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Progress but Fell Short of Program Goals for 2002' which was released 
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February 10, 2004:

Congressional Committees:

Subject: HHS Bioterrorism Preparedness Programs: States Reported 
Progress but Fell Short of Program Goals for 2002:

The anthrax incidents during the fall of 2001 raised concerns about the 
nation's ability to respond to bioterrorist events and other public 
health threats. The incidents strained the public health system, 
including surveillance[Footnote 1] and laboratory workforce 
capacities, at the state and local levels.[Footnote 2] Several months 
after the incidents, the Congress appropriated funds to strengthen 
state and local bioterrorism preparedness.[Footnote 3] The Department 
of Health and Human Services' (HHS) Centers for Disease Control and 
Prevention (CDC) and Health Resources and Services Administration 
(HRSA) distributed the funds in 2002 through two cooperative agreement 
programs with state, municipal, and territorial governments.[Footnote 
4]

To strengthen preparedness, the two cooperative agreement programs--
CDC's Public Health Preparedness and Response for Bioterrorism Program 
and HRSA's National Bioterrorism Hospital Preparedness Program--
require participants to complete specific activities designed to build 
public health and health care capacities. The 2002 cooperative 
agreements for both programs ended on August 30, 2003. For the 2002 
cooperative agreements, CDC's and HRSA's programs distributed 
approximately $918 million and approximately $125 million, 
respectively.[Footnote 5]

The Public Health Security and Bioterrorism Preparedness and Response 
Act of 2002 directs us to report on federal programs that support 
preparedness efforts at the state and local levels.[Footnote 6] We have 
previously reported on state and local efforts and hospital 
preparedness.[Footnote 7] As agreed with the committees of 
jurisdiction, for this report, we examined the extent to which states 
completed 2002 cooperative agreement requirements and whether states 
identified any factors that hindered implementation of CDC's program 
and HRSA's program. In this report, we use the term "state" to refer to 
the 50 states, the District of Columbia, New York City, Chicago, and 
Los Angeles County. Enclosure I contains the information we provided 
during our January 14, 2004 briefing of your staff.

To determine the extent to which states had completed program 
requirements, we relied primarily on the cooperative agreement progress 
reports that CDC and HRSA required the states to submit. We checked the 
data for internal consistency as well as consistency with other sources 
and determined that they were adequate for our purposes. We reviewed 
semi-annual progress reports submitted by the states, covering the 
period through August 30, 2003, for CDC's program and through July 1, 
2003, for HRSA's program.[Footnote 8] For a number of reasons, we use 
broad categories to describe the degree of progress states have made in 
completing requirements. These reasons include: CDC and HRSA changed 
the reporting formats over the course of the agreements, states had 
varying interpretations of what constituted completion of the 
requirements, and the final reports do not reflect follow-up by CDC and 
HRSA to clarify states' responses. We also interviewed officials and 
reviewed relevant documents from CDC, HRSA, and HHS's Office of the 
Assistant Secretary for Public Health Emergency Preparedness. We also 
interviewed officials from 10 states, 1 local health department within 
each of these states, and 2 major metropolitan areas directly funded by 
CDC and HRSA.[Footnote 9] The program participants are not identified 
in this report because of the sensitive nature of the issue. In 
addition, we interviewed representatives and reviewed documents from 
the Association of State and Territorial Health Officials and the 
American Hospital Association and its affiliates. We reviewed documents 
from the National Association of County and City Health Officials, the 
Council of State and Territorial Epidemiologists, and the Association 
of Public Health Laboratories. We performed our work from June 2003 
through February 2004 in accordance with generally accepted government 
auditing standards.

