oversight

Bioterrorism: Preparedness Varied across State and Local Jurisdictions

Published by the Government Accountability Office on 2003-04-07.

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

             United States General Accounting Office

GAO          Report to Congressional Committees




April 2003
             BIOTERRORISM

             Preparedness Varied
             across State and Local
             Jurisdictions




GAO-03-373
                                               April 2003


                                               BIOTERRORISM

                                               Preparedness Varied across State and
Highlights of GAO-03-373, a report to the
Senate Committee on Health, Education,         Local Jurisdictions
Labor, and Pensions; the Senate and
House Committees on Appropriations; and
the House Committee on Energy and
Commerce




Much of the response to a                      State and local officials reported varying levels of preparedness to respond
bioterrorist attack would occur at             to a bioterrorist attack. Officials reported deficiencies in capacity,
the local level. Many local areas              communication, and coordination elements essential to preparedness and
and their supporting state agencies,           response, such as workforce shortages, inadequacies in disease surveillance
however, may not be adequately                 and laboratory systems, and a lack of regional coordination and compatible
prepared to respond to such an
attack. In the Public Health
                                               communications systems. Some elements, such as those involving
Improvement Act that was passed                coordination efforts and communication systems, were being addressed
in 2000, Congress directed GAO to              more readily, whereas others, such as infrastructure and workforce issues,
examine state and local                        were more resource-intensive and therefore more difficult to address. Cities
preparedness for a bioterrorist                with more experience in dealing with public health emergencies were
attack. In this report GAO provides            generally better prepared for a bioterrorist attack than other cities, although
information on state and local                 deficiencies remain in every city.
preparedness and state and local
concerns regarding the federal role            State and local officials reported a lack of adequate guidance from the
in funding and improving                       federal government on what it means to be prepared for bioterrorism. They
preparedness. To gather this                   said they needed specific standards (such as how large an area a response
information, GAO visited seven
cities and their respective state
                                               team should be responsible for) to indicate what they should be doing to be
governments, reviewed documents,               adequately prepared. The need for federal guidance has continued to be an
and interviewed officials. Cities are          issue as states have proceeded in their planning and preparedness activities
not identified because of the                  with funding from HHS. For example, in their progress reports to HHS in late
sensitive nature of this issue.                2002 two states reported that they were seeking guidance from HHS on
                                               assessing vulnerabilities for foodborne or waterborne diseases and
                                               preparedness steps they should take for these hazards. One of these states
                                               has declared that it could not make further efforts on testing for these types
GAO recommends that the
                                               of diseases until it receives more guidance.
Department of Health and Human
Services (HHS), in consultation
with the Department of Homeland                State officials also expressed a desire for more sharing of best practices.
Security,                                      Officials stated that, while each jurisdiction might need to adapt procedures
•   develop specific benchmarks                to its own circumstances, time could be saved and needless duplication of
    that define adequate                       effort avoided if there were better mechanisms for sharing strategies across
    preparedness for a bioterrorist            jurisdictions. They stated that HHS was better positioned to know about
    attack and can be used by                  different strategies that states were pursuing and they want information on
    jurisdictions to guide their               the best practices.
    preparedness efforts; and
•   develop a mechanism for
    evaluating and sharing useful
    solutions to problems among
    jurisdictions.

HHS and the Department of
Homeland Security concurred with
the recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-03-373.

To view the full report, including the scope
and methodology, click on the link above.
For more information, contact Janet Heinrich
at (202) 512-7119.
Contents


Letter                                                                                                1
                       Results in Brief                                                               4
                       Background                                                                     6
                       State and Local Officials Reported Varying Levels of Bioterrorism
                         Preparedness                                                               14
                       State and Local Jurisdictions and Response Organizations Made
                         Progress in Developing Preparedness Plans, but Regional Plans
                         Remained Undeveloped                                                       25
                       State and Local Officials Expressed Concerns regarding Federal
                         Funding and Lack of Guidance                                               28
                       Conclusions                                                                  33
                       Recommendations for Executive Action                                         34
                       Agency Comments                                                              34

Appendix I             Bioterrorism Preparedness in Seven Case Cities                               37



Appendix II            Scope and Methodology                                                        40



Appendix III           Comments from the Department of Health and
                       Human Services                                                               42



Appendix IV            GAO Contact and Staff Acknowledgments                                        46
                       GAO Contact                                                                  46
                       Acknowledgments                                                              46

Related GAO Products                                                                                47



Table
                       Table 1: Bioterrorism Preparedness Elements for the Seven Cities
                                We Visited, December 2001 through March 2002                        37




                       Page i                      GAO-03-373 State and Local Bioterrorism Preparedness
Figure
         Figure 1: Local, State, and Federal Entities Involved in Response to
                  the Covert Release of a Biological Agent                                         8




         Abbreviations

         CDC               Centers for Disease Control and Prevention
         DOJ               Department of Justice
         Epi-X             Epidemic Information Exchange
         FEMA              Federal Emergency Management Agency
         HAN               Health Alert Network
         HHS               Department of Health and Human Services
         HRSA              Health Resources and Services Administration
         MMRS              Metropolitan Medical Response System
         OER               Office of Emergency Response



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         Page ii                           GAO-03-373 State and Local Bioterrorism Preparedness
United States General Accounting Office
Washington, DC 20548




                                   April 7, 2003

                                   Congressional Committees

                                   Since the terrorist attacks of September 11, 2001, and the subsequent
                                   anthrax incidents, there has been great concern about bioterrorism1 in the
                                   United States. With this concern, there is growing recognition that the
                                   unique characteristics of a bioterrorist attack, in contrast to a
                                   conventional attack, would require additional response preparation and
                                   coordination. Much of the response to a bioterrorist attack would occur at
                                   the local level. The intentional release of a biological agent by a terrorist
                                   might not be recognized for several days, during which time a
                                   communicable disease could be spread to those who were not initially
                                   exposed. Hospitals and their emergency departments, as well as private
                                   physicians and nurses, would most likely be the first responders, as
                                   victims began to seek treatment of their symptoms.

                                   In order to be adequately prepared for a bioterrorist attack, state and local
                                   response organizations2 need to have several basic capabilities, whether
                                   they possess them directly or have access to them through regional
                                   agreements. Health care providers, including emergency medical
                                   personnel, need to be trained to recognize symptoms of diseases caused
                                   by biological agents likely to be used in a bioterrorist attack (such as
                                   anthrax and smallpox). Public health departments need to have the




                                   1
                                    Bioterrorism is the threatened or intentional release of biological agents (viruses, bacteria,
                                   or their toxins) for the purpose of influencing the conduct of government or intimidating or
                                   coercing a civilian population. These agents can be released by way of the air (as aerosols),
                                   food, water, or insects.
                                   2
                                    In this report, the term response organizations refers to any organization or individual that
                                   would respond to a bioterrorist incident. These include physicians, hospitals, laboratories,
                                   public health departments, emergency medical services, emergency management agencies,
                                   fire departments, and law enforcement agencies.



                                   Page 1                              GAO-03-373 State and Local Bioterrorism Preparedness
appropriate infrastructure,3 including disease surveillance systems,4 in
place at the state and local levels to detect clusters of suspicious
symptoms or diseases in order to facilitate early detection of an attack 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. Hospitals need to have
adequate facilities and necessary staff to appropriately treat patients. All
organizations involved in the response must be able to communicate easily
with one another as events unfold and critical information is acquired. In
addition, plans that describe how state and local officials would manage
and coordinate an emergency response need to be in place and to have
been tested in an exercise, both at the state and local levels and at the
regional level.

