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Testimony:

Before the Subcommittee on Oversight and Investigations, Committee on 
Energy and Commerce, House of Representatives:

United States General Accounting Office:

GAO:

For Release on Delivery Expected at 2:00 p.m.

Wednesday, May 7, 2003:

SARS OUTBREAK:

Improvements to Public Health Capacity Are Needed for Responding to 
Bioterrorism and Emerging Infectious Diseases:

Statement of Janet Heinrich:

Director, Health Care--Public Health Issues:

GAO-03-769T:

GAO Highlights:

Highlights of GAO-03-769T, a report to the Subcommittee on Oversight 
and Investigations, Committee on Energy and Commerce, House of 
Representatives 

Why GAO Did This Study:

SARS has infected relatively few people nationwide, but it has raised 
concerns about preparedness for large-scale infectious disease 
outbreaks. The initial response to an outbreak occurs in local agencies 
and hospitals, with support from state and federal agencies, and can 
involve disease surveillance, epidemiologic investigation, health care 
delivery, and quarantine management. Officials have learned lessons 
applicable to preparedness for such outbreaks from experiences with 
other major public health threats.

GAO was asked to examine the preparedness of state and local public 
health agencies and hospitals for responding to a large-scale 
infectious disease outbreak and the relationship of federal and state 
planning for an influenza pandemic to preparedness for emerging 
infectious diseases. 

This testimony is based on Bioterrorism: Preparedness Varied across 
State and Local Jurisdictions, GAO-03-373 (Apr. 7, 2003); findings from 
a GAO survey on hospital emergency room capacity (in Hospital Emergency 
Departments: Crowded Conditions Vary among Hospitals and Communities, 
GAO-03-460 (Mar. 14, 2003)) and on hospital emergency preparedness; and 
information updating Influenza Pandemic: Plan Needed for Federal and 
State Response, GAO-01-4 (Oct. 27, 2000). 

What GAO Found:

The efforts of public health agencies and health care organizations to 
increase their preparedness for major public health threats such as 
bioterrorism and the worldwide influenza outbreaks known as pandemics 
have improved the nationís capacity to respond to SARS and other 
emerging infectious disease outbreaks, but gaps in preparedness remain. 
Specifically, GAO found that there are gaps in disease surveillance 
systems and laboratory facilities and that there are workforce 
shortages. The level of preparedness varied across seven cities GAO 
visited, with jurisdictions that have had multiple prior experiences 
with public health emergencies being generally more prepared than 
others. GAO found that planning for regional coordination was lacking 
between states. GAO also found that states were developing plans for 
receiving and distributing medical supplies for emergencies and for 
mass vaccinations in the event of a public health emergency.

GAO found that most hospitals lack the capacity to respond to large-
scale infectious disease outbreaks. Most emergency departments have 
experienced some degree of crowding and therefore in some cases may not 
be able to handle a large influx of patients during a potential SARS or 
other infectious disease outbreak. Most hospitals across the country 
reported participating in basic planning activities for such outbreaks. 
However, few hospitals have adequate medical equipment, such as the 
ventilators that are often needed for respiratory infections such as 
SARS, to handle the large increases in the number of patients that may 
result. 

The public health response to outbreaks of emerging infectious diseases 
such as SARS could be improved by the completion of federal and state 
influenza pandemic response plans that address problems related to the 
purchase, distribution, and administration of supplies of vaccines and 
antiviral drugs during an outbreak. The Centers for Disease Control and 
Prevention has provided interim draft guidance to facilitate state 
plans but has not made the final decisions on plan provisions necessary 
to mitigate the effects of potential shortages of vaccines and 
antiviral drugs in the event of an influenza pandemic.  

www.gao.gov/cgi-bin/getrpt?GAO-03-769T.

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]

Mr. Chairman and Members of the Subcommittee:

I appreciate the opportunity to be here today to discuss the work we 
have done pertaining to the nation's preparedness to manage major 
public health threats, such as the emerging infectious disease known as 
SARS.[Footnote 1] The initial response to an outbreak of infectious 
disease would occur at the local level, with support from state and 
federal agencies, and could involve disease surveillance,[Footnote 2] 
epidemiologic investigation,[Footnote 3] health care delivery, and 
quarantine management. The SARS outbreak has not infected large numbers 
of individuals in the United States, but it has raised concerns about 
the nation's preparedness to manage these components of response should 
it, or other infections, reach large-scale proportions.

