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Testimony:

Before the Subcommittee on Emergency Preparedness and Response, Select 
Committee on Homeland Security, House of Representatives:

United States General Accounting Office:

GAO:

For Release on Delivery Expected at 2:30 p.m.

Wednesday, September 24, 2003:

INFECTIOUS DISEASES:

Gaps Remain in Surveillance Capabilities of State and Local Agencies:

Statement of Janet Heinrich Director, Health Care--Public Health 
Issues:

GAO-03-1176T:

GAO Highlights:

Highlights of GAO-03-1176T, testimony before the Subcommittee on 
Emergency Preparedness and Response, Select Committee on Homeland 
Security, House of Representatives 

Why GAO Did This Study:

Recent challenges, such as the SARS outbreak and the anthrax incidents 
in the fall of 2001, have raised concerns about the nationís 
preparedness for a large-scale infectious disease outbreak or 
bioterrorism event. In order to be adequately prepared for such a 
major public health threat, state and local public health agencies 
need to have several basic capabilities, including disease 
surveillance systems, laboratory facilities, communication systems and 
a sufficient workforce.

GAO was asked to examine the capacity of state and local public health 
agencies and hospitals to detect and report illnesses or conditions 
that may result from a large-scale infectious disease outbreak or 
bioterrorism event. 

This testimony is based largely on recent work, including a report on 
state and local preparedness for a bioterrorist attack; preliminary 
findings from current work on updates of bioterrorism preparedness at 
the state and local levels; and findings from a survey GAO conducted 
on hospital emergency department capacity and emergency preparedness.

What GAO Found:

The efforts of public health agencies and health care organizations to 
increase their preparedness for infectious disease outbreaks and 
bioterrorism have improved the nationís ability to recognize such 
events. However, gaps remain in state and local disease surveillance 
systems, which are essential to public health efforts to respond to 
disease outbreaks or bioterrorist attacks. Other essential elements of 
preparedness include laboratory facilities, workforce, and 
communication systems. State and local officials report that they are 
addressing gaps in communication systems. However, there are still 
significant workforce shortages in state and local health departments. 
GAO also found that while contingency plans are being developed at the 
state and local levels, planning for regional coordination for disease 
outbreaks or bioterrorist events was lacking between states. 

The disease surveillance capacities of many state and local pubic 
health systems depend, in part, on the surveillance capabilities of 
hospitals. Whether a disease outbreak occurs naturally or due to the 
intentional release of a harmful biological agent by a terrorist, much 
of the initial response would occur at the local level, particularly 
at hospitals and their emergency departments. Therefore, hospital 
personnel would be some of the first healthcare workers with the 
opportunity to identify an infectious disease outbreak or a 
bioterrorist event. Most hospitals reported training their staff on 
biological agents and planning coordination efforts with public health 
entities; however, preparedness limitations may impact hospitalsí 
ability to conduct disease surveillance. In addition, hospitals still 
lack the capacity to respond to large-scale infectious disease 
outbreaks. Also, most emergency departments across the country have 
experienced some degree of overcrowding, which could be exacerbated 
during a disease outbreak or bioterrorist event if persons with 
symptoms go to emergency departments for treatment. 

www.gao.gov/cgi-bin/getrpt?GAO-03-1176T.

To view the full testimony, 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 on state and local preparedness to manage outbreaks of 
infectious diseases, which may be naturally occurring or the product of 
bioterrorism. In order to be adequately prepared for such a major 
public health threat, state and local public health agencies need to 
have several basic capabilities, including disease surveillance 
systems.[Footnote 1] Surveillance is public health officials' most 
important tool for detecting and monitoring both existing and emerging 
infections. Effective surveillance can facilitate timely action to 
control outbreaks and inform allocation of resources to meet changing 
disease conditions. Without adequate surveillance, local, state, and 
federal officials cannot know the true scope of existing health 
problems and may not recognize new diseases until many people have been 
affected.

Recent challenges, such as the SARS[Footnote 2] outbreak and the 
anthrax incidents in the fall of 2001, have raised concerns about the 
nation's preparedness to manage a disease outbreak or a bioterrorist 
event should it reach large-scale proportions. Existing surveillance 
systems have weaknesses, such as chronic underreporting and outdated 
laboratory facilities, which raise concerns about the ability of state 
and local agencies to detect emerging diseases or a bioterrorist event. 
As a result, state and local response agencies and organizations have 
recognized the need to strengthen their public health infrastructure 
and capacity. The improvements they are making are intended to 
strengthen their ability to identify and respond to major public health 
threats, including naturally occurring infectious disease outbreaks and 
acts of bioterrorism.