It has been suggested, however, that many state and local areas may not
be adequately prepared to respond to and manage a bioterrorist attack.5
For example, it has been reported that there is an ongoing shortage of
intensive care unit beds and isolation rooms, where infectious disease
patients are treated.6 In addition, a recent report has identified problems
with the public health infrastructure, particularly at the local level, and
stated that public health departments have generally been poorly funded.7




3
 Public health infrastructure is the foundation that supports the planning, delivery, and
evaluation of public health activities and is composed of a well-trained public health
workforce, effective program and policy evaluation, sufficient epidemiology and
surveillance capability to detect outbreaks and monitor incidence of diseases, appropriate
response capacity for public health emergencies, effective laboratories, secure information
systems, and advanced communications systems.
4
 Disease surveillance systems provide for the ongoing collection, analysis, and
dissemination of health-related data to identify, prevent, and control disease.
5
National Association of Counties, Counties Secure America: A Survey of County Public
Health Needs and Preparedness (Washington, D.C.: January 2002) and National
Association of County and City Health Officials, Research Brief: Assessment of Local
Bioterrorism and Emergency Preparedness, no. 5 (Washington, D.C.: October 2001).
6
 Amy Smithson and Leslie-Ann Levy, Ataxia: The Chemical and Biological Terrorism
Threat and the U.S. Response (Washington, D.C.: The Henry L. Stimson Center, October
2000), 242, 262-263.
7
 Institute of Medicine of the National Academies, The Future of the Public’s Health in the
21st Century (Washington, D.C.: The National Academies Press, 2003, forthcoming).




Page 2                             GAO-03-373 State and Local Bioterrorism Preparedness
The Department of Health and Human Services (HHS), the Federal
Emergency Management Agency (FEMA), and the Department of Justice
(DOJ) provide assistance to state and local governments in enhancing
preparedness for bioterrorism and for emergencies of all types.8 In
November 2002, the President signed the Homeland Security Act of 2002,
which established the Department of Homeland Security. As a result of
this legislation, FEMA and certain DOJ and HHS programs with
preparedness and response functions have been transferred to the new
department.

The Public Health Improvement Act directed that we examine state and
local levels of preparedness for a bioterrorist attack.9 We have previously
reported on activities by federal agencies to prepare for and respond to a
bioterrorist attack.10 In this report, we are providing information on the
preparedness of state and local jurisdictions for responding to such an
attack, state and local bioterrorism response planning efforts, and state
and local concerns regarding the federal role in funding and improving
state and local preparedness.

To address our objectives, we conducted multiday site visits to seven
cities and their respective state governments from December 2001 through
March 2002, at a time when states were intensively planning for their
response to a future potential bioterrorist attack following the anthrax
incidents of the previous fall. Cities were selected to provide wide
variation in geographic location, population size, and experience with
natural disasters and large exercises. (See app. I for an overview of each
city we visited, including comparisons across several elements of
preparedness.) We do not identify these cities in this report because of the
sensitive nature of this issue. During the site visits, we interviewed
officials from state and local public health departments, local emergency
medical services, state and local emergency management agencies, local
fire and law enforcement agencies, and hospitals. For each city we visited,
we also reviewed copies of the state’s spring 2002 application for
bioterrorism-related funding through cooperative agreements with HHS’s
Centers for Disease Control and Prevention (CDC) and Health Resources



8
 See, for example, U.S. General Accounting Office, Bioterrorism: Federal Research and
Preparedness Activities, GAO-01-915 (Washington, D.C.: Sept. 28, 2001).
9
Pub. L. No. 106-505, § 102, 114 Stat. 2314, 2323 (2000).
10
    GAO-01-915.




Page 3                             GAO-03-373 State and Local Bioterrorism Preparedness
                   and Services Administration (HRSA). In addition, we reviewed the
                   progress reports on the CDC and HRSA cooperative agreements that were
                   submitted to HHS in late 2002 from the relevant states, covering the period
                   through October 31, 2002. Because of the events of the fall of 2001, and the
                   subsequent federal preparedness funding, changes were occurring at the
                   state and local levels with regard to bioterrorism preparedness during our
                   site visits and subsequent data collection. Changes have continued to
                   occur since our visits, and this report may not reflect all these changes. In
                   addition to making the state and local site visits and reviewing the
                   pertinent documents, we interviewed officials from federal agencies and
                   representatives from national public health associations, and we reviewed
                   reports, including reports of the Advisory Panel to Assess Domestic
                   Response Capabilities for Terrorism Involving Weapons of Mass
                   Destruction,11 concerning state and local preparedness for bioterrorism.
                   Because our focus was on the public health and medical consequences of
                   a bioterrorist event, we do not report on preparedness activities funded by
                   DOJ and FEMA in this study. (See app. II for details regarding our scope
                   and methodology.) We conducted our work from November 2001 through
                   April 2003 in accordance with generally accepted government auditing
                   standards.


                   Officials in the states and cities we visited reported varying levels of
Results in Brief   preparedness to respond to a bioterrorist attack. They recognized
                   deficiencies in preparedness and were beginning to address these gaps
                   and weaknesses. The states and cities we visited were generally better
                   prepared in certain elements than in others. Some elements, such as those
                   involving coordination efforts and communication systems, were being
                   addressed more readily, whereas others, such as infrastructure and
                   workforce issues, were more resource-intensive and therefore more
                   difficult to address. Officials in the seven cities we visited told us of gaps
                   and weaknesses in capacity elements essential to preparedness and
                   response, such as workforce shortages and inadequate laboratory
                   facilities. The level of preparedness varied by city as well as by element.



                   11
                     Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving
                   Weapons of Mass Destruction, Third 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, 2001), and 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).




                   Page 4                          GAO-03-373 State and Local Bioterrorism Preparedness
Those cities that had multiple prior experiences with public health
emergencies caused by natural disasters and with preparation for special
events, such as political conventions, were generally more prepared than
the other cities, which had little or no such experience prior to our site
visits.

State and local jurisdictions and response organizations we visited were
engaged in planning efforts to address problems in bioterrorism
preparedness at the state and local levels, but regional planning between
states was generally lacking. Most of the cities and states we visited had
emergency operation plans for coordinating the response to emergencies.
At the time of our site visits, many of these plans had not specifically
addressed the unique requirements of response to a bioterrorist attack, but
many officials were beginning to incorporate a bioterrorism response
component. Preparing the application plans for the CDC and HRSA
funding helped states to identify problems on which to focus their efforts,
including the need for increased participation of hospitals in local
preparedness and the development of regional plans. Although progress
was made on local planning, regional planning involving multiple
municipalities, counties, or jurisdictions in neighboring states or a
neighboring country lagged. A regional response to a bioterrorist attack
could require participation of officials from neighboring states or a
neighboring country, yet some states lacked sufficient coordination with
their neighboring states and country and had not participated in joint
response planning.

State and local officials had concerns regarding the distribution and
sustainability of federal funding for improving state and local bioterrorism
preparedness programs and the lack of specific standards for determining
adequacy of preparedness. State and local officials disagreed as to
whether federal funding should flow through the state or go directly to the
local jurisdictions, with each group wanting to control the funds. In
addition, hospital officials reported that federal funding intended to
enhance emergency preparedness in their cities had not always been
shared with them in the past. Further, state and local officials stressed that
sustained funding is a key factor in maintaining the effectiveness of federal
funds. Officials requested more federal guidance and sharing of best
practices to assist them in addressing the remaining deficiencies. All types
of response organizations were asking for federal guidance on what it
means to be adequately prepared for bioterrorism. State and local officials
told us that specific benchmarks would help them determine whether they
were adequately prepared to respond to a bioterrorist attack. State



Page 5                       GAO-03-373 State and Local Bioterrorism Preparedness
                             officials also requested that federal agencies do more to identify and share
                             best practices to assist in preparedness and avoid duplication of effort.