Public health officials and health care workers have learned lessons 
applicable to preparedness for large-scale infectious disease outbreaks 
from experiences with other major public health threats. Because of 
prior worldwide influenza outbreaks--known as pandemics[Footnote 4]--
federal and state agencies have begun to focus special attention on 
planning for such events. Similarly, following the anthrax incidents of 
fall 2001, the Congress expressed concern that the nation may not be 
prepared to respond to a large-scale bioterrorist event. State and 
local response agencies and organizations have recognized the need to 
strengthen their infrastructure and capacity to respond to 
bioterrorism. The improvements they are making will also strengthen 
their ability to identify and respond to other major public health 
threats, including naturally occurring infectious disease outbreaks. 
Planning for a response to bioterrorism and influenza pandemics targets 
the public health resources essential for a response to emerging 
infectious diseases.

To assist the Subcommittee in its consideration of our nation's 
capacity to respond to a major public health threat such as SARS, my 
remarks today will focus on (1) the preparedness of state and local 
public health agencies for responding to a large-scale infectious 
disease outbreak, (2) the preparedness of hospitals for responding to a 
large-scale infectious disease outbreak, and (3) the relationship of 
federal and state planning for an influenza pandemic to preparedness 
for emerging infectious diseases.

My testimony today is based largely on our recently released report on 
state and local preparedness for a bioterrorist attack.[Footnote 5] For 
that report, we conducted site visits to seven cities and their 
respective state governments. We also reviewed each state's spring 2002 
applications for bioterrorism preparedness funding distributed by the 
Department of Health and Human Services' (HHS) Centers for Disease 
Control and Prevention (CDC) and Health Resources and Services 
Administration (HRSA), and each state's fall 2002 progress report on 
the use of that funding. In addition, I will present some findings from 
a survey we conducted on hospital emergency department capacity and 
emergency preparedness,[Footnote 6] as well as some information 
updating our 2000 report on federal and state planning for an influenza 
pandemic.[Footnote 7]

In summary, while the efforts of public health agencies and health care 
organizations to increase their preparedness for major public health 
threats such as influenza pandemics and bioterrorism have improved the 
nation's capacity to respond to SARS and other emerging infectious 
disease outbreaks, gaps in preparedness remain. Specifically, we found 
that there are gaps in disease surveillance systems and laboratory 
facilities and that there are workforce shortages. The level of 
preparedness varied across cities we visited, with jurisdictions that 
have had multiple prior experiences with public health emergencies 
being generally more prepared than others. We found that planning for 
regional coordination was lacking between states. We also found that 
states were developing plans for receiving and distributing medical 
supplies for emergencies and for mass vaccinations in the event of a 
public health emergency.

We found that most hospitals across the country lack the capacity to 
respond to large-scale infectious disease outbreaks. Most emergency 
departments have experienced some degree of crowding and therefore in 
some cases may not be able to handle a large influx of patients during 
a potential SARS or other infectious disease outbreak. Although most 
hospitals report participating in basic planning activities for such 
outbreaks, few have adequate medical equipment, such as ventilators 
that are often needed for respiratory infections such as SARS, to 
handle the large increases in the number of patients that may result.

The public health response to outbreaks of emerging infectious diseases 
such as SARS could be improved by the completion of federal and state 
influenza pandemic response plans that address problems related to the 
purchase, distribution, and administration of supplies of vaccines and 
antiviral drugs during an outbreak. CDC has provided interim draft 
guidance to facilitate state plans but has not made the final decisions 
on plan provisions necessary to mitigate the effects of potential 
shortages of vaccines and antiviral drugs in the event of an influenza 
pandemic.

Background:

SARS is a respiratory illness that has recently been reported 
principally in Asia, Europe, and North America. The World Health 
Organization reported on May 5, 2003, that there were an estimated 
6,583 probable cases reported in 27 countries, including 61 cases in 
the United States. There have been 461 deaths worldwide, none of which 
have been in the United States. Of the 56 probable cases in the United 
States reported through April 30, 2003, 37 (66 percent) were 
hospitalized, and 2 (4 percent) required mechanical ventilation. 
Symptoms of the disease, which may be caused by a previously 
unrecognized coronavirus,[Footnote 8] can include a fever, chills, 
headache, other body aches, or a dry cough.

A Canadian official recently reported that more than 60 percent of 
probable SARS cases in Canada, where the bulk of North American cases 
have occurred, resulted from transmission to health care workers and 
patients. Canada's experience with managing the SARS outbreak has shown 
that measures used to prevent and control emerging infectious diseases 
appear to have been useful in controlling this outbreak. One of the 
measures that it has undertaken to control the outbreak is isolating 
probable cases in hospitals, including closing two hospitals to new 
admissions.[Footnote 9] Other measures include isolating people, either 
in their homes or in a hospital, who have had close contact with a SARS 
patient and providing educational materials regarding SARS to people 
who have traveled to locations of concern.

