the state‘s CDC
application plan that some of the state‘s hospitals employed people
from the foreign country and so hospital staffing could be problematic
if borders were closed during an emergency. However, officials in
another state that we visited reported good regional partnerships with
the foreign country that it borders. In fact, the state officials noted
that the needs of a metropolitan area in the neighboring country would
be evaluated and integrated into the state plan. In addition, the state
reported in its progress report that it was developing an agreement
with the neighboring country to provide laboratory surge capacity.
State and Local Officials Expressed Concerns regarding Federal Funding
and Lack of Guidance:
State and local officials and hospital officials expressed concerns
about the distribution and sustainability of federal bioterrorism
preparedness funding, as well as about a lack of guidance on what it
means to be prepared for a bioterrorism event. State and local
officials we met with disagreed about whether federal funding for
bioterrorism preparedness should flow through the state or go directly
to the local jurisdictions. Hospital officials reported that federal
funding from OER‘s MMRS program in their cities had not always been
shared with them in the past. In addition, state and local officials
reported that sustainability in funding over several years would be
beneficial to all jurisdictions. State and local officials requested
more specific federal guidance on what constitutes adequate
preparedness. State officials also requested more sharing of best
practices to assist them in closing the remaining gaps in preparedness.
Funding Concerns Were Related to Distribution and Sustainability:
State and local officials expressed several concerns regarding the
federal funding provided for state and local bioterrorism preparedness
both before and after September 11, 2001. These concerns were related
to the distribution and sustainability of these funds.
Distribution:
State and local officials we met with disagreed about whether federal
funding for bioterrorism preparedness should flow through the state or
go directly to the local jurisdictions. Local officials suggested that
some funding should be allocated directly to local governments because
it would be more efficient since the state would not withhold a
percentage for its own use. However, state officials told us that if
funds went directly to the local level, it would be difficult for them
to direct the funding to the areas of greatest need within the states.
In addition, state officials reported that when money flows through the
states they can control purchases of emergency response equipment to
ensure compatibility across regions of the state.
Progress reports to HHS from the seven states we visited showed great
variability in the speed with which the states committed funds provided
through the CDC cooperative agreements, in part because of the
differing state requirements for distribution. Two of the states had
obligated more than 70 percent of the funding they received from HHS as
of fall 2002, while two other states had obligated only about 20
percent of their funds as of the same time, with the remaining three
states obligating percentages between these figures. Some states
reported that they needed to arrange for grants or take other actions
before they could transfer any of the funds to local jurisdictions.
Hospital officials also raised concerns about the distribution of
federal funding for preparedness. In a national survey, 62 percent of
hospital officials said that a lack of awareness of federally sponsored
preparedness programs was a factor in not participating in preparedness
programs.[Footnote 43] In addition, hospital officials that we spoke
with in two cities added that federal funding from OER‘s MMRS program
in their cities had not been shared with hospitals in the past. The
HRSA program may help alleviate these problems. It has led to increased
coordination among government agencies, which may lead to an increased
awareness of the funding opportunity it provides. In addition, the HRSA
guidance on funding under the cooperative agreement requires that
approximately three-quarters of the funding be spent directly on or in
hospitals, community health clinics, and other health care systems.
HRSA also requires states to undertake certain initial state-level
tasks that would not involve costs to the hospitals, including
designating a hospital bioterrorism preparedness coordinator,
establishing a statewide advisory committee, and conducting a needs
assessment. In their progress reports to HHS, all states we visited
reported that the HRSA funding was being used primarily to support such
initial state-level activities, including conducting assessments,
developing plans, and hiring state-level personnel. HHS recently stated
that most, if not all, states have now determined how funding will be
awarded to hospitals, community health clinics, and other health care
systems.
During our site visits, state officials also expressed concerns in
light of the budget shortfalls and cuts they were experiencing.
Officials from one state expressed concern that the 2002 funding from
HHS might be used to supplant state funding instead of supplementing
it, because of general budgetary cutbacks in the state, although such
use is expressly prohibited by the funding agreements. An official from
another state told us that the funding that its state public health
laboratory received in 2002 from CDC for bioterrorism preparedness was
not enough to offset the general cuts in the state budget for the
public health laboratory. We were not able to determine whether any of
the state funds were supplanted by the HHS funding.
Sustainability:
The public health infrastructure depends on sustained and consistent
investment, yet in the past the funding has been viewed as
unsystematic.[Footnote 44] In fiscal year 2002, states were
experiencing budget shortfalls (as a percentage of general fund
revenues) that were worse than after the recession of the early 1990s
ended,[Footnote 45] and shortfalls in 2003 were expected to be even
worse. The influx of federal funds for bioterrorism preparedness made
it possible for jurisdictions to undertake new efforts in this area, at
a time when other public health programs were experiencing cutbacks.
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 46] We
have noted previously that federal, state, and local governments have a
shared responsibility in preparing for terrorist attacks and other
disasters.[Footnote 47] However, prior to the infusion of federal
funds, few states were investing in their public health infrastructure.
State and Local Officials Requested Specific Federal Benchmarks for
Adequate Preparedness and Sharing of Best Practices:
Officials we spoke with at both the state and the local levels
requested more federal guidance and sharing of best practices to assist
them in closing the remaining gaps in preparedness. Officials from
response organizations in every state we visited reported a lack of
guidance from the federal government on what it means to be prepared
for bioterrorism. In the past, CDC has made efforts to develop guidance
for state and local public health officials on bioterrorism
preparedness. For example, in its core capacity project of 2001, CDC
developed criteria to provide guidance on developing the bioterrorism
preparedness capacity of state and local public health systems.