                             We are recommending that HHS, in consultation with the Department of
                             Homeland Security, help state and local jurisdictions better prepare for a
                             bioterrorist attack by developing specific benchmarks that define
                             adequate preparedness for a bioterrorist attack and can be used by state
                             and local jurisdictions to assess and guide their preparedness efforts. We
                             are also recommending that HHS, in consultation with the Department of
                             Homeland Security, develop a mechanism by which solutions to problems
                             that have been used in one jurisdiction can be evaluated by HHS and, if
                             appropriate, shared with other jurisdictions.

                             We provided a draft of this report to HHS and the Department of
                             Homeland Security for their review. HHS concurred with our
                             recommendations and provided information on measures it is taking to
                             address the concerns we identified. The liaison from the Department of
                             Homeland Security provided oral comments noting the department’s
                             concurrence with the draft report and the recommendations.


                             Initial response to a public health emergency of any type, including a
Background                   bioterrorist attack, is generally a local responsibility that could involve
                             multiple jurisdictions in a region, with states providing additional support
                             when needed. The federal government could also become involved in
                             investigating or responding to an incident. In addition, the federal
                             government provides funding and resources to state and local entities to
                             support preparedness and response efforts.


Response to a Bioterrorist   Response to a release of a biological agent, whether covert or overt, would
Incident                     generally begin at the local level, with the federal government becoming
                             involved as needed.12 Having the necessary resources immediately
                             available at the local level to respond to an emergency can minimize the
                             magnitude of the event and the cost of remediation. In the case of a covert
                             release of a biological agent, it could be hours or days before exposed


                             12
                               For example, in responding to an overt release of a biological agent, the federal
                             government would become involved more quickly. The Federal Bureau of Investigation is
                             the federal agency responsible for investigating all terrorist threats and acts within the
                             United States and would conduct a criminal investigation concurrent with local public
                             health and medical community’s response.




                             Page 6                             GAO-03-373 State and Local Bioterrorism Preparedness
people start exhibiting signs and symptoms of the disease. Figure 1
presents the probable series of responses to such a bioterrorist incident.
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.




Page 7                      GAO-03-373 State and Local Bioterrorism Preparedness
Figure 1: Local, State, and Federal Entities Involved in Response to the Covert Release of a Biological Agent




                                          Page 8                          GAO-03-373 State and Local Bioterrorism Preparedness
a
Health care providers can also contact state entities directly.
b
Federal departments and agencies can also respond directly to local and state entities.




Page 9                                 GAO-03-373 State and Local Bioterrorism Preparedness
                            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.


                            Local and state health departments would collect and monitor data, such
                            as reports from health care providers, for disease trends and outbreaks.
                            Clinical samples would be collected for laboratorians13 to test for
                            identification of illnesses. Epidemiologists14 in the health departments
                            would use the disease surveillance systems to provide for the ongoing
                            collection, analysis, and dissemination of data to identify unusual patterns
                            of disease.

                            The federal government could also become involved, as needed, in
                            investigating or responding to an incident. For certain high-risk diseases,
                            such as the Ebola virus, sample testing would be done at a federal
                            Biosafety Level 4 laboratory15 equipped to handle dangerous and exotic
                            biological agents. CDC has one such laboratory for testing of these
                            dangerous agents. CDC also provides state and local jurisdictions with
                            assistance on epidemiological investigations and treatment advice. Other
                            federal agencies may also assist state and local jurisdictions in the
                            investigation of and response to bioterrorism and other public health
                            emergencies.


HHS Funding for State and   Prior to January 2002, HHS distributed funds for bioterrorism
Local Bioterrorism          preparedness through two main programs. From 1999 to through 2001 it
Preparedness                funded state and local health departments through CDC’s Bioterrorism
                            Preparedness and Response Program. From 1996 through 2001 it provided
                            funding to local jurisdictions, targeting police, firefighters, emergency
                            medical responders, hospitals, and public health agencies through the


                            13
                              A laboratorian is one who works in a laboratory; in the medical and allied health
                            professions, a laboratorian examines or performs tests (or supervises such procedures)
                            with various types of chemical and biologic materials, chiefly to aid in the diagnosis,
                            treatment, and control of disease, or as a basis for health and sanitation practices.
                            14
                             An epidemiologist is a specialist in the study of how disease is distributed in populations
                            and the factors that influence or determine this distribution.
                            15
                              Laboratories are categorized as either Biosafety Level 1, 2, 3, or 4, with Biosafety Level 4
                            laboratories providing the highest degree of protection to personnel, the environment, and
                            the community. Biosafety levels represent combinations of laboratory practices and
                            techniques, safety equipment, and laboratory facilities. Each combination is specifically
                            appropriate for the operations performed, the documented or suspected routes of
                            transmission of the infectious agents, and the laboratory function or activity.




                            Page 10                                GAO-03-373 State and Local Bioterrorism Preparedness
Metropolitan Medical Response System (MMRS)16 of the Office of
Emergency Response (OER), formerly the Office of Emergency
Preparedness, which was transferred to the Department of Homeland
Security on March 1, 2003.17 CDC and HRSA are expanding or developing
programs to help state and local governments, as well as hospitals and
other health care entities, improve preparedness for and response to
bioterrorism and other emergencies.

In January 2002, HHS announced the allocation of $1.1 billion through
CDC, HRSA, and OER for state and local bioterrorism preparedness.18 This
funding supports three separate but related efforts—CDC’s Public Health
Preparedness and Response for Bioterrorism program, HRSA’s
Bioterrorism Hospital Preparedness Program, and OER’s MMRS program.
States applying for funding through cooperative agreements under CDC’s
Public Health Preparedness and Response for Bioterrorism program and
HRSA’s Bioterrorism Hospital Preparedness Program were required to
submit bioterrorism preparedness plans to HHS by April 15, 2002. All 50
states and four major municipalities 19 applied for and received funding
through these cooperative agreements.20 The noncompetitive cooperative
agreements provide that CDC and HRSA funds must be used to


16
 The MMRS program is intended to develop or enhance the local response to a public
health crisis, especially an attack using weapons of mass destruction, by bringing together
hospital and public health officials, emergency managers, and others to deal with the
consequences of an attack. Under the MMRS program, OER contracts with cities to
improve the ability of local jurisdictions to respond to a public health crisis.
17
  DOJ and FEMA also provide funding that supports planning, equipment needs, and
training for traditional emergency responders and for state emergency management
agencies, respectively. These funds are targeted toward police, firefighters, and emergency
medical professionals and are intended to help improve coordination and communication
by encouraging state and local officials to plan and conduct joint exercises for responding
to terrorist events. State and local governments can use these funds to plan for response to
terrorist attacks, conduct exercises to test capabilities, purchase equipment, and train
personnel.
18
 The funds were primarily appropriated by the Department of Defense and Emergency
Supplemental Appropriations for Recovery from and Response to Terrorist Attacks on the
United States Act, Pub. L. No. 107-117, 115 Stat. 2230, 2314 (2002), and the Departments of
Labor, Health and Human Services, and Education, and Related Agencies Appropriations
Act of Fiscal Year 2002, Pub. L. No. 107-116, 115 Stat. 2186, 2198.
19
  The four eligible municipalities were Chicago, the District of Columbia, Los Angeles
County, and New York City.
20
 In addition, CDC funded five American territories: American Samoa, Guam, the Northern
Marianas Islands, Puerto Rico, and the U.S. Virgin Islands. CDC also funded the three freely
associated states of the Pacific: Marshall Islands, Micronesia, and Palau.