To assist the Subcommittee in its consideration of our nation's 
capacity to detect and monitor an outbreak of an infectious disease, my 
remarks today will focus on (1) the preparedness of state and local 
public health agencies for responding to an infectious disease 
outbreak, and (2) the contributions of hospitals to preparedness for an 
infectious disease outbreak.

My testimony today is based largely on our recent work, including a 
report on state and local preparedness for a bioterrorist 
attack.[Footnote 3] For that report, we conducted site visits in 
December 2001 through March 2002 to seven cities and their respective 
state governments. We also reviewed each state's spring 2002 
applications for bioterrorism preparedness funding to 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 discuss some preliminary findings from our 
current work that provides updated information on the preparedness of 
state and local public health agencies. For that work, we are reviewing 
the summer 2003 applications and progress reports and interviewing 
public health officials from 10 states and two major municipalities. I 
also will present some findings from a survey we conducted in 2002 on 
hospital emergency department capacity and emergency 
preparedness.[Footnote 4] We conducted our work in accordance with 
generally accepted government auditing standards.

In summary, state and local officials in the cities we visited reported 
varying levels of public health preparedness to respond to outbreaks of 
emerging infectious diseases such as SARS. They recognized gaps in 
preparedness elements that have been difficult to address, including 
the disease surveillance and laboratory systems and the response 
capacity of the workforce. They also were beginning to address gaps in 
preparedness elements such as communication. We found that planning for 
regional coordination was lacking between states.

Because those with symptoms of an infectious disease might go to 
emergency departments for treatment, hospital personnel would likely be 
some of the first healthcare workers with the opportunity to identify 
an infectious disease outbreak. Therefore, the disease surveillance 
capacities of many state and local public health systems may depend, in 
part, on the surveillance capabilities of hospitals. Most hospitals 
reported training their staff and planning coordination efforts with 
other public health entities. However, even with these preparations in 
place, hospitals lacked the capacity to respond to large-scale 
infectious disease outbreaks.

Background:

Infectious diseases include naturally occurring outbreaks, such as 
SARS, as well as diseases from biological agents that are intentionally 
released by a terrorist, such as smallpox.[Footnote 5] An infectious 
disease outbreak, either naturally occurring or from an intentional 
release, may not be recognized for a week or more because symptoms may 
not appear for several days after the initial exposure, during which 
time a communicable disease could be spread to those who were not 
initially exposed.

The initial response to an infectious disease 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. Figure 1 presents the probable series 
of responses to a covert release of a biological agent. 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]

In order to be adequately prepared for emerging infectious diseases 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 the event of an 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.

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 a disease, as it did 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. The funding supported development and 
improvements in a number of areas CDC considers critical to 
preparedness and response, including surveillance capacity to rapidly 
detect outbreaks of illness that may be the result of bioterrorism or 
other public health threats.

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. Earlier this month, HHS announced that 
approximately $870 million and $498 million have been provided for 
fiscal year 2003 through the CDC and HRSA programs, respectively, to 
states and municipalities to continue these efforts.

Despite Improvements, Gaps Remain in Disease Surveillance Capabilities 
of State and Local Public Health Agencies:

In the cities we visited, state and local officials reported varying 
levels of public health preparedness to respond to outbreaks of 
emerging infectious diseases such as SARS. They recognized gaps in 
preparedness elements that have been difficult to address, including 
the disease surveillance and laboratory systems and the response 
capacity of the workforce. They also were beginning to address gaps in 
preparedness elements such as communication. We found that planning for 
regional coordination was lacking between states.

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

States and local areas had weaknesses in some public health 
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. States and local areas were addressing gaps in 
communication.

Surveillance Systems:

State and local officials for the cities we visited in early 2002 
recognized and were attempting to address inadequacies in their 
surveillance systems. 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 6] to detect infectious disease 
outbreaks.[Footnote 7] 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 8] Three of 
the cities we visited were attempting to improve their surveillance 
capabilities by incorporating active surveillance components into their 
systems. For our ongoing work, state and local officials told us that 
their surveillance systems had improved somewhat. The officials 
reported that CDC funds have enabled them make some of these 
improvements in their surveillance systems, including the development 
of Web-based disease reporting and active surveillance systems.