In order to be adequately prepared for a major public health threat 
such as SARS in the United States, state and local public health 
agencies need to have several basic capabilities, whether they possess 
them directly or have access to them through regional agreements. 
Public health departments need to have disease surveillance systems and 
epidemiologists to detect clusters of suspicious symptoms or diseases 
in order to facilitate early detection of disease and treatment of 
victims. Laboratories need to have adequate capacity and necessary 
staff to test clinical and environmental samples in order to identify 
an agent promptly so that proper treatment can be started and 
infectious diseases prevented from spreading. All organizations 
involved in the response must be able to communicate easily with one 
another as events unfold and critical information is acquired, 
especially in a large-scale infectious disease outbreak. In 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.

Local health care organizations, including hospitals, are generally 
responsible for the initial response to a public health emergency. In 
the event of a large-scale infectious disease outbreak, hospitals and 
their emergency departments would be on the front line, and their 
personnel would take on the role of first responders. Because hospital 
emergency departments are open 24 hours a day, 7 days a week, exposed 
individuals would be likely to seek treatment from the medical staff on 
duty. Staff would need to be able to recognize and report any illness 
patterns or diagnostic clues that might indicate an unusual infectious 
disease outbreak to their state or local health department. Hospitals 
would need to have the capacity and staff necessary to treat severely 
ill patients and limit the spread of infectious disease. In addition, 
hospitals would need adequate stores of equipment and supplies, 
including medications, personal protective equipment, quarantine and 
isolation facilities, and air handling and filtration equipment.

The federal government also has a role in preparedness for and response 
to major public health threats. It becomes involved in investigating 
the cause of the disease, as it is doing with SARS. In addition, the 
federal government provides funding and resources to state and local 
entities to support preparedness and response efforts. CDC's Public 
Health Preparedness and Response for Bioterrorism program provided 
funding through cooperative agreements in fiscal year 2002 totaling 
$918 million to states and municipalities to improve bioterrorism 
preparedness and response, as well as other public health emergency 
preparedness activities. HRSA's Bioterrorism Hospital Preparedness 
Program provided funding through cooperative agreements in fiscal year 
2002 of approximately $125 million to states and municipalities to 
enhance the capacity of hospitals and associated health care entities 
to respond to bioterrorist attacks. In March 2003, HHS announced that 
the CDC and HRSA programs would provide funding of approximately $870 
million and $498 million, respectively, for fiscal year 2003. Among the 
other public health emergency response resources that the federal 
government provides is the Strategic National Stockpile, which contains 
pharmaceuticals, antidotes, and medical supplies that can be delivered 
anywhere in the United States within 12 hours of the decision to 
deploy.

Just as was true with the identification of the coronavirus as the 
likely causative agent in SARS, deciding which influenza viral strains 
are dominant depends on data collected from domestic and international 
surveillance systems that identify prevalent strains and characterize 
their effect on human health.[Footnote 10] Antiviral drugs and vaccines 
against influenza are expected to be in short supply if a pandemic 
occurs. Antiviral drugs, which can be used against all forms of viral 
diseases, have been as effective as vaccines in preventing illness from 
influenza and have the advantage of being available now. HHS assumes 
shortages of antiviral drugs and vaccines will occur in a pandemic 
because demand is expected to exceed current rates of production. For 
example, increasing production capacity of antiviral drugs can take at 
least 6 to 9 months, according to manufacturers.

State and Local Officials Reported Varying Levels of Public Health 
Preparedness for Infectious Disease Outbreaks:

In the cities we visited, state and local officials reported varying 
levels of public health preparedness to respond to outbreaks of 
diseases such as SARS. They recognized gaps in preparedness elements 
such as communication and were beginning to address them. Gaps also 
remained in other preparedness elements that have been more difficult 
to address, including the disease surveillance and laboratory systems 
and the response capacity of the workforce. In addition, we found that 
the level of preparedness varied across the cities. Jurisdictions that 
had multiple prior experiences with public health emergencies were 
generally more prepared than those with little or no such experience 
prior to our site visits. We found that planning for regional 
coordination was lacking between states. In addition, states were 
working on plans for receiving and distributing the Strategic National 
Stockpile and for administering mass vaccinations.

Progress Has Been Made in Elements of Public Health Preparedness, But 
Gaps Remain:

States and local areas were addressing gaps in public health 
preparedness elements, such as communication, but weaknesses remained 
in other preparedness elements, including the disease surveillance and 
laboratory systems and the response capacity of the workforce. Gaps in 
capacity often are not amenable to solution in the short term because 
either they require additional resources or the solution takes time to 
implement.