However, these criteria were broad and nonspecific. State and local
officials told us they needed specific benchmarks (such as how large an
area a response team should be responsible for) to indicate what they
should be doing to be adequately prepared. Local officials were turning
to state officials for guidance, and state officials wanted to be able
to turn to the federal government.
Response organizations have been hindered in their efforts to prepare
for bioterrorism because they do not know what agents pose the most
credible threat, which makes it difficult to know when they are
prepared. There have been federal efforts to devise lists of threats,
but as we reported,[Footnote 48] these efforts have been fragmented, as
is evident in the different biological agent threat lists that were
developed by federal departments and agencies. In addition, medical
organizations have historically not been recipients of intelligence
regarding threat information. The Institute of Medicine and the
National Research Council have stated that this practice needs to be
changed.[Footnote 49]
The need for federal guidance has continued to be an issue as states
have proceeded in their planning and preparedness activities using the
HHS funding. For example, in their progress reports to HHS in late
2002, two of the states we visited reported that they were seeking
guidance from HHS on assessing vulnerabilities for foodborne or
waterborne diseases and preparedness steps they should take for these
hazards. One of these states declared that it could not make further
efforts on testing for waterborne or agricultural diseases until it
received more guidance. States also reported needing guidance in such
areas as using the CDC emergency notification systems.
State and local officials were interested in receiving detailed
guidance from HHS to be able to better assess their progress and
develop realistic time frames. One state we visited wrote in its
progress report that CDC‘s development of pre-event guidelines for use
of the vaccinia vaccine for smallpox would be crucial for providing
consistent practices nationwide. It also wrote that it would be useful
to have an approved method for evaluating laboratory response to ensure
that minimum standards were being met. Two other states wrote that they
would like CDC to provide guidance for developing emergency operation
plans.
CDC has begun to provide more detailed guidance in some areas. For
example, it is developing standards for the National Electronic Disease
Surveillance System, which serves as the foundation for many states‘
bioterrorism information systems. Under this system, standards are
being developed to ensure uniform data collection and electronic
reporting practices across the nation. Another initiative that is
providing guidance on communication is CDC‘s Public Health Information
Network. This network is intended to build on and integrate existing
public health communication systems and will include public health data
standards to ensure the compatibility of the communication systems used
by the health care community and federal, state, and local public
authorities. In addition, CDC has made efforts in developing new
laboratory protocols. One state noted that CDC‘s efforts have been of
the highest standard, and the protocols received have been designed for
easy implementation at the state level.
Officials at the state level also expressed a desire for more sharing
of best practices. Officials stated that although each jurisdiction
might need to adapt procedures to its own circumstances, time could be
saved and needless duplication of effort avoided if there were better
mechanisms for sharing strategies across jurisdictions. They contended
that HHS was positioned to know about different strategies that states
were pursuing. For example, one state wrote in its progress report that
it would be useful for HHS to provide information on syndromic
surveillance systems that were operational. In its progress report,
another state wrote that it had requested the portions of other states‘
application plans related to risk communication and health information
dissemination. The state wanted to include its Native American
population in preparedness planning and was looking for best practices
on how to involve tribal governments in planning.
Some officials particularly expressed a desire for increased
information sharing of best practices among state and local
jurisdictions on various types of training. Many jurisdictions were
developing training programs to increase bioterrorism preparedness. One
state official told us during our visit that his agency needed training
material on handling incidents, but he did not want to duplicate
others‘ efforts by developing his own materials. In their progress
reports, five of the seven states we visited indicated that they would
like CDC‘s help in obtaining training information. One state wrote that
establishing national standards for training and training aids for
laboratories would minimize the need for individual states or regions
to develop their own materials. Another state requested assistance with
Strategic National Stockpile and smallpox education and training
materials, and a third state requested training videos or videos of
tabletop exercises to study. One state suggested that it would be
useful for CDC to organize an Internet site and teleconferences among
states to facilitate information sharing.
Conclusions:
As concerns about bioterrorism and other public health emergencies,
including newly emerging infectious diseases such as West Nile virus,
have surfaced over the past few years, cities across the nation have
been working to increase their preparedness for responding to such
events. An essential first step for cities was to recognize some of the
deficiencies that existed in their public health infrastructures and
how these would affect their ability to respond to a bioterrorism
event.
Cities have recognized and begun to work on deficiencies in elements of
coordination, communication, and capacity necessary for bioterrorism
preparedness. Progress in addressing capacity issues has lagged behind
progress in other areas, in part because finding solutions to
deficiencies in capacity can be complicated by the magnitude of the
resource needs. For example, the resources that hospitals would require
for responding to a biological attack would be greater than what are
normally needed. Local authorities can shift resources between
functions and plan for ways to expand capacity in an emergency.
However, shifting resources between functions can cause serious
problems if the emergency is an extended one and other important
responsibilities are not being met. Needs for additional capacity for
responding to bioterrorism emergencies must be balanced with
preparedness for all types of emergencies and must not detract from
meeting the everyday needs of cities for emergency care. Regional plans
can help address capacity deficiencies by providing for the sharing
across localities of resources that, while adequate for everyday needs,
may be in short supply on a local level in an emergency.