Results:

States reported progress toward the CDC program's goal of strengthening 
public health preparedness, but identified factors that hindered them 
from meeting all of CDC's 2002 cooperative agreement requirements. All 
states reported progress in developing the capacities CDC considers 
critical for public health preparedness, but no state completed all 
program requirements. Some of the 14 requirements that CDC considers 
critical benchmarks of preparedness were more likely to be completed 
than others. Four critical benchmarks were met by most of the states. 
These benchmarks included the establishment of a bioterrorism advisory 
committee and coverage of 90 percent of the state's population by the 
Health Alert Network--a nationwide program designed to ensure 
communication capacity at all state and local health departments. Two 
critical benchmarks were met by few of the states: development of a 
statewide response plan and development of a regional response plan. 
The remaining eight critical benchmarks were met by around half the 
states. These benchmarks included assessment of emergency preparedness 
and response capabilities, development of a system that can receive and 
evaluate urgent disease reports at all times, and development of an 
interim Strategic National Stockpile[Footnote 10] plan. In addition, 
state and local officials reported three main factors that hindered 
their ability to complete all of CDC's requirements: (1) redirection of 
resources to the National Smallpox Vaccination Program,[Footnote 11] 
(2) difficulties in increasing personnel as a result of state and local 
budget deficits, and (3) delays caused by state and local management 
practices, such as contracting and hiring procedures.

Similarly, states reported progress toward the HRSA program's goal of 
strengthening hospital preparedness but identified factors that have 
hindered their efforts to complete all of HRSA's 2002 program 
requirements. While no state has completed all of HRSA's requirements-
-to conduct needs assessments, to meet three critical benchmarks of 
hospital preparedness, and to address priority issues--states have 
until March 31, 2004, to complete most of them. No state reported 
completing all components of its needs assessment. Almost all states 
reported that they had met two of the three critical benchmarks: 
designation of a coordinator for hospital preparedness planning and 
establishment of a hospital preparedness planning 
committee. No state reported meeting the third benchmark--development 
of a plan for the hospitals in the state to respond to an epidemic 
involving at least 500 patients. States reported varying degrees of 
progress in addressing the priority issues that HRSA required them to 
address, such as receipt and distribution of medications and vaccines, 
personal protection of health care workers, quarantine capacity, and 
communications. State officials expressed concern that HRSA funding was 
insufficient for states to meet the requirements of the 2002 program. 
Similarly, hospital representatives reported that redirection of 
resources to the National Smallpox Vaccination Program and delays 
caused by lengthy contracting processes for distributing funds from the 
state to the hospitals hindered efforts to implement the program.

In summary, although the states' progress fell short of 2002 program 
goals, CDC's and HRSA's cooperative agreement programs have enabled 
states to make much needed improvements in the public health and health 
care capacities critical for preparedness. States are more prepared now 
than they were prior to these programs, but much remains to be 
accomplished.

Agency Comments:

We provided a draft of this report to HHS. HHS informed us that it had 
no comment on the draft report but provided technical comments, which 
we incorporated where appropriate.


We are sending copies of this report to the Secretary of HHS, the 
Director of CDC, the Administrator of HRSA, and other interested 
officials. We will also provide copies to others upon request. In 
addition, the report will be available at no charge on the GAO Web site 
at http://www.gao.gov.

If you or your staff have any questions or need additional information, 
please contact me at (202) 512-7119. Another contact and key 
contributors are listed in enclosure III.

Janet Heinrich:

Director, Health Care--Public Health Issues:

Signed by Janet Heinrich:

Enclosures - 3:

List of Committees:

The Honorable Judd Gregg:

Chairman:

The Honorable Edward M. Kennedy:

Ranking Minority Member:

Committee on Health, Education, Labor, and Pensions:

United States Senate:

The Honorable Ted Stevens:

Chairman:

The Honorable Robert C. Byrd:

Ranking Minority Member:

Committee on Appropriations:

United States Senate:

The Honorable W.J. "Billy" Tauzin:

Chairman:

The Honorable John D. Dingell:

Ranking Minority Member:

Committee on Energy and Commerce:

House of Representatives:

The Honorable C.W. Bill Young:

Chairman:

The Honorable David R. Obey:

Ranking Minority Member:

Committee on Appropriations:

House of Representatives:

Enclosure 1: 

[See PDF for slideshow]

[End of slideshow]

CDC Focus Areas, Critical Capacities, and Critical Benchmarks (2002):

To strengthen public health preparedness, CDC identified focus areas 
for states to improve their public health capacity. Within each focus 
area, CDC identified the specific capacities that are critical for 
states to be prepared to respond to a bioterrorist event or other 
public health emergency. To guide states in building these critical 
capacities, CDC specified a number of requirements for the 2002 
cooperative agreements, and designated some of them as critical 
benchmarks. Table 1 lists the focus areas and their associated critical 
capacities and critical benchmarks.

Table 1: CDC Focus Areas, Critical Capacities, and Critical Benchmarks 
for the 2002 Cooperative Agreements:

Focus area: Focus area A; Critical capacity: Preparedness Planning and 
Readiness Assessment;

Critical capacity #1: To establish a process for strategic leadership, 
direction, coordination, and assessment of activities to ensure state 
and local readiness, interagency collaboration, and preparedness for 
bioterrorism, other outbreaks of infectious disease, and other public 
health threats and emergencies; Critical benchmark: Critical benchmark 
#1: Designate an executive director of the bioterrorism preparedness 
and response program; Critical benchmark #2: Establish a bioterrorism 
advisory committee.

Critical capacity #2: To conduct integrated assessments of public 
health system capacities related to bioterrorism, other infectious 
disease outbreaks, and other public health threats and emergencies to 
aid and improve planning, coordination, and implementation; Critical 
benchmark: Critical benchmark #3: Assessment of emergency preparedness 
and response capabilities; Critical benchmark #4: Assessment of 
statutes, regulations, and ordinances that provide for credentialing, 
licensure, and delegation of authority for executing emergency public 
health measures.

Critical capacity #3: To respond to emergencies caused by bioterrorism, 
other infectious disease outbreaks, and other public health threats and 
emergencies through the development and exercise of a comprehensive 
public health emergency preparedness and response plan; Critical 
benchmark: Critical benchmark #5: Development of a statewide response 
plan and provisions for exercising the plan; Critical benchmark #6: 
Development of regional response plans.

Critical capacity #4: To ensure that state, local, and regional 
preparedness for and response to bioterrorism, other infectious 
outbreaks, and other public health threats and emergencies are 
effectively coordinated with federal response assets; Critical 
benchmark: Critical benchmark #7: Develop an interim plan to receive 
and manage items from the Strategic National Stockpile (SNS).

Critical capacity #5: To effectively manage the CDC SNS, should it be 
deployed--translating SNS plans into firm preparations, periodic 
testing of SNS preparedness, and periodic training for entities and 
individuals that are part of SNS preparedness; Critical benchmark: No 
critical benchmarks were identified for 2002 cooperative agreements.

Focus area: Focus area B; Critical capacity: Surveillance and 
Epidemiology Capacity;

Critical capacity #6: To rapidly detect a terrorist event through a 
highly functioning, mandatory reportable disease surveillance system, 
as evidenced by ongoing timely and complete reporting by providers and 
laboratories, especially of illnesses and conditions possibly resulting 
from bioterrorism, other infectious disease outbreaks, and other public 
health threats and emergencies; Critical benchmark: Critical benchmark 
#8: Develop a system to receive and evaluate urgent disease reports on 
a 24-hour-per-day, 7-day-per-week basis.

Critical capacity #7: To rapidly and effectively investigate and 
respond to a potential terrorist event as evidenced by a comprehensive 
and exercised epidemiologic response plan that addresses surge 
capacity, delivery of mass prophylaxis and immunizations, and pre-event 
development of specific epidemiologic investigation and response needs; 
Critical benchmark: Critical benchmark #9: Assess current epidemiologic 
capacity and achieve the goal of at least one epidemiologist for each 
metropolitan statistical area.