Communication:

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 a public health 
emergency. Many cities had purchased communication systems that allow 
officials from different organizations to communicate with one another 
in real time. In addition, state and local health agencies were working 
with CDC to build the Health Alert Network (HAN), an information and 
communication system. The nationwide HAN program has provided funding 
to establish infrastructure at the local level to improve the 
collection and transmission of information related to public health 
preparedness. Goals of the HAN program include providing high-speed 
Internet connectivity, broadcast capacity for emergency communication, 
and distance-learning infrastructure for training.

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, 
and all of the states we visited were making efforts to improve their 
disease surveillance systems. Six of the cities we visited used a 
passive surveillance system[Footnote 11] to detect infectious disease 
outbreaks.[Footnote 12] However, passive systems may be inadequate to 
identify a rapidly spreading outbreak in its earliest and most 
manageable stage because, as officials in three states noted, there is 
chronic underreporting and a time lag between diagnosis of a condition 
and the health department's receipt of the report. To improve disease 
surveillance, six of the states and two of the cities we visited were 
developing surveillance systems using electronic databases. Several 
cities were also evaluating the use of nontraditional data sources, 
such as pharmacy sales, to conduct surveillance.[Footnote 13] Three of 
the cities we visited were attempting to improve their surveillance 
capabilities by incorporating active surveillance components into their 
systems.

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 in the fall of 2001. During these incidents, the 
demand for laboratory testing was significant even in states where no 
anthrax was found and affected the ability of the laboratories to 
perform their routine public health functions. Following the incidents, 
over 70,000 suspected anthrax samples were tested in laboratories 
across the country.

Officials in the states we visited were working on other solutions to 
their laboratory problems. States were examining various ways to manage 
peak loads, including entering into agreements with other states to 
provide surge capacity, incorporating clinical laboratories into 
cooperative laboratory systems, and purchasing new equipment. One state 
was working to alleviate its laboratory problems by upgrading two local 
public health laboratories to enable them to process samples of more 
dangerous pathogens and by establishing agreements with other states to 
provide backup capacity. Another state reported that it was using the 
funding from CDC to increase the number of pathogens the state 
laboratory could diagnose. The state also reported that it has worked 
to identify laboratories in adjacent states that are capable of being 
reached within 3 hours over surface roads. In addition, all of the 
states reported that their laboratory response plans had been revised 
to cover reporting and sharing laboratory results with local public 
health and law enforcement agencies.

Workforce:

At the time of our site visits, shortages in personnel existed in state 
and local public health departments and laboratories and were difficult 
to remedy. Officials from state and local health departments told us 
that staffing shortages were a major concern. Two of the states and 
cities that we visited were particularly concerned that they did not 
have enough epidemiologists to do the appropriate investigations in an 
emergency. 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 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. Increased funding for hiring 
staff cannot necessarily solve these shortages in the near term because 
for many types of laboratory positions there are not enough trained 
individuals in the workforce. According to the Association of Public 
Health Laboratories, training laboratory personnel to provide them with 
the necessary skills will take time and require a strategy for building 
the needed workforce.[Footnote 14]

Level of Preparedness Varied across Cities We Visited:

We found that the overall level of public health 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 15] 
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.

Even the cities that were better prepared were not strong in all 
elements. For example, one city reported that communications had been 
effective during public health emergencies and that the city had an 
active disease surveillance system. However, officials reported gaps in 
laboratory capacity. Another one of the better-prepared cities was 
connected to HAN and the Epidemic Information Exchange (Epi-
X),[Footnote 16] 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 a public health 
emergency.

Planning for Regional Coordination Was Lacking between States:

Response organization officials were concerned about a lack of planning 
for regional coordination between states of the public health response 
to an infectious disease outbreak. As called for by the guidance for 
the CDC and HRSA funding, all of the states we visited organized their 
planning on the basis of regions within their states, assigning local 
areas to particular regions for planning purposes. A concern for 
response organization officials was the lack of planning for regional 
coordination between states. A hospital official in one city we visited 
said that state lines presented a "real wall" for planning purposes. 
Hospital officials in one state reported that they had no agreements 
with other states to share physicians. However, one local official 
reported that he had been discussing these issues and had drafted 
mutual aid agreements for hospitals and emergency medical services. 
Public health officials from several states reported developing working 
relationships with officials from other states to provide backup 
laboratory capacity.

States Have Begun Planning for Receiving and Distributing Items from 
the Strategic National Stockpile and for Administering Mass 
Vaccinations:

States have begun planning for use of the Strategic National 
Stockpile.[Footnote 17] To determine eligibility for the CDC funding, 
applicants were required to develop interim plans to receive and manage 
items from the stockpile, including mass distribution of antibiotics, 
vaccines, and medical materiel. However, having plans for the 
acceptance of the deliveries from the stockpile is not enough. Plans 
have to include details about dividing the materials that are delivered 
in large pallets and distributing the medications and vaccines.