Our observations of state and local preparedness for bioterrorism in
selected cities bring certain other needs into focus as well. First,
there is not yet a consensus on what constitutes adequate preparedness
for a public health emergency, including a bioterrorist incident, at
the state and local levels. There have been some efforts to provide
guidelines for hospital preparedness, but specific standards for state
and local preparedness are lacking. Officials from state and local
response organizations expressed a need for specific benchmarks from
the federal government, which could lead to consistent standards across
all states. This could also facilitate needed regional planning across
state boundaries.
Second, we noted several instances in which cities found solutions to
deficiencies that they identified. For example, cities developed
methods for triaging samples during the anthrax incidents. Federal
mechanisms for sharing innovations and other resources, such as fact
sheets on infectious diseases and training materials, could prevent
states and cities from having to develop solutions to common problems
individually. The federal government could take additional steps to
assist these states and cities in efficiently and effectively
increasing their preparedness.
Recommendations for Executive Action:
To help state and local jurisdictions better prepare for a bioterrorist
attack, we recommend that the Secretary of Health and Human Services,
in consultation with the Secretary of Homeland Security,
* develop specific benchmarks that define adequate preparedness for a
bioterrorist attack and can be used by state and local jurisdictions to
assess and guide their preparedness efforts and:
* develop a mechanism by which solutions to problems that have been
used in one jurisdiction can be evaluated by HHS and, if appropriate,
shared with other jurisdictions.
Agency Comments:
We provided a draft of this report to HHS and the Department of
Homeland Security. HHS submitted written comments, which are reprinted
in appendix III. HHS said the report provides an informative assessment
of preparedness for bioterrorism and other public health emergencies at
the state and local levels. HHS concurred with our recommendations. The
liaison from the Department of Homeland Security provided oral comments
noting the department‘s concurrence with the draft report and the
recommendations.
In its comments, HHS stated that it is taking steps to address the
concerns we identified. For example, the department noted that both CDC
and HRSA will issue guidance that will emphasize coordination of
planning on a regional level. HHS also stated that CDC and HRSA will be
developing guidelines and templates to assist states in identifying
specific benchmarks and that the Office of the Assistant Secretary for
Public Health Emergency Preparedness will be leading an effort to
create a repository of best practices.
HHS noted that it has been a year since our site visits and that during
that period both state and local health departments have made further
strides in their efforts to achieve preparedness for bioterrorism and
other public health emergencies. We noted in the draft report that we
include information obtained from state officials several months after
our site visits. As we also noted in the draft report, we recognize
that changes continue to occur. However, many of the problems we
identified will require sustained efforts, and HHS said that it is now
taking steps that are intended to facilitate further progress.
HHS also provided technical comments, which we incorporated where
appropriate.
We are sending copies of this report to the Secretary of Health and
Human Services and the Secretary of Homeland Security, and other
interested officials. We will also provide copies to others upon
request. In addition, the report will be available at no charge on
GAO‘s Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please call
me at (202) 512-7119. Another contact and key contributors are listed
in appendix IV.
Janet Heinrich
Director, Health Care--Public Health Issues:
Signed by Janet Heinrich:
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 Obey
Ranking Minority Member
Committee on Appropriations
House of Representatives:
[End of section]
Appendix I: Bioterrorism Preparedness in Seven Case Cities:
Table 1 provides comparisons across several elements of preparedness
for each of the seven cities we visited. The purpose of this table is
to provide additional context for the discussion in the report and some
understanding of the strengths and weaknesses of each city in preparing
for a bioterrorist attack and how these strengths and weaknesses vary
among the cities. The information in this table was obtained from
December 2001 through March 2002. The cities have continued to make
changes to improve their bioterrorism preparedness; however, this table
does not reflect those changes.
Table 1: Bioterrorism Preparedness Elements for the Seven Cities We
Visited, December 2001 through March 2002:
Context:
City population; City A: Under 300,000; City B: 300,000-1,000,000; City
C: Over 1,000,000; City D: 300,000-1,000,000; City E: Over 1,000,000;
City F: 300,000-1,000,000; City G: Under 300,000.
State has a foreign border; City A: Yes; City B: No; City C: No; City
D: Yes; City E: Yes; City F: No; City G: No.
Metropolitan area has a port; City A: Yes; City B: Yes; City C: Yes;
City D: Yes; City E: Yes; City F: No; City G: Yes.
City had received funding from the Metropolitan Medical Response System
(MMRS)[A] program; City A: No; City B: Yes; City C: Yes; City D: Yes;
City E: Yes; City F: Yes; City G: Yes.
City had responded to suspected anthrax incidents, other public health
emergencies, or both within previous 5 years; City A: Yes; City B: Yes;
City C: Yes; City D: Yes; City E: Yes; City F: Yes; City G: Yes.
City prepared and hosted a National Security Special Event[B] within
previous 5 years; City A: No; City B: No; City C: Yes; City D: Yes;
City E: Yes; City F: No; City G: No.
Disease surveillance, follow-up, and agent identification:
Statewide passive disease surveillance system[C]; City A: Yes; City B:
Yes; City C: Yes; City D: Yes; City E: Yes; City F: Yes; City G: Yes.
Statewide active disease surveillance system[D]; City A: Yes; City B:
Yes; City C: No; City D: No; City E: Yes; City F: No; City G: Yes.
Local active disease surveillance system[D]; City A: No; City B: No[E];
City C: No[E]; City D: Yes; City E: Yes; City F: No; City G: No.
One or more epidemiologists in local public health agency; City A: No;
City B: Yes; City C: Yes; City D: Yes; City E: Yes; City F: Yes; City
G: Yes.
One or more epidemiologists in state public health agency; City A: Yes;
City B: Yes; City C: Yes; City D: Yes; City E: Yes; City F: Yes; City
G: Yes.