Page 11                            GAO-03-373 State and Local Bioterrorism Preparedness
supplement and not supplant any current federal, state, and local funds
that would otherwise be used for bioterrorism and other public health
preparedness activities and that these activities should be coordinated
with any MMRS programs in the jurisdiction. Also in 2002, additional
funding was appropriated for expanding the National Pharmaceutical
Stockpile, renamed the Strategic National Stockpile,21 and supporting
bioterrorism-related research at the National Institutes of Health’s
National Institute of Allergy and Infectious Diseases.22

Of the $1.1 billion, the CDC 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.23 24 The
HRSA 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




21
 The Strategic National Stockpile is a repository of pharmaceuticals, antidotes, and
medical supplies that can be delivered to the site of a bioterrorist (or other) attack.
22
 The funds allocated were appropriated by the Department of Defense and Emergency
Supplemental Appropriations for Recovery from and Response to Terrorist Attacks on the
United States Act, 115 Stat. at 2314.
23
  To determine eligibility for the funding, CDC required the applicants to submit plans for
use of the funds in six focus areas: preparedness planning and readiness assessment,
surveillance and epidemiology capacity, laboratory capacity for biological agents,
communications and information technology, risk communication and health information
dissemination, and education and training. Each focus area included critical capacities that
had to be addressed. These are the core expertise and infrastructure elements that need to
be in place as soon as possible to enable a public health system to prepare for and respond
to bioterrorism and other infectious disease outbreaks. An example of a critical capacity
under the laboratory capacity for biological agents focus area is to develop and implement
a jurisdiction-wide program to provide rapid and effective laboratory services in support of
the response to public health threats and emergencies.
24
 In November 2002, HHS released supplemental guidance for implementing the new
National Smallpox Vaccination Program. These guidelines state that recipients are
encouraged to use funds made available through the CDC cooperative agreements to plan
and implement this program and should redirect the funding as necessary.




Page 12                             GAO-03-373 State and Local Bioterrorism Preparedness
respond to bioterrorist attacks.25 The department released the first 20
percent of these funds to states and the municipalities within weeks of the
January announcement. HHS identified 17 “critical benchmarks” (14 for
the CDC funding and 3 for the HRSA funding) that officials were required
to address in their application plans. HHS used the critical benchmarks to
screen application plans for approval before it released the remaining 80
percent of the CDC and HRSA funding. The benchmarks for the CDC
program included such activities as designating an executive director of
the state bioterrorism preparedness and response program, developing an
interim plan to receive and manage items from the Strategic National
Stockpile, and preparing a time line for the development of regional plans
to respond to bioterrorism. In addition, CDC is allowing states to use this
funding to address preparedness efforts between states and in regions that
border a foreign country. The benchmarks for the HRSA program included
development of a timeline for developing and implementing a regional
hospital plan for dealing with a potential epidemic involving at least 500
patients. HHS requires progress reports from the states at approximately
6-month intervals to provide oversight of CDC and HRSA programs and to
determine future funding.26 The remaining funds that were allocated for
state and local preparedness in January 2002 supported OER’s MMRS
program.27




25
 HRSA’s guidance on the preparation of application plans for funding required states and
municipalities to lay out their plans for conducting a needs analysis of hospitals, which
would enable states and municipalities to allocate their resources most effectively to
improve preparedness. States and municipalities also needed to discuss their developing
bioterrorism preparedness plans and protocols for hospitals and other health care entities,
such as community health centers. In addition, states and municipalities were required to
address four priority-planning areas: medications and vaccines; personal protection,
quarantine, and decontamination; communications; and biological disaster drills.
26
 In addition, a department official told us that the Office of the Inspector General will have
a role in ensuring that program participants are accountable for their use of the funds. This
oversight will include reviewing cooperative agreement requirements, examining program
participants’ performance and financial records for completeness and timeliness, and
performing pilot reviews of CDC program participants to determine whether bioterrorism
preparedness funds were used in accordance with the cooperative agreement terms and
conditions.
27
 OER contracts totaling $10 million in fiscal year 2002 were used to establish an MMRS
capability in 25 additional cities (bringing the total to 122 cities receiving MMRS funding). It
was expected that by the end of 2002 80 percent of the U.S. population would reside in an
area covered by an MMRS contract.




Page 13                             GAO-03-373 State and Local Bioterrorism Preparedness
                           State and local officials reported varying levels of preparedness to respond
State and Local            to a bioterrorist attack. They recognized deficiencies in preparedness and
Officials Reported         were beginning to address them. We found that the states and cities we
                           visited were making greater progress in certain elements of preparedness
Varying Levels of          than in others. Some elements, such as those involving coordination
Bioterrorism               efforts and communication systems, were being addressed more readily,
                           whereas others, such as infrastructure and workforce issues, were more
Preparedness               resource-intensive and therefore more difficult to address. The level of
                           preparedness varied across the cities, with jurisdictions that had multiple
                           prior experiences with public health emergencies generally being more
                           prepared than the other cities, which had little or no such experience prior
                           to our site visits.

Progress Was Made in       The cities we visited generally made greater progress in coordination and
Elements of Preparedness   communication preparedness than in other elements of preparedness.
Related to Coordination    Coordination efforts where progress was made included participation by
                           relevant government and private sector officials in meetings to discuss
and Communication          how to work together in an emergency and participation in joint training
                           exercises. Communication efforts included the purchase and
                           implementation of new communication systems and development of
                           procedures for communicating with the public and the media. Despite
                           these advances, deficiencies in coordination and communication
                           remained.

                           Most of the cities we visited had made efforts to improve coordination
                           among the response organizations. Experience from public health
                           emergencies, especially the terrorist attacks of September 11, 2001, and
                           the subsequent anthrax incidents, provided momentum for local response
                           organizations—including fire departments, emergency medical services,
                           law enforcement, public health departments, emergency management
                           agencies, and hospitals—to improve coordination. Organizations, such as
                           hospitals, that previously were not substantially involved increased their
                           participation in preparedness meetings and agreements. Further, most of
                           the states we visited reported having established better links between the
                           public health departments and the hospitals since the September 11, 2001,
                           terrorist attacks and the subsequent anthrax incidents than had previously
                           existed. For example, after September 11, 2001, a hospital in one of the
                           cities reported that the public health department had given it a telephone
                           number to reach public health officials 24 hours a day, 7 days a week.

                           In many aspects, the anthrax incidents in October 2001 were exercises in
                           cooperation between the health care community and traditional first
                           responders. Many cities were inundated with calls about suspicious


                           Page 14                     GAO-03-373 State and Local Bioterrorism Preparedness
packages and powders. In several of the cities we visited, public health
officials reported working with police and fire officials to create a system
to determine which specimens were most suspicious. These triage systems
greatly reduced the number of costly full-emergency responses. For
example, during the height of the public’s concern about anthrax, one city,
which was experiencing as many as 75 to 90 reports of a white powder per
day, decided against sending out a complete hazardous materials unit for
every report. Instead it sent a team consisting of a fire official, a hazardous
materials official, a police official, and a public health official and this
team made an initial assessment of whether the full team was needed to
respond.