Of the seven states we visited, five states had completed plans for the 
receipt and distribution of items from the stockpile. One state that 
was working on its plan stated that it would be completed in January 
2003. Only one state had conducted exercises of its stockpile 
distribution plan, while the other states were planning to conduct 
exercises or drills of their plans sometime in 2003.

In addition, five states reported on their plans for mass vaccinations 
and seven states reported on their plans for large-scale administration 
of smallpox vaccine in response to an outbreak. Some states we visited 
had completed plans for mass vaccinations, whereas other states were 
still developing their plans. The mass vaccination plans were generally 
closely tied to the plans for receiving and administering the 
stockpile. In addition, two states had completed smallpox response 
plans, which include plans for administering mass smallpox vaccinations 
to the general population, whereas four of the other states were 
drafting plans. The remaining state was discussing such a plan. 
However, only one of the states we visited has tested in an exercise 
its plan for conducting mass smallpox vaccinations.

Most Hospitals Lack Response Capacity for Large-Scale Infectious 
Disease Outbreaks:

We found that most hospitals lack the capacity to respond to large-
scale infectious disease outbreaks. Persons with symptoms of infectious 
disease would potentially go to emergency departments for treatment. 
Most emergency departments across the country have experienced some 
degree of crowding and therefore in some cases may not be able to 
handle a large influx of patients during a potential SARS outbreak. In 
addition, although most hospitals across the country reported 
participating in basic planning activities for large-scale infectious 
disease outbreaks, few have acquired the medical equipment resources, 
such as ventilators, to handle large increases in the number of 
patients that may result from outbreaks of diseases such as SARS.

Most Emergency Departments Have Experienced Some Degree of Crowding:

Our survey found that most emergency departments have experienced some 
degree of overcrowding.[Footnote 18] Persons with symptoms of 
infectious disease would potentially go to emergency departments for 
treatment, further stressing these facilities. The problem of 
overcrowding is much more pronounced in some hospitals and areas than 
in others. In general, hospitals that reported the most problems with 
crowding were in the largest metropolitan statistical areas (MSA) and 
in the MSAs with high population growth. For example, in fiscal year 
2001, hospitals in MSAs with populations of 2.5 million or more had 
about 162 hours of diversion (an indicator of crowding),[Footnote 19] 
compared with about 9 hours for hospitals in MSAs with populations of 
less than 1 million. Also the median number of hours of diversion in 
fiscal year 2001 for hospitals in MSAs with a high percentage 
population growth was about five times that for hospitals in MSAs with 
lower percentage population growth.

Diversion varies greatly by MSA. Figure 1 shows each MSA and the share 
of hospitals within the MSA that reported being on diversion more than 
10 percent of the time--or about 2.4 hours or more per day--in fiscal 
year 2001. Areas with the greatest diversion included Southern 
California and parts of the Northeast. Of the 248 MSAs for which data 
were available,[Footnote 20] 171 (69 percent) had no hospitals 
reporting being on diversion more than 10 percent of the time. By 
contrast, 53 MSAs (21 percent) had at least one-quarter of responding 
hospitals on diversion for more than 10 percent of the time.

Figure 1: Percentage of Hospitals on Diversion More Than 10 Percent of 
the Time, by MSA, Fiscal Year 2001:

[See PDF for image]

Note: Percentage of hospitals reflects those hospitals that responded 
to the survey; responses were not weighted to represent all hospitals 
in the MSA.

[A] MSAs with a response rate of 50 percent or less or MSAs with 50 
percent or more of data missing for responding hospitals. In 12 MSAs, 
no hospitals responded; these MSAs were excluded from the map.

[End of figure]

Hospitals in the largest MSAs and in MSAs with high population growth 
that have reported crowding in emergency departments may have 
difficulty handling a large influx of patients during a potential SARS 
outbreak, especially if this outbreak occurred in the winter months 
when the incidence of influenza is quite high. Thus far, the largest 
SARS outbreaks worldwide have primarily occurred in areas with dense 
populations.[Footnote 21]

Most Hospitals Reported Planning and Training Efforts, but Fewer Than 
Half Have Participated in Drills or Exercises:

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 city 
officials had come to realize that the first responders to a 
bioterrorism incident could be a hospital's medical staff. Officials 
from the state began to emphasize the need for a local approach to 
hospital preparedness. They said, however, that it was difficult to 
impress the importance of cooperation on hospitals because hospitals 
had not seen themselves as part of a local response system. The local 
government officials were asking them to create plans that integrated 
the city's hospitals and addressed such issues as off-site triage of 
patients and off-site acute care.

In our survey of over 2,000 hospitals,[Footnote 22] 4 out of 5 
hospitals reported having a written emergency response plan for large-
scale infectious disease outbreaks. Of the hospitals with emergency 
response plans, most include a description of how to achieve surge 
capacity for obtaining additional pharmaceuticals, other supplies, and 
staff. In addition, almost all hospitals reported participating in 
community interagency disaster preparedness committees.