Laboratory Facilities:

Officials from all of the states we visited in early 2002 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. According to preliminary 
data from our interviews and review of 2003 progress reports, officials 
reported that CDC funds enabled them to make improvements to their 
laboratory infrastructure, including upgrading their laboratory 
facilities, purchasing reagents and equipment, and improving their 
capability to test for select biologic agents.

Officials in the states we visited in 2002 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 early 2002 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. Officials at one state department of 
public health we visited said that the department 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.

Workforce capacity issues may also hinder implementation of infectious 
disease control measures. For example, the shortage of epidemiologists 
could grow worse if, in the event of a severe outbreak, existing health 
care workers became infected as a result of their more frequent 
exposure to a contaminated environment or became exhausted working 
longer hours. Workforce shortages could be further exacerbated because 
of the need to conduct contact tracing.[Footnote 9] According to World 
Health Organization officials, an individual infected with SARS came in 
contact with, on average, 30 to 40 people in Asian countries--all of 
whom had to be contacted and informed of their possible exposure.

During our site visits in early 2002, shortages in laboratory personnel 
were also cited. Officials in one city noted that they had difficulty 
filling and maintaining laboratory positions and that 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 10] For our current work updating these findings, 
many of the state and local officials we interviewed cited shortages in 
trained epidemiologists or laboratory personnel as persistent.

In 2002, 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 11] We 
have noted previously that federal, state, and local governments have a 
shared responsibility in preparing for terrorist attacks and other 
disasters.[Footnote 12] However, prior to the infusion of federal 
funds, few states were investing in their public health infrastructure.

Communication:

We found that officials were beginning to address communication 
problems. For example, six of the seven cities we visited in early 2002 
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. For our current 
work, our preliminary review of the 2003 progress reports from 12 
jurisdictions shows that 11 reported that over 90 percent of their 
population was covered by HAN.

Some State and Local Contingency Planning Underway, but Regional 
Coordination Is Lacking:

As part of the effort to prepare for a possible outbreak of an 
infectious disease, there is contingency planning at the state and 
local levels. Health departments, for instance, are in the process of 
developing contingency response plans for SARS. The SARS preparations 
have been modeled after a checklist designed for pandemic influenza. To 
facilitate these preparations, the Association of State and Territorial 
Health Officials and the National Association of County and City Health 
Officials, in collaboration with CDC, published a checklist for state 
and local health officials to use in the event of a SARS resurgence. 
The checklist encompasses a broad spectrum of preparedness activities, 
such as legal issues related to isolation and quarantine, strategies 
for communicating information to health care providers, and suggestions 
for ensuring other community partners such as law enforcement and 
school officials are prepared.

During our 2002 site visits, however, we found that response 
organization officials were concerned about a lack of planning for 
regional coordination between states during an infectious disease 
outbreak. As called for by the guidance for the CDC and HRSA funding, 
all of the states we visited in 2002 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.

Hospital Preparedness Improved, but Limitations in Response Capacity 
Remain:

Because those with symptoms of an infectious disease might go to 
emergency departments for treatment, hospital personnel would likely be 
some of the first healthcare workers with the opportunity to identify 
an emerging infectious disease outbreak. Therefore, the disease 
surveillance capacities of many state and local public health systems 
may depend, in part, on the surveillance capabilities of hospitals. 
Most hospitals reported training their staff and planning coordination 
efforts with other public health entities. However, even with these 
preparations in place, hospitals lacked the capacity to respond to 
large-scale infectious disease outbreaks.

Hospitals Provide Vital Disease Surveillance Capacity:

The disease surveillance capacities of many state and local public 
health systems may depend, in part, on the surveillance capabilities of 
hospitals. During the recent SARS outbreak in North America, for 
instance, hospital emergency rooms played an important role in 
identifying those who had the disease. According to hospital officials 
in California and New York, hospital emergency room or other waiting 
room staff routinely used questionnaires to screen incoming patients 
for fever, cough, and travel to a country with active cases of SARS. 
They said that hospitals' signs in various locations generally used by 
incoming patients and visitors also asked individuals to identify 
themselves to hospital staff if they met these criteria. In Toronto, 
which experienced a much greater prevalence of SARS than the United 
States, everyone entering a hospital was required to answer screening 
questions and to have their temperature checked before they were 
allowed to enter.