One or more Biosafety Level 3 laboratories in the state[F]; City A:
Yes; City B: Yes; City C: Yes; City D: Yes; City E: Yes; City F: Yes;
City G: Yes.
Treatment capacity:
Drug stockpile maintained by city[G]; City A: No; City B: Yes; City C:
Yes; City D: Yes; City E: Yes; City F: No; City G: Yes.
Drug stockpile maintained by hospital[H]; City A: Yes; City B: Yes;
City C: Yes; City D: Yes; City E: Yes; City F: No; City G: Yes.
Hospital had sufficient bioterrorism response training, per self-
report; City A: No; City B: No; City C: No; City D: No; City E: No;
City F: No; City G: No.
Hospital had sufficient equipment for bioterrorism response, per self-
report[I]; City A: No; City B: No; City C: No; City D: No; City E: No;
City F: No; City G: No.
Responder communications:
Communications between emergency responders had been effective during
public health emergencies, per self-report; City A: No; City B: No;
City C: No; City D: No; City E: Yes; City F: No; City G: No.
City had compatible radio system; City A: Yes; City B: Yes; City C:
Yes; City D: Yes; City E: Yes; City F: No; City G: Yes.
State public health resources:
State had a plan for using the Strategic National Stockpile; City A:
Yes[J]; City B: Yes[J]; City C: Yes; City D: Yes; City E: Yes[J]; City
F: Yes; City G: Yes[J].
State public health office used Health Alert Network (HAN)[K]; City A:
No; City B: Yes; City C: No; City D: Yes; City E: Yes; City F: No; City
G: Yes.
Local public health office used HAN[K]; City A: No; City B: Yes; City
C: No; City D: Yes; City E: Yes; City F: No; City G: Yes.
Cooperation among responders:
Written agreements exist to cooperate with neighboring state(s); City
A: Yes; City B: No; City C: Yes; City D: No; City E: No; City F: Yes;
City G: No.
Coordination with neighboring country; City A: No; City B: NA[L]; City
C: NA[L]; City D: Yes; City E: No; City F: NA[L]; City G: NA[L].
Local officials had developed a system for triaging samples prior to
the 2001 anthrax incidents; City A: No; City B: No; City C: No; City D:
No; City E: Yes[M]; City F: No; City G: No.
Source: GAO.
Note: GAO analysis of information obtained from visits to each of the
cities.
[A] The MMRS program is an Office of Emergency Response (OER) program
intended to develop or enhance the local response to a public health
crisis, especially an attack using weapons of mass destruction. It
takes a comprehensive local approach by assembling hospitals, emergency
managers, the public health establishment, and others to deal with the
consequences of an attack. Cities enter into contracts with OER for a
predetermined period. For more information on the MMRS program, see
U.S. General Accounting Office, Bioterrorism: Federal Research and
Preparedness Activities,
GAO-01-915 (Washington, D.C.: Sept. 28, 2001).
[B] Presidential Decision Directive 62 created a category of special
events called National Security Special Events, which are events of
such significance that they warrant greater federal planning and
protection than other special events. Such events include presidential
inaugurations and major political party conventions.
[C] Passive disease surveillance systems rely on laboratory and
hospital staff, physicians, and other relevant sources to take the
initiative to provide data on illnesses to health departments, where
officials analyze and interpret the information as it comes in.
[D] 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.
[E] City had implemented an active disease surveillance system in the
past for a public health emergency or special event but had
discontinued the system.
[F] Biosafety levels represent combinations of laboratory practices and
techniques, safety equipment, and laboratory facilities. Each
combination is specifically appropriate for the operations performed,
the documented or suspected routes of transmission of the infectious
agents, and the laboratory function or activity. In Biosafety Level 3
facilities, work is done with indigenous or exotic agents with a
potential for respiratory transmission, and which may cause serious and
potentially lethal infection. Level 3 laboratories provide the second-
highest degree of protection to personnel, the environment, and the
community.
[G] The drug stockpile is maintained by the local responders (not
including individual hospitals). These city stockpiles are independent
of the federal Strategic National Stockpile, a repository of
pharmaceuticals, antidotes, and medical supplies that can be delivered
to the site of a bioterrorist (or other) attack.
[H] A ’yes“ entry indicates that officials from at least one hospital
that we spoke with in that city gave a positive response. These
hospital stockpiles are independent of the federal Strategic National
Stockpile.
[I] Equipment includes personal protective gear or decontamination
equipment.
[J] The state had a draft plan or was developing a plan.
[K] HAN is a Centers for Disease Control and Prevention program that
supports the exchange of key public health information over the
Internet and other communication methods, such as two-way radio.
[L] NA means not applicable; this state has no foreign borders.
[M] During the anthrax incidents of 2001, the locality built on the
existing triage system.
[End of table]
[End of section]
Appendix II: Scope and Methodology:
We visited seven cities selected to provide wide variation in
geographic location, population size, and experience with natural
disasters and large exercises. Recommendations from experts, including
officials from the Department of Health and Human Services (HHS) Office
of Emergency Response and the National Association of County and City
Health Officials, were also considered in the selection of cities. We
also visited each city‘s state government. The cities visited are not
identified in this report because of the sensitive nature of the issue.
During the multiday site visits, which we conducted from December 2001
through March 2002, we interviewed officials from state and local
public health departments, local emergency medical services, state and
local emergency management agencies, local fire and law enforcement
agencies, and hospitals and national public health care associations.