Our survey showed that hospitals have provided training to staff on 
biological agents, but fewer than half have participated in exercises 
related to bioterrorism. Most hospitals we surveyed reported providing 
training about identifying and diagnosing symptoms for the six 
biological agents identified by the CDC as most likely to be used in a 
bioterrorist attack. At least 90 percent of hospitals reported 
providing training for two of these agents--smallpox and anthrax--and 
approximately three-fourths of hospitals reported providing training 
about the other four--plague, botulism, tularemia, and hemorrhagic 
fever viruses.

Most Hospitals Lack Adequate Equipment, Facilities, and Staff Required 
to Respond to a Large-Scale Infectious Disease Outbreak:

Most hospitals lack adequate equipment, isolation facilities, and staff 
to treat a large increase in the number of patients for an infectious 
disease such as SARS. To prevent transmission of SARS in health care 
settings, CDC recommends that health care workers use personal 
protective equipment, including gowns, gloves, respirators, and 
protective eyewear.[Footnote 23] SARS patients in the United States are 
being isolated until they are no longer infectious. CDC estimates that 
patients require mechanical ventilation in 10 to 20 percent of SARS 
cases.[Footnote 24]

In the seven cities we visited, hospital, state, and local officials 
reported that hospitals needed additional equipment and capital 
improvements--including medical stockpiles, personal protective 
equipment, quarantine and isolation facilities, and air handling and 
filtering equipment--to enhance preparedness. Five of the states we 
visited reported shortages of hospital medical staff, including nurses 
and physicians, necessary to increase response capacity in an 
emergency. One of the states we visited reported that only 11 percent 
of its hospitals could readily increase their capacity for treating 
patients with infectious diseases requiring isolation, such as smallpox 
and SARS. Another state reported that most of its hospitals have little 
or no capacity for isolating patients diagnosed with or being tested 
for infectious diseases.

According to our hospital survey, availability of medical equipment 
varied greatly between hospitals, and few hospitals seemed to have 
adequate equipment and supplies to handle a large-scale infectious 
disease outbreak. While most hospitals had, for every 100 staffed beds, 
at least 1 ventilator, 1 personal protective equipment suit, or 1 
isolation bed, half of the hospitals had, for every 100 staffed beds, 
fewer than 6 ventilators, 3 or fewer personal protective equipment 
suits, and fewer than 4 isolation beds.

Key Federal Decisions for Influenza Pandemic Planning Could Facilitate 
Response to Emerging Infectious Diseases:

The completion of final federal influenza pandemic response plans that 
address the problems related to the purchase, distribution, and 
administration of supplies of vaccines and antiviral drugs during a 
pandemic could facilitate the public health response to emerging 
infectious disease outbreaks. CDC has provided interim draft guidance 
to facilitate state plans but has not made the final decisions on plan 
provisions necessary to mitigate the effects of potential shortages of 
vaccines and antiviral drugs. Until such decisions are made, the 
timeliness and adequacy of response efforts may be compromised.

In the most recent version of its pandemic influenza planning guidance 
for states, CDC lists several key federal decisions related to vaccines 
and antiviral drugs that have not been made. These decisions include 
determining the amount of vaccines and antiviral drugs that will be 
purchased at the federal level; the division of responsibility between 
the public and the private sectors for the purchase, distribution, and 
administration of vaccines and drugs; and how population groups will be 
prioritized and targeted to receive limited supplies of vaccines and 
drugs. In each of these areas, until federal decisions are made, states 
will not be able to develop strategies consistent with federal action.

The interim draft guidance for state pandemic plans says that resources 
can be expected to be available through federal contracts to purchase 
influenza vaccine and some antiviral agents, but some state funding may 
be required. The amounts of antiviral drugs to be purchased and 
stockpiled are yet to be determined, even though these drugs are 
available and can potentially be used for both treatment and prevention 
during a pandemic.

CDC has indicated in its interim draft guidance that the policies for 
purchasing, distributing, and administering vaccines and drugs by the 
private and public sectors will change during a pandemic, but some 
decisions necessary to prepare for these expected changes have not been 
made. During a typical annual influenza response, influenza vaccine and 
antiviral drug distribution is primarily handled directly by 
manufacturers through private vendors and pharmacies to health care 
providers. During a pandemic, however, CDC interim draft guidance 
indicates that many of these private-sector responsibilities may be 
transferred to the public sector at the federal, state, or local levels 
and that priority groups within the population would need to be 
established for receiving limited supplies of vaccines and drugs.

