Public Health and Border Security:

HHS and DHS Should Further Strengthen Their Ability to Respond to TB Incidents

GAO-09-58: Published: Oct 14, 2008. Publicly Released: Nov 13, 2008.

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In spring 2007, the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS), and state and local health officials worked together to interdict two individuals with drug-resistant infectious tuberculosis (TB) from crossing U.S. borders and direct them to treatment. Concerns arose that HHS's and DHS's responses to the incidents were delayed and ineffective. GAO was asked to examine (1) the factors that affected HHS's and DHS's responses to the incidents, (2) the extent to which HHS and DHS made changes to response procedures as a result of the incidents, and (3) HHS's and DHS's efforts to assess the effectiveness of changes made as a result of the incidents. GAO reviewed agency documents and interviewed officials about the procedures in place at the time of the incidents and changes made since.

Various factors--a lack of comprehensive procedures for information sharing and coordination and border inspection shortfalls--hindered the federal response to the two TB incidents. GAO's past work and federal internal control standards call for collaborative communication and coordination across agencies; communication flowing down, across, and up agencies to help managers carry out their internal control responsibilities; and effective leadership, capabilities, and accountability to ensure effective preparedness and response to hazardous situations. HHS and DHS finalized a memorandum of understanding in October 2005 intended to promote communication and coordination in response to public health incidents, but they had not fully developed operational procedures to share information and coordinate their efforts. Thus, HHS and DHS lost time locating or identifying the individuals to interdict them at the U.S. border. Also, HHS lacked procedures to coordinate with state and local health officials to determine when to use federal isolation and quarantine authorities, which further contributed to the delay in the federal response to one of the incidents. Finally, DHS had deficiencies in its process for inspecting individuals at the border, which caused delays in locating the individuals with TB. HHS and DHS have subsequently implemented procedures and tools intended to address deficiencies identified by the incidents, consistent with GAO's past work and internal control standards, but the departments could take additional steps to enhance their ability to respond to future TB incidents. Since the 2007 incidents, HHS and DHS have developed formal procedures for HHS to request DHS's assistance, and DHS has (1) developed a watch list for airlines to identify individuals with TB and other infectious diseases who are to be stopped from traveling and (2) revised its border inspection process to include a requirement that individuals with TB identified by HHS be subject to further inspection. DHS has also enhanced its process for creating public health alerts based on some variations of biographic information (e.g., name, date of birth, or travel document information), but has not explored the benefits of creating these alerts based on other variations, which impeded DHS's ability to interdict one of the individuals at the border. In addition, HHS has not yet completed efforts to provide information on changes in procedures to state and local health officials, who typically originate requests for assistance, to help mitigate delays in accessing federal assistance. HHS and DHS identified additional actions that need to be taken to further strengthen their response, but have not developed plans for completing them. HHS and DHS have activities under way to assess the effectiveness of the new procedures and tools, including performance monitoring and cross-agency meetings to discuss and revise the new procedures and tools based on actual experiences. HHS and DHS have coordinated on more than 70 requests for assistance since the 2007 incidents through February 2008; officials said they view each incident as a test of the efficacy of their responses.

Status Legend:

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  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To ensure continuing improvements in HHS's and DHS's new procedures and tools developed in response to the 2007 TB incidents and to improve awareness of these changes, the Secretary of HHS and the Secretary of DHS should work together to develop plans with time frames for completing additional actions that require cross-agency coordination to respond to future TB incidents.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Implemented

    Comments: In fiscal year 2008, we analyzed how the Department of Homeland Security (DHS), the Department of Health and Human Services (HHS), and state and local health officials worked together to interdict two individuals with drug resistant infectious tuberculosis at U.S. borders, prevent their crossing the border, and direct them to treatment. We reported, among other things, that HHS and DHS should work together to develop plans for completing additional actions that require cross agency coordination to respond to future tuberculosis incidents. Since the issuance of our report, DHS and HHS continued to work together to protect the traveling public from individuals that pose a serious public health threat. In April 2011, DHS and HHS officials signed an agreement to implement a plan that is intended to enhance the Do Not Board List and Process -- a list and process designed to protect the traveling public from individuals that pose a serious public health threat. The agreement states that DHS will use the Homeland Security Information Network (HSIN) to streamline the information sharing process between DHS and HHS. HSIN is a national, secure web-based portal for information sharing and collaboration between federal, state, local, tribal, territorial, private sector, and international partners engaged in the homeland security mission. In addition, DHS and HHS agreed that DHS will routinely provide a report that captures information about individuals who attempted air travel, but were successfully denied travel due to their presence on the Do Not Board List and individuals who conducted air travel despite being on the List. This agreement demonstrates that DHS and HHS have a completed plan in place that should improve the Do Not Board List and Process and protect the traveling public from individuals that pose a serious public health threat. Therefore, this recommendation is closed as implemented.