We asked them about their activities related to preparing for and
responding to bioterrorism, lessons learned from past natural disasters
and the anthrax incidents in October 2001, past and current federal
funding for helping state and local agencies prepare for bioterrorism,
and gaps and weaknesses as well as strengths and successes in their
readiness for bioterrorism. We reviewed copies of the bioterrorism
preparedness plans states sent to HHS in spring 2002 for cooperative
agreement funding from the Centers for Disease Control and Prevention
(CDC) and the Health Resources and Services Administration (HRSA). In
addition, to update our data, we obtained follow-up information from
state and local officials and reviewed the 6-month progress reports on
the CDC and HRSA cooperative agreements that were submitted to HHS in
late 2002 from the relevant states, covering the period through October
31, 2002. Because our focus was on the public health and medical
consequences of a bioterrorist event, we do not report on preparedness
efforts funded by the Department of Justice and the Federal Emergency
Management Agency in this study.
The results of our visits cannot be generalized to the entire country.
In addition, the hospitals we included in our site visits were chosen
based on recommendations of local public health officials and hospital
associations. This resulted in a mix of private and public hospitals,
but because of the selection method, the results cannot be generalized
to all hospitals in the areas we visited.
We interviewed officials from HHS‘s Office of the Assistant Secretary
for Public Health Emergency Preparedness regarding its efforts to
improve state and local preparedness for responding to a bioterrorist
incident.
We reviewed reports from the Advisory Panel to Assess Domestic Response
Capabilities for Terrorism Involving Weapons of Mass
Destruction[Footnote 50] and reports from several associations,
including the American Hospital Association, the National Association
of County and City Health Officials, and the American College of
Emergency Physicians. We conducted interviews with representatives from
several associations, including the American Hospital Association, the
Association of State and Territorial Health Officials, and the National
Governors Association. We also reviewed a report by the U.S. Conference
of Mayors about local costs associated with bioterrorism
preparedness.[Footnote 51] In addition, we examined the President‘s
budget request for bioterrorism preparedness for fiscal year 2003.
Because of the events of the fall of 2001, and the subsequent federal
preparedness funding, changes were occurring at the state and local
levels with regard to bioterrorism preparedness during our site visits
and subsequent data collection. Changes have continued to occur and
this report may not reflect all these changes.
We conducted our work from November 2001 through April 2003 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix III: Comments from the Department of Health and Human
Services:
MAR 27 2003:
Ms. Janet Heinrich:
Director, Health Care - Public Health Issues United States General:
Accounting Office Washington, D.C. 20548:
Dear Ms. Heinrich:
Enclosed are the department‘s comments on your draft report entitled,
’Bioterrorism: Preparedness Varied across State and Local
Jurisdictions.“ The comments represent the tentative position of the
department and are subject to reevaluation when the final version of
this report is received.
The department also provided several technical comments directly to
your staff.
The department appreciates the opportunity to comment on this draft
report before its publication.
Sincerely,
Dennis J. Duquette:
Acting Principal Deputy Inspector General:
Signed by Dennis J. Duquette:
Enclosure:
The Office of Inspector General (OIG) is transmitting the department‘s
response to this draft report in our capacity as the department‘s
designated focal point and coordinator for General Accounting Office
reports. The OIG has not conducted an independent assessment of these
comments and therefore expresses no opinion on them.
Comments of the Department of Health and Human Services on the General
Accounting Office‘s Draft Report, ’Bioterrorism: Preparedness
Varied across State and Local Jurisdictions“ (GAO-03-373):
General Comments:
The Department of Health and Human Services (department) appreciates
the opportunity to review and comment on the draft report of the
General Accounting Office (GAO) entitled Bioterrorism: Preparedness
Varied Across State and Local Jurisdictions. The department commends
the GAO for an informative assessment of preparedness for bioterrorism
and other public health emergencies at the state and local levels. The
GAO‘s findings for the seven cities and states probably are
representative to a considerable extent of the situation across the
country at that time. Having said that, the department would like to
reinforce the point made in the report that changes have continued to
take place since the GAO site visits and this report does not reflect
all such changes. Indeed, it has been a year since the completion of
the GAO site visits and, in that period of time, both state and local
health departments have made further strides in their efforts to
achieve preparedness for bioterrorism and other public health
emergencies.
GAO Recommendations for Executive Action:
To help state and local jurisdictions better prepare for a bioterrorist
attack, we recommend that the Secretary of Health and Human Services,
in consultation with the Secretary of Homeland Security:
* develop specific benchmarks that define adequate preparedness for a
bioterrorist attack and which can be used by state and local
jurisdictions to assess and guide their preparedness efforts,
* develop a mechanism by which solutions to problems that have been
used
in one jurisdiction can be evaluated by HHS and, if appropriate, shared
with other jurisdictions.
Department Response:
The department would like to respond to some of the principal findings
in the report and provide additional information on measures it is
taking to address the concerns identified by GAO.
Regional Planning. We recognize that since public health emergencies,
including bioterrorist attacks, do not respect geopolitical lines,
preparedness planning and implementation must be carried out on a
regional basis (regions defined to include geographical areas that
cover not only multiple counties within a state but also those
involving two or more states and those that cross international
borders). To that end, the guidances to be issued this year by both the
Centers for Disease Control and Prevention (CDC) and the Health
Resources and Services Administration (HRSA) will reinforce our
emphasis on coordination of planning on a regional level.
Workforce Shortages. This is a concern we are addressing through
several different mechanisms. Both the CDC and HRSA guidances this year
will continue to focus on the education and training needed to prepare
for and respond to bioterrorism and other public health emergencies.