State officials are particularly concerned that a national plan has not 
been issued with final recommendations for how population groups should 
be prioritized to receive vaccines and antiviral drugs. In its interim 
draft guidance, CDC lists eight population groups that should be 
considered in establishing priorities among groups for receiving 
vaccines and drugs during a pandemic. The list includes such groups as 
health care workers and public health personnel involved in the 
pandemic response, persons traditionally considered to be at increased 
risk of severe influenza illness and mortality, and preschool and 
school-aged children.

Although state officials acknowledge the need for flexibility in 
planning because many aspects of a pandemic cannot be known in advance, 
the absence of more detail leaves them uncertain about how to plan for 
the use of limited supplies of vaccine and drugs. In our 2000 report on 
the influenza pandemic, we recommended that HHS determine the 
capability of the private and public sectors to produce, distribute, 
and administer vaccines and drugs and complete the national response 
plan.[Footnote 25] To date, only limited progress has been made in 
addressing these recommendations.

Concluding Observations:

Many actions taken at the state and local level to prepare for a 
bioterrorist event have enhanced the ability of state and local 
response agencies and organizations to manage an outbreak of an 
infectious disease such as SARS. However, there are significant gaps in 
public health surveillance systems and laboratory capacity, and the 
number of personnel trained for disease detection is insufficient. Most 
emergency departments across the country have experienced some degree 
of overcrowding. Hospitals have begun planning and training efforts to 
respond to large-scale infectious disease outbreaks, but many hospitals 
lack adequate equipment, medical stockpiles, personal protective 
equipment, and quarantine and isolation facilities. Federal and state 
plans for the purchase, distribution, and administration of supplies of 
vaccines and drugs in response to an influenza pandemic have still not 
been finalized. The lack of these final plans has serious implications 
for efforts to mobilize the distribution of vaccines and drugs for 
other infectious disease outbreaks.

Mr. Chairman, this completes my prepared statement. I would be happy to 
respond to any questions you or other Members of the Subcommittee may 
have at this time.

Contact and Staff Acknowledgments:

For further information about this testimony, please contact me at 
(202) 512-7119. Robert Copeland, Marcia Crosse, Martin T. Gahart, 
Deborah Miller, Roseanne Price, and Ann Tynan also made key 
contributions to this statement.

[End of section]

Related GAO Products:

Smallpox Vaccination: Implementation of National Program Faces 
Challenges. GAO-03-578. Washington, D.C.: April 30, 2003.

Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have 
Improved Public Health Response Capacity, but Gaps Remain. GAO-03-654T. 
Washington, D.C.: April 9, 2003.

Bioterrorism: Preparedness Varied across State and Local Jurisdictions. 
GAO-03-373. Washington, D.C.: April 7, 2003.

Hospital Emergency Departments: Crowded Conditions Vary among Hospitals 
and Communities. GAO-03-460. Washington, D.C.: March 14, 2003.

Homeland Security: New Department Could Improve Coordination but 
Transferring Control of Certain Public Health Programs Raises Concerns. 
GAO-02-954T. Washington, D.C.: July 16, 2002.

Homeland Security: New Department Could Improve Biomedical R&D 
Coordination but May Disrupt Dual-Purpose Efforts. GAO-02-924T. 
Washington, D.C.: July 9, 2002.

Homeland Security: New Department Could Improve Coordination but May 
Complicate Priority Setting. GAO-02-893T. Washington, D.C.: June 28, 
2002.

Homeland Security: New Department Could Improve Coordination but May 
Complicate Public Health Priority Setting. GAO-02-883T. Washington, 
D.C.: June 25, 2002.

Bioterrorism: The Centers for Disease Control and Prevention's Role in 
Public Health Protection. GAO-02-235T. Washington, D.C.: November 15, 
2001.

Bioterrorism: Review of Public Health Preparedness Programs. GAO-02-
149T. Washington, D.C.: October 10, 2001.

Bioterrorism: Public Health and Medical Preparedness. GAO-02-141T. 
Washington, D.C.: October 9, 2001.

Bioterrorism: Coordination and Preparedness. GAO-02-129T. Washington, 
D.C.: October 5, 2001.

Bioterrorism: Federal Research and Preparedness Activities. GAO-01-
915. Washington, D.C.: September 28, 2001.

West Nile Virus Outbreak: Lessons for Public Health Preparedness. GAO/
HEHS-00-180. Washington, D.C.: September 11, 2000.

Combating Terrorism: Need for Comprehensive Threat and Risk Assessments 
of Chemical and Biological Attacks. GAO/NSIAD-99-163. Washington, D.C.: 
September 14, 1999.

Combating Terrorism: Observations on Biological Terrorism and Public 
Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16, 
1999.

FOOTNOTES

[1] SARS is the abbreviation for severe acute respiratory syndrome.