Critical capacity #8: To rapidly and effectively investigate and 
respond to a potential terrorist event, as evidenced by ongoing 
effective state and local response to naturally occurring individual 
cases of urgent public health importance, outbreaks of disease, and 
emergency public health interventions such as emergency 
chemoprophylaxis or immunization activities; Critical benchmark: No 
critical benchmarks were identified for 2002 cooperative agreements.

Focus area: Focus area C; Critical capacity: Laboratory Capacity--
Biologic Agents;

Critical capacity #9: To develop and implement a statewide program to 
provide rapid and effective laboratory services in support of the 
response to bioterrorism, other infectious disease outbreaks, and other 
public health threats and emergencies; Critical benchmark: Critical 
benchmark #10: Develop a plan to improve working relationships and 
communication between clinical labs and higher level Laboratory 
Response Network (LRN)[A] labs.

Critical capacity #10: As an LRN member, to ensure adequate and secure 
laboratory facilities, reagents, and equipment to rapidly detect and 
correctly identify biological agents likely to be used in a 
bioterrorist incident; Critical benchmark: No critical benchmarks were 
identified for 2002 cooperative agreements.

Focus area: Focus area D; Critical capacity: Laboratory Capacity--
Chemical Agents;

Critical capacity: No critical capacities/benchmarks were identified 
for 2002 cooperative agreements; Critical benchmark:

Focus area: Focus area E; Critical capacity: Health Alert Network/
Communications and Information Technology.

Critical capacity #11: To ensure effective communications connectivity 
among public health departments, health care organizations, law 
enforcement organizations, public officials, and others by: (a) 
continuous, high-speed connectivity to the Internet; (b) routine use of 
e-mail for notification of alerts and other critical communication; and 
(c) a directory of public health participants (including primary 
clinical personnel), their roles, and contact information covering all 
jurisdictions; Critical benchmark: Critical benchmark #11: Ensure that 
90 percent of the population is covered by the Health Alert Network; 
Critical benchmark #12: Develop a communications system that provides a 
24-hour-per-day, 7-day-per-week flow of critical health information.

Critical capacity #12: To ensure a method of emergency communication 
for participants in public health emergency response that is fully 
redundant with e-mail; Critical benchmark: No critical benchmarks were 
identified for 2002 cooperative agreements.

Critical capacity #13: To ensure the ongoing protection of critical 
data and information systems and capabilities for continuity of 
operations; Critical benchmark: No critical benchmarks were identified 
for 2002 cooperative agreements.

Critical capacity #14: To ensure secure electronic exchange of 
clinical, laboratory, environmental, and other public health 
information in standard formats between the computer systems of public 
health partners; Critical benchmark: No critical benchmarks were 
identified for 2002 cooperative agreements.

Focus area: Focus area F; Critical capacity: Risk Communication and 
Health Information Dissemination.

Critical capacity #15: To provide needed health/risk information to the 
public and key partners during a terrorism event by establishing 
critical baseline information about the current communication needs and 
barriers within individual communities, and identifying effective 
channels of communication for reaching the general public and special 
populations during public health threats and emergencies; Critical 
benchmark: Critical benchmark #13: Develop an interim plan for risk 
communication and information dissemination.

Focus area: Focus area G; Critical capacity: Education and Training;

Critical capacity #16: To ensure the delivery of appropriate education 
and training to key public health professionals, infectious disease 
specialists, emergency department personnel, and other health care 
providers in preparedness for and response to bioterrorism, other 
infectious disease outbreaks, and other public health threats and 
emergencies, either directly or through the use (where possible) of 
existing curricula and other sources, including schools of public 
health and medicine, academic health centers, CDC training networks, 
and other providers; Critical capacity #16: To ensure the delivery of 
appropriate education and training to key public health professionals, 
infectious disease specialists, emergency department personnel, and 
other health care providers in preparedness for and response to 
bioterrorism, other infectious disease outbreaks, and other public 
health threats and emergencies, either directly or through the use 
(where possible) of existing curricula and other sources, including 
schools of public health and medicine, academic health centers, CDC 
training networks, and other providers; Critical benchmark: Critical 
benchmark #14: Prepare a timeline to assess training needs.