For state and local health departments that do not have sufficient
fiscal resources at this time for hiring, an effort is being made to
advance necessary funding from the CDC and HRSA FY 2003 cooperative
agreements to meet this need as well as others that may be creating
impediments to achieving state and local public health emergency
preparedness.
This year HRSA is also mounting a new $28 million initiative on
continuing education and curriculum development for clinical providers
who may be involved in the triage, diagnosis, treatment or definitive
care of terrorist victims. With respect to the longer term challenge of
creating an adequate public health workforce, we have already awarded a
cooperative agreement to the Association of Schools of Public Health
with the intent of having 19 Schools of Public Health develop and
implement a curriculum to train personnel specifically in the array of
skills needed by state and local health departments to respond to
bioterrorism and other public health emergencies.
Laboratory Capacity. Laboratories play a critical role in the detection
and diagnosis of illnesses resulting from exposure to either biological
or chemical agents. No therapy or prophylaxis can be initiated without
laboratory identification and confirmation of the agent in question.
Therefore, discussion of state and local efforts in laboratory capacity
building should not be consolidated with discussion of surveillance
activities. We recommend that these two topics each be accorded its own
section in the report.
Specific Benchmarks and Detailed Guidance. In response to the concern
articulated by various state and local health departments that they
need more specific benchmarks and more detailed guidance, we are in
fact including a larger number of specific benchmarks in this year‘s
guidance. Furthermore, both CDC and HRSA will be developing additional
guidelines as well as templates that will be shared with all awardee
jurisdictions. Every effort will be made to ensure that these
guidelines will allow states to better assess their progress toward
achieving an adequate level of preparedness and to determine when they
have achieved that level.
Sharing ofBest Practices. This is a goal that we strongly endorse. In
fact, the Office of the Assistant Secretary for Public Health Emergency
Preparedness, working closely with CDC and HRSA, will be leading an
effort to create a repository of ’best practices,“ that could include,
but not be limited to readiness assessment, 24/7 disease reporting,
laboratory proficiency testing, risk communication or Information
Technology interoperability. Such ’best practices“ will be identified,
validated and then shared with state and local health departments. This
project will reduce the duplication of time, effort and resources that
take place when each jurisdiction tries to ’reinvent the wheel.“ We
intend to initiate this project by no later than early summer.
Last year at its first annual meeting with recipients of its
cooperative agreements, HRSA highlighted a number of best practices in
areas that would be beneficial to state health departments attempting
to address hospital preparedness. As HRSA begins to plan for this
year‘s annual meeting of its grantees, the sharing of best practices
will be considered a high priority agenda item.
On a related effort, HRSA will be publishing very shortly a Federal
Register Notice announcing an initiative that will provide funding to
relevant national professional organizations to collaborate on the
development of core competencies essential for hospital leadership and
for clinical care to be provided by hospital-based personnel in
bioterrorism, radiological, or chemical disasters.
Thank you for a valuable report. It adds to and reinforces what we
already know about the activities/concerns of state and local health
departments as they go about preparing for and responding to
bioterrorism and other public health emergencies.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Marcia Crosse, (202) 512-7119:
Acknowledgments:
In addition to the contact named above, George Bogart, Barbara Chapman,
Robert Copeland, Deborah Miller, and Roseanne Price made key
contributions to this report.
[End of section]
Related GAO Products:
Chemical and Biological Defense: Observations on DOD‘s Risk Assessment
of Defense Capabilities. GAO-03-137T. Washington, D.C.: October 1,
2002.
Anthrax Vaccine: GAO‘s Survey of Guard and Reserve Pilots and Aircrew.
GAO-02-445. Washington, D.C.: September 20, 2002.
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.
Chemical and Biological Defense: Improved Risk Assessment and Inventory
Management Are Needed. GAO-01-667. 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.
Chemical and Biological Defense: Program Planning and Evaluation Should
Follow Results Act Framework. GAO/NSIAD-99-159. Washington, D.C.:
August 16, 1999.
Combating Terrorism: Observations on Biological Terrorism and Public
Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16,
1999.
[End of section]
FOOTNOTES
[1] Bioterrorism is the threatened or intentional release of biological
agents (viruses, bacteria, or their toxins) for the purpose of
influencing the conduct of government or intimidating or coercing a
civilian population. These agents can be released by way of the air (as
aerosols), food, water, or insects.
[2] In this report, the term response organizations refers to any
organization or individual that would respond to a bioterrorist
incident. These include physicians, hospitals, laboratories, public
health departments, emergency medical services, emergency management
agencies, fire departments, and law enforcement agencies.
[3] Public health infrastructure is the foundation that supports the
planning, delivery, and evaluation of public health activities and is
composed of a well-trained public health workforce, effective program
and policy evaluation, sufficient epidemiology and surveillance
capability to detect outbreaks and monitor incidence of diseases,
appropriate response capacity for public health emergencies, effective
laboratories, secure information systems, and advanced communications
systems.
[4] Disease surveillance systems provide for the ongoing collection,
analysis, and dissemination of health-related data to identify,
prevent, and control disease.
[5] National Association of Counties, Counties Secure America: A Survey
of County Public Health Needs and Preparedness (Washington, D.C.:
January 2002) and National Association of County and City Health
Officials, Research Brief: Assessment of Local Bioterrorism and
Emergency Preparedness, no. 5 (Washington, D.C.: October 2001).