[2] Disease surveillance uses systems that provide for the ongoing 
collection, analysis, and dissemination of health-related data to 
identify, prevent, and control disease.

[3] An epidemiologic investigation seeks to determine how a disease is 
distributed in a population and the factors that influence or determine 
this distribution. 

[4] Influenza pandemics are worldwide influenza epidemics that can have 
successive "waves" of disease and last for up to 3 years. Three 
pandemics occurred in the twentieth century: the "Spanish flu" of 1918, 
which killed at least 20 million people worldwide; the "Asian flu" of 
1957; and the "Hong Kong flu" of 1968.

[5] U.S. General Accounting Office, Bioterrorism: Preparedness Varied 
across State and Local Jurisdictions, GAO-03-373 (Washington, D.C.: 
Apr. 7, 2003).

[6] These findings include those related to emergency department 
capacity, which we reported in U.S. General Accounting Office, Hospital 
Emergency Departments: Crowded Conditions Vary among Hospitals and 
Communities, GAO-03-460 (Washington, D.C.: Mar. 14, 2003) and hospital 
emergency preparedness for mass casualty incidents from ongoing work. 
We did our work on the survey from May 2002 through May 2003 in 
accordance with generally accepted government auditing standards.

[7] U.S. General Accounting Office, Influenza Pandemic: Plan Needed for 
Federal and State Response, GAO-01-4 (Washington, D.C.: Oct. 27, 2000).

[8] The coronavirus is one of a group of viruses that are responsible 
for some but not all common colds. They are so named because their 
microscopic appearance is that of a virus particle surrounded by a 
crown.

[9] The two hospitals have since been reopened.

[10] CDC participates in international disease and laboratory 
surveillance sponsored by the World Health Organization, which operates 
in 83 countries.

[11] 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.

[12] Officials in one city told us that although it had no local 
disease surveillance, its state maintained a passive disease 
surveillance system.

[13] This type of active surveillance system in which the public health 
department obtains information from such sources as hospitals and 
pharmacies and conducts ongoing analysis of the data to search for 
certain combinations of signs and symptoms, is sometimes referred to as 
a syndromic surveillance system. One federal official has stated that 
research examining the usefulness of syndromic surveillance needs to 
continue. See S. Lillibridge, Disease Surveillance, Bioterrorism, and 
Homeland Security, Conference Summary and Proceedings Prepared by the 
Annapolis Center for Science-Based Public Policy (Annapolis, Md.: U.S. 
Medicine Institute for Health Studies, Dec. 4, 2001).

[14] Association of Public Health Laboratories, "State Public Health 
Laboratory Bioterrorism Capacity," Public Health Laboratory Issues in 
Brief: Bioterrorism Capacity (Washington, D.C.: October 2002).

[15] 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.

[16] 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.

[17] HHS is planning to purchase approximately 2,700 ventilators by 
September 2003 to supplement those now available in the Strategic 
National Stockpile to enhance preparedness for a potential outbreak of 
SARS in the United States.

[18] GAO-03-460.

[19] Diversions occur when hospitals request that en route ambulances 
bypass their emergency departments and transport patients that would 
have been otherwise taken to those emergency departments to other 
medical facilities.

[20] The 248 MSAs include those MSAs for which (1) more than half of 
hospitals in the MSA returned surveys and (2) more than half of those 
hospitals that returned surveys provided data on diversion hours.

[21] These areas include mainland China and the Hong Kong Special 
Administrative Region within the People's Republic of China; Singapore; 
Taiwan; and Toronto, Canada.

[22] Between May and September 2002, we surveyed over 2,000 short-term, 
nonfederal general medical and surgical hospitals with emergency 
departments located in metropolitan statistical areas. (See U.S. 
General Accounting Office, Hospital Emergency Departments: Crowded 
Conditions Vary among Hospitals and Communities, GAO-03-460 
(Washington, D.C.: Mar. 14, 2003) for information on the survey 
universe and development of the survey.) For the part of the survey 
that specifically addressed hospital preparedness for mass casualty 
incidents, we obtained responses from 1,482 hospitals for the third 
section of the survey addressing emergency preparedness, a response 
rate of about 73 percent.

[23] CDC, Interim Domestic Guidance for Management of Exposures to 
Severe Acute Respiratory Syndrome (SARS) for Healthcare and Other 
Institutional Settings (Apr. 12, 2003), http://www.cdc.gov/ncidod/
sars/exposureguidance.htm (downloaded May 5, 2003).

[24] CDC, Frequently Asked Questions: Severe Acute Respiratory Syndrome 
(SARS), http://www.cdc.gov/ncidod/sars/faq.htm (downloaded May 5, 
2003). 

[25] GAO-01-4.