Coordination improved not only horizontally, that is, across different
entities within jurisdictions, but also vertically, that is, between local and
state agencies. According to their progress reports, all of the states we
visited used the 2002 federal funding in part to identify needs and
coordinate and integrate information technology systems. In all of these
states, emergency management communication systems were integrated
both vertically between state and local agencies and horizontally between
local government and hospitals. Only one of these states reported in its
progress report to HHS that it continued to have major difficulties in
improving coordination across different governmental levels because its
communication system was not capable of sending and receiving critical
health information.

In addition, we found that officials were beginning to address
communication problems. For example, six of the seven cities we visited
were examining how communication would take place in an emergency.
Many cities have purchased communication systems that allow officials
from different organizations to communicate with one another in real
time. Officials in one area told us that the fire and police departments in
their area had incompatible radio systems and, consequently, were unable
to communicate directly. This locality intended to install a compatible
radio system. It was also considering purchasing wireless communication
and messaging devices because of their success in other jurisdictions on
September 11, 2001.

State officials reported that they were beginning to make progress in
developing procedures for communication. Responding to the anthrax
incidents revealed a number of communication issues. For example, state
and local agency officials identified problems with how information about
the anthrax incidents was given to the public. These problems included
not always getting facts about anthrax out quickly, not explaining what


Page 15                       GAO-03-373 State and Local Bioterrorism Preparedness
was occurring, and releasing inconsistent messages. Officials in one city
told us that they set up an advisory group of retired media personnel to
help them examine how they could use the media to help convey their
message. Following a chemical exercise, public health officials in the same
city realized that better lines of communication were needed. In response,
members of the core bioterrorism team were issued pagers so that they
could be contacted more easily. In addition, two states we visited reported
to HHS that the outbreaks of West Nile virus in summer 2002 provided
successful tests of their communication capabilities.

In addition to these improvements, the 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 a
bioterrorism incident as well as other emergency health events and
disease surveillance. Goals of the HAN program include providing high-
speed Internet connectivity, broadcast capacity for emergency
communication, and distance-learning infrastructure for training.

Despite these improvements, deficiencies in communication and
coordination remained. For example, while four of the states we visited
said in their progress reports that they had completed integrating all of
their jurisdictions into HAN, two states had not yet achieved CDC’s goal to
cover 90 percent of the state’s population.28 One of these states reported
that, although it had developed a plan for emergency communication with
the public, local needs were still being assessed. This state reported that
coordination across multiple governmental levels was problematic and
time-consuming, and progress in meeting goals for planning was slow. In
addition, as of November 2002, only two of the states we visited reported
that they had conducted preparedness exercises that encompassed all
jurisdictions in the state. According to the states’ progress reports, all
states we visited intended to conduct exercises on at least some portion of
their various preparedness plans, such as the plan for receiving and
distributing the Strategic National Stockpile, in 2003.




28
 The seventh state reported that although 95 percent of the state’s population was covered
by HAN, all of the jurisdictions in the state were not integrated into the system.




Page 16                           GAO-03-373 State and Local Bioterrorism Preparedness
Progress in Improving   In contrast to the improvements made in coordination and
Preparedness Capacity   communication, progress related to the response capacity of the
Lagged                  workforce, the surveillance and laboratory systems, and hospitals
                        generally lagged. Deficiencies 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.

Workforce               At the time of our site visits, shortages in personnel existed in state and
                        local public health departments, laboratories, and hospitals and were
                        difficult to remedy. Officials from state and local health departments told
                        us that staffing shortages were a major concern. One official from a state
                        health department said that local health departments in his state were able
                        to handle the additional work generated by the anthrax incidents only by
                        putting aside their normal daily workload. Local officials also stated that
                        their normal daily workload suffered when staff were diverted from their
                        usual responsibilities to work on bioterrorism response planning. Local
                        officials recognized that diverting staff from their usual duties is
                        appropriate in a time of crisis but were concerned about the impact on
                        their other public health responsibilities over the longer term. Two of the
                        states and cities that we visited were particularly concerned that they did
                        not have enough epidemiologists to do the appropriate investigations in an
                        emergency. One state department of public health we visited had lost
                        approximately one-third of its staff because of budget cuts over the past
                        decade. This department had been attempting to hire more
                        epidemiologists. Barriers to finding and hiring epidemiologists included
                        noncompetitive salaries and a general shortage of people with the
                        necessary skills.

                        Shortages in laboratory and hospital personnel were also cited. Officials in
                        one city noted that they had difficulty filling and maintaining laboratory
                        positions. People that accepted the positions often left the health
                        department for better-paying positions. Five of the states we visited
                        reported shortages of hospital medical staff, including nurses and
                        physicians, necessary to increase response capacity in an emergency.
                        Increased funding for hiring staff cannot necessarily solve these shortages
                        because for many types of positions, such as laboratorians, there are not
                        enough trained individuals in the workforce. According to the Association
                        of Public Health Laboratories, training laboratorians to provide them with




                        Page 17                      GAO-03-373 State and Local Bioterrorism Preparedness
                           the necessary skills will take time and require a strategy for building the
                           needed workforce.29

                           Three states cited ongoing shortages of personnel, which they were
                           addressing in their progress reports. Two states had reported that they
                           plan to hire veterinarians30 to assist in their preparedness efforts. One of
                           these two states also noted difficulties in recruiting personnel when there
                           was no guarantee of funding beyond the current year, meaning that
                           prospective employees may not be offered permanent positions. Another
                           state, however, has had success in hiring epidemiologists.

Surveillance Systems and   State and local officials for the cities we visited recognized and were
Laboratory Facilities      attempting to address inadequacies in their surveillance systems and
                           laboratory facilities. Local officials were concerned that their surveillance
                           systems were inadequate to detect a bioterrorist event. Six of the cities we
                           visited used a passive surveillance system31 to detect infectious disease
                           outbreaks.32 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 electronic
                           surveillance systems. In one city we visited, the public health department
                           received clinical information electronically from existing hospital


                           29
                            Association of Public Health Laboratories, “State Public Health Laboratory Bioterrorism
                           Capacity,” Public Health Laboratory Issues in Brief: Bioterrorism Capacity (Washington,
                           D.C.: October 2002).
                           30
                            As we found with the West Nile virus, the links between public and animal health
                           agencies are becoming more important. Many emerging diseases affect both animals and
                           humans, as do many viruses or other disease-causing agents that might be used in
                           bioterrorist attacks. See U.S. General Accounting Office, West Nile Virus Outbreak:
                           Lessons for Public Health Preparedness, GAO/HEHS-00-180 (Washington, D.C.: Sept. 11,
                           2000).
                           31
                             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.
                           32
                            Officials in one city told us that although it had no local disease surveillance, its state
                           maintained a passive disease surveillance system.




                           Page 18                              GAO-03-373 State and Local Bioterrorism Preparedness
databases, which required no additional work by the hospitals. Several
cities were also evaluating the use of nontraditional data sources, such as
pharmacy sales, to conduct surveillance. Three of the cities we visited
were attempting to improve their surveillance capabilities by
incorporating active surveillance components into their systems.33 For
example, one city asked six hospitals to participate in a type of active
system in which the public health department obtains information from
the hospitals and conducts ongoing analysis of the data to search for
certain combinations of signs and symptoms.34 The city also had an active
surveillance system for influenza.