[6] Amy Smithson and Leslie-Ann Levy, Ataxia: The Chemical and
Biological Terrorism Threat and the U.S. Response (Washington, D.C.:
The Henry L. Stimson Center, October 2000), 242, 262-263.
[7] Institute of Medicine of the National Academies, The Future of the
Public‘s Health in the 21st Century (Washington, D.C.: The National
Academies Press, 2003, forthcoming).
[8] See, for example, U.S. General Accounting Office, Bioterrorism:
Federal Research and Preparedness Activities, GAO-01-915 (Washington,
D.C.: Sept. 28, 2001).
[9] Pub. L. No. 106-505, § 102, 114 Stat. 2314, 2323 (2000).
[10] GAO-01-915.
[11] Advisory Panel to Assess Domestic Response Capabilities for
Terrorism Involving Weapons of Mass Destruction, Third 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, 2001), and 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).
[12] For example, in responding to an overt release of a biological
agent, the federal government would become involved more quickly. The
Federal Bureau of Investigation is the federal agency responsible for
investigating all terrorist threats and acts within the United States
and would conduct a criminal investigation concurrent with local public
health and medical community‘s response.
[13] A laboratorian is one who works in a laboratory; in the medical
and allied health professions, a laboratorian examines or performs
tests (or supervises such procedures) with various types of chemical
and biologic materials, chiefly to aid in the diagnosis, treatment, and
control of disease, or as a basis for health and sanitation practices.
[14] An epidemiologist is a specialist in the study of how disease is
distributed in populations and the factors that influence or determine
this distribution.
[15] Laboratories are categorized as either Biosafety Level 1, 2, 3, or
4, with Biosafety Level 4 laboratories providing the highest degree of
protection to personnel, the environment, and the community. Biosafety
levels represent combinations of laboratory practices and techniques,
safety equipment, and laboratory facilities. Each combination is
specifically appropriate for the operations performed, the documented
or suspected routes of transmission of the infectious agents, and the
laboratory function or activity.
[16] The MMRS program is intended to develop or enhance the local
response to a public health crisis, especially an attack using weapons
of mass destruction, by bringing together hospital and public health
officials, emergency managers, and others to deal with the consequences
of an attack. Under the MMRS program, OER contracts with cities to
improve the ability of local jurisdictions to respond to a public
health crisis.
[17] DOJ and FEMA also provide funding that supports planning,
equipment needs, and training for traditional emergency responders and
for state emergency management agencies, respectively. These funds are
targeted toward police, firefighters, and emergency medical
professionals and are intended to help improve coordination and
communication by encouraging state and local officials to plan and
conduct joint exercises for responding to terrorist events. State and
local governments can use these funds to plan for response to terrorist
attacks, conduct exercises to test capabilities, purchase equipment,
and train personnel.
[18] The funds were primarily appropriated by the 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.
[19] The four eligible municipalities were Chicago, the District of
Columbia, Los Angeles County, and New York City.
[20] In addition, CDC funded five American territories: American Samoa,
Guam, the Northern Marianas Islands, Puerto Rico, and the U.S. Virgin
Islands. CDC also funded the three freely associated states of the
Pacific: Marshall Islands, Micronesia, and Palau.
[21] The Strategic National Stockpile is a repository of
pharmaceuticals, antidotes, and medical supplies that can be delivered
to the site of a bioterrorist (or other) attack.
[22] The funds allocated were appropriated by the Department of Defense
and Emergency Supplemental Appropriations for Recovery from and
Response to Terrorist Attacks on the United States Act, 115 Stat. at
2314.
[23] To determine eligibility for the funding, CDC required the
applicants to submit plans for use of the funds in six focus areas:
preparedness planning and readiness assessment, surveillance and
epidemiology capacity, laboratory capacity for biological agents,
communications and information technology, risk communication and
health information dissemination, and education and training. Each
focus area included critical capacities that had to be addressed. These
are the core expertise and infrastructure elements that need to be in
place as soon as possible to enable a public health system to prepare
for and respond to bioterrorism and other infectious disease outbreaks.
An example of a critical capacity under the laboratory capacity for
biological agents focus area is to develop and implement a
jurisdiction-wide program to provide rapid and effective laboratory
services in support of the response to public health threats and
emergencies.
[24] In November 2002, HHS released supplemental guidance for
implementing the new National Smallpox Vaccination Program. These
guidelines state that recipients are encouraged to use funds made
available through the CDC cooperative agreements to plan and implement
this program and should redirect the funding as necessary.
[25] HRSA‘s guidance on the preparation of application plans for
funding required states and municipalities to lay out their plans for
conducting a needs analysis of hospitals, which would enable states and
municipalities to allocate their resources most effectively to improve
preparedness. States and municipalities also needed to discuss their
developing bioterrorism preparedness plans and protocols for hospitals
and other health care entities, such as community health centers. In
addition, states and municipalities were required to address four
priority-planning areas: medications and vaccines; personal
protection, quarantine, and decontamination; communications; and
biological disaster drills.
[26] In addition, a department official told us that the Office of the
Inspector General will have a role in ensuring that program
participants are accountable for their use of the funds. This oversight
will include reviewing cooperative agreement requirements, examining
program participants‘ performance and financial records for
completeness and timeliness, and performing pilot reviews of CDC
program participants to determine whether bioterrorism preparedness
funds were used in accordance with the cooperative agreement terms and
conditions.
[27] OER contracts totaling $10 million in fiscal year 2002 were used
to establish an MMRS capability in 25 additional cities (bringing the
total to 122 cities receiving MMRS funding). It was expected that by
the end of 2002 80 percent of the U.S. population would reside in an
area covered by an MMRS contract.