    Recommendation: To ensure continuing improvements in HHS's and DHS's new procedures and tools developed in response to the 2007 TB incidents and to improve awareness of these changes, the Secretary of HHS and the Secretary of DHS should work together to continue to inform and educate state and local health officials about the new procedures and tools.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Implemented

    Comments: In response to our recommendation, in September 2010 CDC developed 2 companion products, the CDC Guidance for Requesting the Addition of an Individual to the Do Not Board and Border Lookout Lists and a checklist of action items for a Do Not Board/Lookout request. These companion products were made available to state and local health officials by providing them, with a letter explaining the documents, to three associations representing these officials, for posting on their member Web sites. CDC also posted links to the companion products on various agency Web sites, a CDC official said, and made presentations to state and local health officials about the new tools and procedures. In addition, a CDC official said the agency is developing a web-based training module for state and local health officials, with the intent to provide continuing education credits for using the training module. By taking these steps, HHS has helped ensure that relevant state and local health officials are aware of the federal assistance at their disposal and may be better equipped to use the new procedures and tools.

    Recommendation: To ensure continuing improvements in HHS's and DHS's new procedures and tools developed in response to the 2007 TB incidents and to improve awareness of these changes, the Secretary of HHS and the Secretary of DHS should work together to continue to inform and educate state and local health officials about the new procedures and tools.

    Agency Affected: Department of Homeland Security

    Status: Closed - Implemented

    Comments: In response to our recommendation, in September 2010 CDC developed 2 companion products, the CDC Guidance for Requesting the Addition of an Individual to the Do Not Board and Border Lookout Lists and a checklist of action items for a Do Not Board/Lookout request. These companion products were made available to state and local health officials by providing them, with a letter explaining the documents, to three associations representing these officials, for posting on their member Web sites. CDC also posted links to the companion products on various agency Web sites, a CDC official said, and made presentations to state and local health officials about the new tools and procedures. In addition, a CDC official said the agency is developing a web-based training module for state and local health officials, with the intent to provide continuing education credits for using the training module. By taking these steps, HHS has helped ensure that relevant state and local health officials are aware of the federal assistance at their disposal and may be better equipped to use the new procedures and tools.

    Recommendation: To ensure continuing improvements in HHS's and DHS's new procedures and tools developed in response to the 2007 TB incidents and to improve awareness of these changes, the Secretary of DHS should direct CBP to determine whether the benefits exceed the costs of enhancing TECS capabilities when creating public health alerts to include variations on other types of biographic information that could further enhance its ability to locate individuals who are subject to public health alerts and, if so, to implement this enhancement.

    Agency Affected: Department of Homeland Security

    Status: Closed - Implemented

    Comments: In fiscal year 2008, we analyzed how the Department of Homeland Security (DHS), the Department of Health and Human Services, and state and local health officials worked together to interdict two individuals with drug resistant infectious tuberculosis at U.S. borders, prevent their crossing the border, and direct them to treatment. We reported, among other things, that the U.S. Customs and Border Protection (CBP)--a DHS agency--had enhanced its process for creating public health alerts based on some variations of biographic information (e.g., name, date of birth, or travel document information), but had not explored the benefits of creating these alerts based on other variations--a problem that impeded DHS's ability to interdict one of the individuals at the border. CBP provided documentation showing that its Treasury Enforcement Communication System (TECS) data processing procedures had been modified and new policy and procedures established when public health alerts are created and entered. Now, when CBP officials create public health alerts in TECS, they review the subject's biographical information to determine if variations of the information are necessary to ensure the subject of the public health alert is properly identified at ports of entry. If the biographical information can be varied, the officials are to enter the varied information as a part of the alert. We found that the TECS data processing modifications and new policy and procedures could enhance CBP's ability to better identify individuals who are the subject of public health alerts and consider this recommendation to be implemented.

    Recommendation: To ensure continuing improvements in HHS's and DHS's new procedures and tools developed in response to the 2007 TB incidents and to improve awareness of these changes, the Secretary of HHS and the Secretary of DHS should work together to develop plans with time frames for completing additional actions that require cross-agency coordination to respond to future TB incidents.

    Agency Affected: Department of Homeland Security

    Status: Closed - Implemented

    Comments: In fiscal year 2008, we analyzed how the Department of Homeland Security (DHS), the Department of Health and Human Services (HHS), and state and local health officials worked together to interdict two individuals with drug resistant infectious tuberculosis at U.S. borders, prevent their crossing the border, and direct them to treatment. We reported, among other things, that HHS and DHS should work together to develop plans for completing additional actions that require cross agency coordination to respond to future tuberculosis incidents. Since the issuance of our report, DHS and HHS continued to work together to protect the traveling public from individuals that pose a serious public health threat. In April 2011, DHS and HHS officials signed an agreement to implement a plan that is intended to enhance the Do Not Board List and Process -- a list and process designed to protect the traveling public from individuals that pose a serious public health threat. The agreement states that DHS will use the Homeland Security Information Network (HSIN) to streamline the information sharing process between DHS and HHS. HSIN is a national, secure web-based portal for information sharing and collaboration between federal, state, local, tribal, territorial, private sector, and international partners engaged in the homeland security mission. In addition, DHS and HHS agreed that DHS will routinely provide a report that captures information about individuals who attempted air travel, but were successfully denied travel due to their presence on the Do Not Board List and individuals who conducted air travel despite being on the List. This agreement demonstrates that DHS and HHS have a completed plan in place that should improve the Do Not Board List and Process and protect the traveling public from individuals that pose a serious public health threat. Therefore, this recommendation is closed as implemented.

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