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

In our survey of over 2,000 metropolitan hospitals,[Footnote 13] most 
reported that they have provided training to staff on biological 
agents, but fewer than half have participated in drills or 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.

Our hospital survey found that 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.

At the time of our site visits between December 2001 and March 2002, 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.

Most Emergency Departments Have Experienced Some Degree of Crowding:

Our survey of metropolitan hospitals found that most emergency 
departments have experienced some degree of overcrowding.[Footnote 14] 
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 15] 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.

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 
infectious disease outbreak, especially if this outbreak occurred in 
the winter months when the incidence of influenza is quite high. For 
example, public health officials with whom we spoke said that in the 
event of a large-scale SARS outbreak, entire hospital wards may need to 
be used as separate SARS isolation facilities. Moreover, certain 
hospitals within a community may need to be designated as SARS 
hospitals.

Concluding Observations:

Efforts at the state and local level have improved the ability to 
identify and respond to infectious disease outbreaks and bioterrorism. 
These improvements have included upgrades to laboratory facilities and 
communication systems. Hospitals have also begun planning and training 
efforts to respond to large-scale infectious disease outbreaks. Despite 
these improvements, gaps in preparedness remain. We found that some 
disease surveillance systems may be inadequate, that there are 
shortages of key personnel in some localities, and that most hospital 
emergency departments across the country have experienced some degree 
of overcrowding, which could be exacerbated during a disease outbreak.

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 Janet 
Heinrich at (202) 512-7119. Angela Choy, Krister Friday, Martin T. 
Gahart, Gay Hee Lee, and Deborah Miller also made key contributions to 
this statement.

[End of section]

Related GAO Products:

Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but 
Lack Certain Capacities for Bioterrorism Response. GAO-03-924. 
Washington, D.C.: August 6, 2003.

Severe Acute Respiratory Syndrome: Established Infectious Disease 
Control Measures Helped Contain Spread, But a Large-Scale Resurgence 
May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003.

Bioterrorism: Information Technology Strategy Could Strengthen Federal 
Agencies' Abilities to Respond to Public Health Emergencies. GAO-03-
139. Washington, D.C.: May 30, 2003.

SARS Outbreak: Improvements to Public Health Capacity are Needed for 
Responding to Bioterrorism and Emerging Infectious Diseases. GAO-03-
769T. Washington, D.C.: May 7, 2003.

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

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

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

[4] Findings from the survey 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 to hospital emergency preparedness for mass casualty incidents, 
which we reported in U.S. General Accounting Office, Hospital 
Preparedness: Most Urban Hospitals Have Emergency Plans but Lack 
Certain Capacities for Bioterrorism Response, GAO-03-924 (Washington, 
D.C.: Aug. 6, 2003).

[5] CDC developed a critical agent list that focuses on the biological 
agents that would have the greatest impact on public health. This list 
includes a category of agents identified by CDC as most likely to be 
used in a bioterrorist attack and includes communicable diseases such 
as smallpox and pneumonic plague.

[6] 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.

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

[8] 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. A senior HHS official 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).

[9] Contact tracing is the identification and tracking of individuals 
who may have been exposed to a person with a specific disease.

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

[11] Advisory Panel to Assess Domestic Response Capabilities for 
Terrorism Involving Weapons of Mass Destruction, 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). The Advisory Panel 
was established to assess federal agency efforts to enhance domestic 
preparedness, the progress of federal training programs for local 
emergency responses, and deficiencies in federal programs for response 
to incidents involving weapons of mass destruction; to recommend 
strategies for ensuring effective coordination of federal agency 
response efforts and for ensuring fully effective local response 
capabilities for weapons of mass destruction incidents; and to assess 
appropriate state and local roles in funding effective local response 
capabilities. The Advisory Panel issues annual reports to the President 
and to the Congress and has submitted four annuals reports to date.

[12] See U.S. General Accounting Office, Homeland Security: Effective 
Intergovernmental Coordination Is Key to Success, GAO-02-1013T 
(Washington, D.C.: Aug. 23, 2002).

[13] 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, a response rate 
of about 73 percent.

[14] GAO-03-460.

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