[28] The seventh state reported that although 95 percent of the state‘s
population was covered by HAN, all of the jurisdictions in the state
were not integrated into the system.
[29] Association of Public Health Laboratories, ’State Public Health
Laboratory Bioterrorism Capacity,“ Public Health Laboratory Issues in
Brief: Bioterrorism Capacity (Washington, D.C.: October 2002).
[30] As we found with the West Nile virus, the links between public and
animal health agencies are becoming more important. Many emerging
diseases affect both animals and humans, as do many viruses or other
disease-causing agents that might be used in bioterrorist attacks. 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).
[31] 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.
[32] Officials in one city told us that although it had no local
disease surveillance, its state maintained a passive disease
surveillance system.
[33] In addition, all of the states we visited were making efforts to
improve their disease surveillance systems.
[34] This type of active surveillance system is sometimes referred to
as a syndromic surveillance system. One federal official has stated
that research examining the usefulness of syndromic surveillance needs
to continue. See S. Lillibridge, (untitled), in 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).
[35] Association of Public Health Laboratories, 1, 3.
[36] J. Witt-Kushner, J.R. Astles, J.C. Ridderhof, and others, ’Core
Functions and Capabilities of State Public Health Laboratories: A
Report of the Association of Public Health Laboratories,“ Morbidity and
Mortality Weekly Report, vol. 51, no. RR-14 (2002), 1-8.
[37] CDC has established the Laboratory Response Network to maintain
state-of-the-art capabilities for biological agent identification and
characterization. The Laboratory Response Network 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.
[38] In Biosafety Level 3 laboratories, work is done with indigenous or
exotic agents with a potential for respiratory transmission, and which
may cause serious and potentially lethal infection. Biosafety Level 3
laboratories provide the second-highest degree of protection to
personnel, the environment, and the community.
[39] A. David Mangelsdorff, Chemical and Bioterrorism Preparedness
Checklist (Chicago: American Hospital Association, Oct. 3, 2001),
http://www.hospitalconnect.com/aha/key_issues/disaster_readiness/
resources/HospitalReady.html (downloaded Oct. 22, 2002). The checklist
was developed to help hospitals describe and assess their state of
preparedness for chemical and biological incidents.
[40] Presidential Decision Directive 62 created a category of special
events called National Security Special Events, which are events of
such significance that they warrant greater federal planning and
protection than other special events. In addition to major political
party conventions, such events include presidential inaugurations.
[41] S. Allan, ’The Challenges of Local Preparedness for Bioterrorism
and Other Emergencies,“ NACCHO Exchange: Promoting Effective Local
Public Health Practice, vol. 1, no. 1 (2002), 1-5.
[42] Epi-X is a secure, Web-based exchange for public health officials
to rapidly exchange information on disease outbreaks, exposures to
environmental hazards, and other health events as they are identified
and investigated.
[43] Advisory Panel to Assess Domestic Response Capabilities for
Terrorism Involving Weapons of Mass Destruction, Third Annual Report,
G-7-9.
[44] Institute of Medicine of the National Academies, xi.
[45] In 1991, which was the formal end of the recession, state budget
shortfalls were 6.2 percent of total state general fund revenues. In
1992, shortfalls were 6.5 percent of revenues. Fiscal year 2002 state
budget shortfalls are estimated to be 7.8 percent of estimated total
general fund revenues.
[46] Advisory Panel to Assess Domestic Response Capabilities for
Terrorism Involving Weapons of Mass Destruction, Fourth Annual Report,
v.
[47] See U.S. General Accounting Office, Homeland Security: Effective
Intergovernmental Coordination Is Key to Success, GAO-02-1013T
(Washington, D.C.: Aug. 23, 2002).
[48] GAO-01-915.
[49] Institute of Medicine, Chemical and Biological Terrorism: Research
and Development to Improve Civilian Medical Response (Washington, D.C.:
National Academy Press, 1999), and National Research Council, Making
the Nation Safer: The Role of Science and Technology in Countering
Terrorism (Washington, D.C.: National Academies Press, 2002).
[50] Advisory Panel to Assess Domestic Response Capabilities for
Terrorism Involving Weapons of Mass Destruction, Third 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, 2001), and 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).
[51] The United States Conference of Mayors, The Cost of Heightened
Security in America‘s Cities: A 192-City Survey (Washington, D.C.: City
Policy Associates, January 2002).
GAO‘s Mission:
The General Accounting Office, the investigative arm of Congress,
exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability
of the federal government for the American people. GAO examines the use
of public funds; evaluates federal programs and policies; and provides
analyses, recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO‘s commitment to
good government is reflected in its core values of accountability,
integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through the Internet. GAO‘s Web site ( www.gao.gov ) contains
abstracts and full-text files of current reports and testimony and an
expanding archive of older products. The Web site features a search
engine to help you locate documents using key words and phrases. You
can print these documents in their entirety, including charts and other
graphics.
Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as ’Today‘s Reports,“ on its
Web site daily. The list contains links to the full-text document
files. To have GAO e-mail this list to you every afternoon, go to
www.gao.gov and select ’Subscribe to daily E-mail alert for newly
released products“ under the GAO Reports heading.
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. General Accounting Office
441 G Street NW,
Room LM Washington,
D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director, NelliganJ@gao.gov (202) 512-4800 U.S.
General Accounting Office, 441 G Street NW, Room 7149 Washington, D.C.
20548:
