oversight

Infectious Diseases: Gaps Remain in Surveillance Capabilities of State and Local Agencies

Published by the Government Accountability Office on 2003-09-24.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                                United States General Accounting Office

GAO                             Testimony
                                Before the Subcommittee on Emergency
                                Preparedness and Response, Select
                                Committee on Homeland Security, House
                                of Representatives
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
                                                  September 24, 2003


                                                  INFECTIOUS DISEASES

                                                  Gaps Remain in Surveillance Capabilities
Highlights of GAO-03-1176T, testimony             of State and Local Agencies
before the Subcommittee on Emergency
Preparedness and Response, Select
Committee on Homeland Security, House
of Representatives




Recent challenges, such as the                    The efforts of public health agencies and health care organizations to
SARS outbreak and the anthrax                     increase their preparedness for infectious disease outbreaks and
incidents in the fall of 2001, have               bioterrorism have improved the nation’s ability to recognize such events.
raised concerns about the nation’s                However, gaps remain in state and local disease surveillance systems, which
preparedness for a large-scale                    are essential to public health efforts to respond to disease outbreaks or
infectious disease outbreak or
bioterrorism event. In order to be
                                                  bioterrorist attacks. Other essential elements of preparedness include
adequately prepared for such a                    laboratory facilities, workforce, and communication systems. State and local
major public health threat, state                 officials report that they are addressing gaps in communication systems.
and local public health agencies                  However, there are still significant workforce shortages in state and local
need to have several basic                        health departments. GAO also found that while contingency plans are being
capabilities, including disease                   developed at the state and local levels, planning for regional coordination for
surveillance systems, laboratory                  disease outbreaks or bioterrorist events was lacking between states.
facilities, communication systems
and a sufficient workforce.                       The disease surveillance capacities of many state and local pubic health
                                                  systems depend, in part, on the surveillance capabilities of hospitals.
GAO was asked to examine the                      Whether a disease outbreak occurs naturally or due to the intentional release
capacity of state and local public
health agencies and hospitals to
                                                  of a harmful biological agent by a terrorist, much of the initial response
detect and report illnesses or                    would occur at the local level, particularly at hospitals and their emergency
conditions that may result from a                 departments. Therefore, hospital personnel would be some of the first
large-scale infectious disease                    healthcare workers with the opportunity to identify an infectious disease
outbreak or bioterrorism event.                   outbreak or a bioterrorist event. Most hospitals reported training their staff
                                                  on biological agents and planning coordination efforts with public health
This testimony is based largely on                entities; however, preparedness limitations may impact hospitals’ ability to
recent work, including a report on                conduct disease surveillance. In addition, hospitals still lack the capacity to
state and local preparedness for a                respond to large-scale infectious disease outbreaks. Also, most emergency
bioterrorist attack; preliminary                  departments across the country have experienced some degree of
findings from current work on
                                                  overcrowding, which could be exacerbated during a disease outbreak or
updates of bioterrorism
preparedness at the state and local               bioterrorist event if persons with symptoms go to emergency departments
levels; and findings from a survey                for treatment.
GAO conducted on hospital
emergency department capacity
and emergency preparedness.




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.
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.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 SARS2 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.




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.



Page 1                                                                       GAO-03-1176T
My testimony today is based largely on our recent work, including a report
on state and local preparedness for a bioterrorist attack.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.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



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).



Page 2                                                                   GAO-03-1176T
             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.


             Infectious diseases include naturally occurring outbreaks, such as SARS,
Background   as well as diseases from biological agents that are intentionally released by
             a terrorist, such as smallpox.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.




             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.



             Page 3                                                                      GAO-03-1176T
Figure 1: Local, State, and Federal Entities Involved in Response to the Covert
Release of a Biological Agent




Page 4                                                                GAO-03-1176T
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.


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


Page 5                                                                                  GAO-03-1176T
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.




Page 6                                                          GAO-03-1176T
                           In the cities we visited, state and local officials reported varying levels of
Despite                    public health preparedness to respond to outbreaks of emerging infectious
Improvements, Gaps         diseases such as SARS. They recognized gaps in preparedness elements
                           that have been difficult to address, including the disease surveillance and
Remain in Disease          laboratory systems and the response capacity of the workforce. They also
Surveillance               were beginning to address gaps in preparedness elements such as
                           communication. We found that planning for regional coordination was
Capabilities of State      lacking between states.
and Local Public
Health Agencies

Progress Has Been Made     States and local areas had weaknesses in some public health preparedness
in Elements of Public      elements, including the disease surveillance and laboratory systems and
Health Preparedness, but   the response capacity of the workforce. Gaps in capacity often are not
                           amenable to solution in the short term because either they require
Gaps Remain                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 system6 to detect
                           infectious disease outbreaks.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



                           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.



                           Page 7                                                                          GAO-03-1176T
                        were also evaluating the use of nontraditional data sources, such as
                        pharmacy sales, to conduct surveillance.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


                        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).



                        Page 8                                                                     GAO-03-1176T
            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.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



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



            Page 9                                                                      GAO-03-1176T
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.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.11 We have noted previously that federal, state, and local
governments have a shared responsibility in preparing for terrorist attacks
and other disasters.12 However, prior to the infusion of federal funds, few
states were investing in their public health infrastructure.




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).



Page 10                                                                    GAO-03-1176T
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      As part of the effort to prepare for a possible outbreak of an infectious
Contingency Planning      disease, there is contingency planning at the state and local levels. Health
Underway, but Regional    departments, for instance, are in the process of developing contingency
                          response plans for SARS. The SARS preparations have been modeled after
Coordination Is Lacking   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

                          Page 11                                                          GAO-03-1176T
                          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.


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


Hospitals Provide Vital   The disease surveillance capacities of many state and local public health
Disease Surveillance      systems may depend, in part, on the surveillance capabilities of hospitals.
Capacity                  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.




                          Page 12                                                        GAO-03-1176T
Most Hospitals Reported     In our survey of over 2,000 metropolitan hospitals,13 most reported that
Planning and Training       they have provided training to staff on biological agents, but fewer than
Efforts, but Fewer Than     half have participated in drills or exercises related to bioterrorism. Most
                            hospitals we surveyed reported providing training about identifying and
Half Have Participated in   diagnosing symptoms for the six biological agents identified by the CDC as
Drills or Exercises         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.



                            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.



                            Page 13                                                                    GAO-03-1176T
Most Emergency            Our survey of metropolitan hospitals found that most emergency
Departments Have          departments have experienced some degree of overcrowding.14 Persons
Experienced Some Degree   with symptoms of infectious disease would potentially go to emergency
                          departments for treatment, further stressing these facilities. The problem
of Crowding               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),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.


                          Efforts at the state and local level have improved the ability to identify and
Concluding                respond to infectious disease outbreaks and bioterrorism. These
Observations              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.


                          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.



                          Page 14                                                                 GAO-03-1176T
                    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.


                    For further information about this testimony, please contact Janet
Contact and Staff   Heinrich at (202) 512-7119. Angela Choy, Krister Friday, Martin T. Gahart,
Acknowledgments     Gay Hee Lee, and Deborah Miller also made key contributions to this
                    statement.




                    Page 15                                                       GAO-03-1176T
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             Page 16                                                     GAO-03-1176T
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           Page 17                                                    GAO-03-1176T
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