Source: CDC.

[A] CDC established the LRN to maintain state-of-the-art capabilities 
for biological agent identification and characterization. The LRN is a 
multilevel system designed to link state and local public health 
laboratories with advanced capacity clinical, military, veterinary, 
agricultural, water, and food-testing laboratories.

[End of table]

Enclosure III: 

GAO Contact and Staff Acknowledgments:

GAO Contact:

Michele Orza, (202) 512-6970:

Acknowledgments:

The following staff members made important contributions to this work: 
Angela:

Choy, Chad Davenport, Maria Hewitt, Krister Friday, and Nkeruka 
Okonmah.

(290293):

FOOTNOTES

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



[2] See U.S. General Accounting Office, Bioterrorism: Public Health 
Response to Anthrax Incidents of 2001, GAO-04-152 (Washington, D.C.: 
Oct. 15, 2003).



[3] Department of Defense and Emergency Supplemental Appropriations for 
Recovery from and Response to Terrorist Attacks on the United States 
Act, Pub. L. No. 107-117, 115 Stat. 2230, 2314 (2002), and the 
Departments of Labor, Health and Human Services and Education, and 
Related Agencies Appropriations Act of Fiscal Year 2002, Pub. L. No. 
107-116, 115 Stat. 2186, 2198.



[4] A cooperative agreement is used as a mechanism to provide financial 
support when substantial interaction is expected between the executive 
agency and a state, local government, or other recipient carrying out 
the funded activity. Under their programs, CDC and HRSA made funding 
available to the following: all 50 states; the District of Columbia; 
the country's three largest municipalities (New York City, Chicago, and 
Los Angeles County); the territories of American Samoa, Guam, and the 
U.S. Virgin Islands; and the commonwealths of the Northern Mariana 
Islands and Puerto Rico. CDC also made funding available to the 
republics of Palau and the Marshall Islands and the Federated States of 
Micronesia. 



[5] In 2003, the Congress appropriated additional funds for 
bioterrorism preparedness. Consolidated Appropriations Resolution, 
2003, Pub. L. No. 108-7, Division G, Title II, 117 Stat. 11, 322. HHS 
renewed the cooperative agreements for the period of August 31, 2003 
through August 30, 2004. CDC's and HRSA's programs distributed about 
$870 million and about $498 million, respectively. 



[6] Pub. L. No. 107-188,  157, 116 Stat. 594, 633 (2002).



[7] U.S. General Accounting Office, Bioterrorism: Preparedness Varied 
across State and Local Jurisdictions, GAO-03-373 (Washington, D.C.: 
Apr. 7, 2003), and Hospital Preparedness: Most Urban Hospitals Have 
Emergency Plans but Lack Certain Capacities for Bioterrorism Response, 
GAO-03-924 (Washington, D.C.: Aug. 6, 2003). 



[8] The final progress report for one state was missing for the CDC 
program. HRSA did not require states to complete some of the 
requirements until March 31, 2004.



[9] We selected these program participants in order to provide a range 
of population sizes, geographic locations, and experience with 
responding to disasters and conducting large drills and exercises. Each 
of the 10 local health departments in our sample serves a major 
metropolitan area within a state.

[10] The Strategic National Stockpile, formerly the National 
Pharmaceutical Stockpile, is a repository of pharmaceuticals and 
medical supplies that can be delivered to the site of a biological or 
other attack.



[11] In December 2002, HHS directed states to offer smallpox 
vaccination to public health and health care workers; however, 
additional funds ($100 million) were not made available to carry out 
the vaccinations until May 2003. For more information on the National 
Smallpox Vaccination Program, see U.S. General Accounting Office, 
Smallpox Vaccination: Implementation of National Program Faces 
Challenges, GAO-03-578 (Washington, D.C.: Apr. 30, 2003).