However, work to improve surveillance systems has proved challenging.
For example, despite initiatives to develop active surveillance systems, the
officials in one city considered event detection to be a weakness in their
system, in part because they did not have authority to access hospital
information systems. In addition, various local public health officials in
other cities reported that they lacked the resources to sustain active
surveillance.

Officials from all of the states we visited reported problems with their
public health laboratory systems and said that they needed to be
upgraded. All states were planning to purchase the equipment necessary
for rapidly identifying a biological agent. State and local officials in most
of the areas that we visited told us that the public health laboratory
systems in their states were stressed, in some cases severely, by the
sudden and significant increases in workload during the anthrax incidents.
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. Public health laboratories in some areas
quickly ran out of space for testing and storing samples. State and local
officials had to rely on laboratory assistance at the federal level, and CDC


33
 In addition, all of the states we visited were making efforts to improve their disease
surveillance systems.
34
 This type of active surveillance system is sometimes referred to as a syndromic
surveillance system. One federal official has stated that research examining the usefulness
of syndromic surveillance needs to continue. See S. Lillibridge, (untitled), in 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 19                            GAO-03-373 State and Local Bioterrorism Preparedness
received over 6,000 anthrax-related samples and had to operate its
anthrax-testing laboratory 24 hours a day, 7 days a week and open an
additional laboratory to test all the samples. Eighty-five percent of state
and territorial public health laboratories reported that the need to perform
bioterrorism testing during the anthrax incidents had a negative impact on
their ability to do routine work, delaying testing for tuberculosis, sexually
transmitted diseases, and other infectious diseases.35

Further, public health laboratories have a minimal association with private
laboratories (that is, laboratories that are associated with private hospitals
or are independent) or sometimes lack ties to laboratories in other states
that could serve as a backup to ensure timely testing of samples. One state
we visited had one state public health laboratory, no backup laboratory,
and no written agreements with neighboring states to provide support. A
task force of the Association of Public Health Laboratories has written
that a lack of close ties can lead to a lack of communication and a lack of
coordination of laboratory testing, both of which are needed to support
public health interventions.36 All states we visited recognized these
problems and, in their progress reports to HHS, reported that they were
using the funds to improve the Laboratory Response Network.37

According to their progress reports, officials in the states we visited were
working on solutions to their laboratory problems. States were examining
various ways to manage peak loads, including training additional staff in
the newest bioterrorism response methods, 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 providing
training on protocols for handling bioterrorist agents, upgrading two local




35
 Association of Public Health Laboratories, 1, 3.
36
 J. Witt-Kushner, J.R. Astles, J.C. Ridderhof, and others, “Core Functions and Capabilities
of State Public Health Laboratories: A Report of the Association of Public Health
Laboratories,” Morbidity and Mortality Weekly Report, vol. 51, no. RR-14 (2002), 1-8.
37
  CDC has established the Laboratory Response Network to maintain state-of-the-art
capabilities for biological agent identification and characterization. The Laboratory
Response Network is a multilevel system designed to link state and local public health
laboratories with advanced capacity clinical, military, veterinary, agricultural, water, and
food-testing laboratories.




Page 20                             GAO-03-373 State and Local Bioterrorism Preparedness
            public health laboratories to Biosafety Level 3 laboratories,38 and
            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
            were revised to cover reporting and sharing laboratory results with local
            public health and law enforcement agencies.

Hospitals   Federal, state, and local officials were concerned that hospitals might not
            have the capacity to accept and treat sudden, large increases in the
            number of patients, as might be seen in a bioterrorist attack. Hospital,
            state, and local officials reported that hospitals needed additional
            equipment and capital improvements—including medical stockpiles,
            personal protective equipment, decontamination facilities, quarantine and
            isolation facilities, and air handling and filtering equipment—to enhance
            preparedness.

            The resources that hospitals would require for responding to a bioterrorist
            attack with mass casualties are far greater than what are needed for
            everyday performance. Meeting these needs fully would be extremely
            difficult because bioterrorism preparedness is expensive and hospitals are
            reluctant to create capacity that is not needed on a routine basis and may
            never be utilized at a particular facility. Although hospitals may not be able
            to fully meet all preparedness needs, they can take action to increase their
            preparedness by developing plans for their internal emergency response
            operations, and some hospital officials reported taking these initial
            actions. For example, officials at one hospital we visited appointed a
            bioterrorism coordinator and developed plans for taking care of the
            families of hospital staff, transporting patients to the hospital, and
            communicating during an emergency. However, from its assessments of
            hospital capacity, one of the states we visited reported that only 11
            percent of its hospitals could readily increase their capacity for treating
            patients with communicable diseases requiring isolation, such as
            smallpox. Another state reported that most of its hospitals have little or no
            capacity for isolating patients diagnosed with or being tested for


            38
              In Biosafety Level 3 laboratories, work is done with indigenous or exotic agents with a
            potential for respiratory transmission, and which may cause serious and potentially lethal
            infection. Biosafety Level 3 laboratories provide the second-highest degree of protection to
            personnel, the environment, and the community.




            Page 21                            GAO-03-373 State and Local Bioterrorism Preparedness
                          communicable diseases. A third state was working with the state hospital
                          association to provide every hospital in the state with portable
                          decontamination units.

                          Efforts have been made to assist hospitals in preparing for bioterrorism.
                          For example, the hospital association in one city we visited was
                          developing a set of recommendations, based on the American Hospital
                          Association checklist,39 along with cost estimates, for health care facilities
                          to improve their preparedness. The association’s recommendations
                          included that each hospital have a 3-day supply of basic personal
                          protective equipment (such as gloves, gowns, and shoe covers) on hand
                          for staff, a 3-day supply of specified pharmaceuticals, emergency power, a
                          loud speaker or other mechanism to communicate with a large group of
                          converging casualties outside of the hospital entrance, and an external
                          decontamination facility capable of handling 50 victims per hour. These
                          guidelines give hospitals criteria by which they can measure their
                          preparedness and, in turn, improve their internal emergency response
                          operation plans.

                          In their progress reports to HHS, all the states we visited discussed a
                          number of activities they were undertaking with the HRSA funding to
                          increase hospital preparedness. These included hiring state hospital
                          bioterrorism program coordinators and medical directors, exploring the
                          feasibility of coordinating hospitals’ bioterrorism emergency planning
                          across states, and supplying selected hospitals with biohazard suits and
                          decontamination systems.


Level of Preparedness     We found that the overall level of bioterrorism preparedness varied by
Varied across Cities We   city. In the cities we visited, we observed that those cities that had
Visited                   recurring experience with public health emergencies, including those
                          resulting from natural disasters, or with preparation for National Security
                          Special Events, such as political conventions,40 were generally more


                          39
                           A. David Mangelsdorff, Chemical and Bioterrorism Preparedness Checklist (Chicago:
                          American Hospital Association, Oct. 3, 2001),
                          http://www.hospitalconnect.com/aha/key_issues/disaster_readiness/resources/HospitalRea
                          dy.html (downloaded Oct. 22, 2002). The checklist was developed to help hospitals
                          describe and assess their state of preparedness for chemical and biological incidents.
                          40
                            Presidential Decision Directive 62 created a category of special events called National
                          Security Special Events, which are events of such significance that they warrant greater
                          federal planning and protection than other special events. In addition to major political
                          party conventions, such events include presidential inaugurations.



                          Page 22                            GAO-03-373 State and Local Bioterrorism Preparedness
prepared than cities with little or no such experience. Cities that had dealt
with multiple public health emergencies in the past might have been
further along because they had learned which organizations and officials
need to be involved in preparedness and response efforts and moved to
include all pertinent parties in the efforts. Experience with natural
disasters raised the awareness of local officials regarding the level of
public health emergency preparedness in their cities and the kinds of
preparedness problems they needed to address. For example, in one city
we visited, officials found that emergency operations center personnel
became separated from one another during earthquakes and had trouble
staying in contact. These problems made decision making difficult. The
officials told us that the personnel needed to learn how to use their radio
system more effectively. (See app. I for details concerning preparedness
by city.)

All the cities we visited had to respond to suspected anthrax incidents in
fall 2001; however, each city found different deficiencies in its capabilities.
The anthrax incidents presented challenges for jurisdictions across the
country, not just in the communities where anthrax was found. Among the
problems that surfaced during the anthrax incidents, for example, were
several dealing with coordination across agencies and communication
among departments and jurisdictions and with the public. A local official
reported that there was no mechanism to coordinate the public
information, medical recommendations, and epidemiologic assessments
throughout the state and neighboring areas and that this created
considerable confusion and frustration for the public and medical
community.41 In addition, officials in several states became aware of
different types of limitations in their state and local communication
capabilities during the anthrax incidents. For example, in one rural state,
which had no confirmed anthrax cases but numerous false alarms, the
state public health department faxed messages containing critical
information to hospitals throughout the state. Officials in the department
realized that this one-way system was insufficient because they also
needed to be able to receive communications rapidly. They were able to
increase their communication capabilities by setting up a 24-hour toll-free
telephone number staffed by officials, who could respond to questions
from hospitals. In another state, public health laboratory officials found



41
 S. Allan, “The Challenges of Local Preparedness for Bioterrorism and Other
Emergencies,” NACCHO Exchange: Promoting Effective Local Public Health Practice, vol.
1, no. 1 (2002), 1-5.




Page 23                         GAO-03-373 State and Local Bioterrorism Preparedness
that it was difficult for many facilities to print files received from CDC
because their Internet connections were inadequate. Ultimately, the state
created CD-ROMs containing the protocols describing how to deal with
suspected anthrax samples, and a state public health official drove more
than 500 miles across the state to deliver them.

One of the cities we visited, which had experienced a large natural disaster
in the late 1990s, was in the early stages of bioterrorism preparedness.
This city is in a predominantly rural state, which started receiving funds
for establishing a HAN system for public health information in fiscal year
2002. There were five epidemiologists at the state level and none at the
local level, so the city depended on the state to determine when a disease
investigation was warranted. The state had a limited passive surveillance
system, with plans for a more elaborate, active surveillance system.

In contrast, another city we visited was much further along in bioterrorism
preparedness. In addition to dealing with natural disasters and other
public health emergencies, the city had also prepared for and hosted a
National Security Special Event. The state had been receiving funding for
HAN since 1999. Epidemiologists were employed at the state and local
levels. The city had a passive surveillance system, and it also had an active
surveillance system for influenza, which has symptoms similar to those of
the early stages of diseases attributable to several likely bioterrorist
agents, such as anthrax.

Even the cities that were better prepared were not strong in all elements.
For example, one city had successfully developed an integrated approach
to preparedness in which multiple organizations, both governmental and
nongovernmental, examined where terrorist attacks are likely to occur,
how they could be mitigated, and what resources were necessary. City
officials also reported that communications had been effective during
public health emergencies and that the city had an active disease
surveillance system. However, officials also reported deficiencies in
laboratory capacity and said that hospitals had not received sufficient
bioterrorism response training. Another one of the better-prepared cities
was connected to HAN and the Epidemic Information Exchange (Epi-X),42
and all county emergency management agencies in the state were linked.



42
  Epi-X is a secure, Web-based exchange for public health officials to rapidly exchange
information on disease outbreaks, exposures to environmental hazards, and other health
events as they are identified and investigated.




Page 24                           GAO-03-373 State and Local Bioterrorism Preparedness
                         However, the state did not have written agreements with its neighboring
                         states for responding to an emergency, and a major hospital in the city we
                         visited lacked sufficient equipment for a bioterrorism response.


                         State and local jurisdictions and response organizations made progress in
State and Local          developing plans to improve their preparedness. They had begun to
Jurisdictions and        include bioterrorism in their agencies’ overall emergency operation plans,
                         and preparing the application plans for HHS funding helped states focus
Response                 their planning efforts. In addition, hospitals, which were beginning to be
Organizations Made       seen as part of a local response system, were starting to participate in
                         local response planning. While progress was made in local planning,
Progress in              regional planning between states lagged. A regional response to a
Developing               bioterrorist attack would potentially require the mutual participation of
Preparedness Plans,      officials from neighboring states or, in several instances, a neighboring
                         country, yet some states lacked such coordination with their neighboring
but Regional Plans       states and country and had not participated in joint response planning.
Remained
Undeveloped
State and Local          At the time of our site visits, although most of the cities and states we
Jurisdictions Had        visited had emergency operation plans, many of these plans did not
Increased Bioterrorism   specifically address the unique requirements of response to a bioterrorist
                         attack. However, many of the response organizations in these cities and
Planning Efforts         states had begun to develop emergency operation plans that include
                         bioterrorism response. Officials from all of these response organizations
                         stated that planning for a bioterrorist incident is difficult because they do
                         not know what it means to be prepared and therefore are not sure if their
                         plans will be adequate.

                         At the time of our site visits, all seven states were in the stage of “planning
                         to plan” for bioterrorism. While all of these states had previously taken
                         steps to assess the readiness levels of their localities, they continued to
                         need further assessments. For example, most were doing some
                         assessments of capacity, such as assessments of hospital capacity and
                         equipment. Although some of these efforts were time-consuming because
                         of the need to develop assessment tools, such as surveys, the information
                         on needs and current status is essential for the states to be able to plan.

                         Preparing the application plans for HHS helped states to identify problems
                         in bioterrorism preparedness by requiring them to address specified
                         preparedness focus areas. In the application process, states were required


                         Page 25                       GAO-03-373 State and Local Bioterrorism Preparedness
                              to assess their capabilities in the focus areas and discuss how they
                              planned to address their deficiencies. For example, under the surveillance
                              and epidemiologic capacity focus area in its application plan for CDC
                              funding, one state we visited identified a lack of adequate staffing,
                              expertise, and resources. Officials reported in the plan that the department
                              of public health was developing regional medical epidemiology teams,
                              each of which would include a part-time practicing physician and a full-
                              time epidemiologist, with enough teams to cover all the regions in the
                              state. These teams would establish ongoing relationships with area
                              hospital infection control programs, emergency departments, and other
                              health care providers. Another state reported in its HRSA application plan
                              that it did not have the capability to track resources, supplies, and the
                              distribution of patients at the regional level. It planned to expand an
                              existing electronic tracking system to track each hospital’s capacity,
                              resources, and patient distribution on a real-time basis.


Hospitals Were Beginning      At the time of our site visits, we found that hospitals were beginning to
to Recognize Need for         coordinate with other local response organizations and collaborate with
Inclusion in Local Planning   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 the city 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.

                              Government officials, health care association representatives, and hospital
                              officials in many of the areas that we visited stated that hospitals had
                              become more interested in these issues and more involved in planning
                              efforts than prior to September 11, 2001. They noted that health care
                              providers in hospitals gained an awareness of the seriousness of the threat
                              of bioterrorism and began to ask for information, lectures, and
                              presentations of their cities’ emergency plans. Hospital representatives, as
                              well as state and local officials, told us that hospital personnel were more
                              interested in attending training on biological agents and that hospitals had
                              formed better connections with local public health departments in many
                              areas. We also found that some hospitals were starting to collaborate with
                              one another on planning efforts.


                              Page 26                       GAO-03-373 State and Local Bioterrorism Preparedness
Regional Planning Was    Response organization officials were concerned about a lack of planning
Lacking between States   for regional coordination between states. As called for by the guidance for
                         the cooperative agreements, all of the states we visited organized their
                         planning on a regional basis, assigning local areas to particular regions for
                         planning purposes. However, the state-defined regions encompassed areas
                         within the state only. A concern for response organization officials was the
                         lack of planning for regional coordination between states and with a
                         neighboring country of the public health response to a bioterrorist attack.
                         With regard to coordination efforts 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 border issues and had drafted
                         mutual aid agreements for hospitals and emergency medical services.
                         Public health officials from several states reported developing working
                         relationships with officials from other states to provide backup laboratory
                         capacity.

                         States varied with regard to the intensity of their coordination efforts with
                         a neighboring country. Officials in one state told us that the state lacked
                         the needed coordination with the foreign country that it borders, but they
                         reported in the state’s CDC application plan that workforce plans and
                         infectious disease surveillance and reporting are the two priorities for the
                         state with the neighboring country. The emergency management officials
                         in the city we visited in that state reported that the border guards knew
                         and informally coordinated with one another. Officials in this state
                         reported in the state’s CDC application plan that some of the state’s
                         hospitals employed people from the foreign country and so hospital
                         staffing could be problematic if borders were closed during an emergency.
                         However, officials in another state that we visited reported good regional
                         partnerships with the foreign country that it borders. In fact, the state
                         officials noted that the needs of a metropolitan area in the neighboring
                         country would be evaluated and integrated into the state plan. In addition,
                         the state reported in its progress report that it was developing an
                         agreement with the neighboring country to provide laboratory surge
                         capacity.




                         Page 27                      GAO-03-373 State and Local Bioterrorism Preparedness
                              State and local officials and hospital officials expressed concerns about
State and Local               the distribution and sustainability of federal bioterrorism preparedness
Officials Expressed           funding, as well as about a lack of guidance on what it means to be
                              prepared for a bioterrorism event. State and local officials we met with
Concerns regarding            disagreed about whether federal funding for bioterrorism preparedness
Federal Funding and           should flow through the state or go directly to the local jurisdictions.
                              Hospital officials reported that federal funding from OER’s MMRS
Lack of Guidance              program in their cities had not always been shared with them in the past.
                              In addition, state and local officials reported that sustainability in funding
                              over several years would be beneficial to all jurisdictions. State and local
                              officials requested more specific federal guidance on what constitutes
                              adequate preparedness. State officials also requested more sharing of best
                              practices to assist them in closing the remaining gaps in preparedness.


Funding Concerns Were         State and local officials expressed several concerns regarding the federal
Related to Distribution and   funding provided for state and local bioterrorism preparedness both
Sustainability                before and after September 11, 2001. These concerns were related to the
                              distribution and sustainability of these funds.

Distribution                  State and local officials we met with disagreed about whether federal
                              funding for bioterrorism preparedness should flow through the state or go
                              directly to the local jurisdictions. Local officials suggested that some
                              funding should be allocated directly to local governments because it
                              would be more efficient since the state would not withhold a percentage
                              for its own use. However, state officials told us that if funds went directly
                              to the local level, it would be difficult for them to direct the funding to the
                              areas of greatest need within the states. In addition, state officials reported
                              that when money flows through the states they can control purchases of
                              emergency response equipment to ensure compatibility across regions of
                              the state.

                              Progress reports to HHS from the seven states we visited showed great
                              variability in the speed with which the states committed funds provided
                              through the CDC cooperative agreements, in part because of the differing
                              state requirements for distribution. Two of the states had obligated more
                              than 70 percent of the funding they received from HHS as of fall 2002,
                              while two other states had obligated only about 20 percent of their funds
                              as of the same time, with the remaining three states obligating percentages
                              between these figures. Some states reported that they needed to arrange
                              for grants or take other actions before they could transfer any of the funds
                              to local jurisdictions.



                              Page 28                       GAO-03-373 State and Local Bioterrorism Preparedness
                 Hospital officials also raised concerns about the distribution of federal
                 funding for preparedness. In a national survey, 62 percent of hospital
                 officials said that a lack of awareness of federally sponsored preparedness
                 programs was a factor in not participating in preparedness programs.43 In
                 addition, hospital officials that we spoke with in two cities added that
                 federal funding from OER’s MMRS program in their cities had not been
                 shared with hospitals in the past. The HRSA program may help alleviate
                 these problems. It has led to increased coordination among government
                 agencies, which may lead to an increased awareness of the funding
                 opportunity it provides. In addition, the HRSA guidance on funding under
                 the cooperative agreement requires that approximately three-quarters of
                 the funding be spent directly on or in hospitals, community health clinics,
                 and other health care systems. HRSA also requires states to undertake
                 certain initial state-level tasks that would not involve costs to the
                 hospitals, including designating a hospital bioterrorism preparedness
                 coordinator, establishing a statewide advisory committee, and conducting
                 a needs assessment. In their progress reports to HHS, all states we visited
                 reported that the HRSA funding was being used primarily to support such
                 initial state-level activities, including conducting assessments, developing
                 plans, and hiring state-level personnel. HHS recently stated that most, if
                 not all, states have now determined how funding will be awarded to
                 hospitals, community health clinics, and other health care systems.

                 During our site visits, state officials also expressed concerns in light of the
                 budget shortfalls and cuts they were experiencing. Officials from one state
                 expressed concern that the 2002 funding from HHS might be used to
                 supplant state funding instead of supplementing it, because of general
                 budgetary cutbacks in the state, although such use is expressly prohibited
                 by the funding agreements. An official from another state told us that the
                 funding that its state public health laboratory received in 2002 from CDC
                 for bioterrorism preparedness was not enough to offset the general cuts in
                 the state budget for the public health laboratory. We were not able to
                 determine whether any of the state funds were supplanted by the HHS
                 funding.

Sustainability   The public health infrastructure depends on sustained and consistent
                 investment, yet in the past the funding has been viewed as unsystematic.44


                 43
                  Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving
                 Weapons of Mass Destruction, Third Annual Report, G-7-9.
                 44
                  Institute of Medicine of the National Academies, xi.




                 Page 29                           GAO-03-373 State and Local Bioterrorism Preparedness
                             In fiscal year 2002, states were experiencing budget shortfalls (as a
                             percentage of general fund revenues) that were worse than after the
                             recession of the early 1990s ended,45 and shortfalls in 2003 were expected
                             to be even worse. The influx of federal funds for bioterrorism
                             preparedness made it possible for jurisdictions to undertake new efforts in
                             this area, at a time when other public health programs were experiencing
                             cutbacks.

                             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.46 We have noted previously that federal, state, and local
                             governments have a shared responsibility in preparing for terrorist attacks
                             and other disasters.47 However, prior to the infusion of federal funds, few
                             states were investing in their public health infrastructure.


State and Local Officials    Officials we spoke with at both the state and the local levels requested
Requested Specific Federal   more federal guidance and sharing of best practices to assist them in
Benchmarks for Adequate      closing the remaining gaps in preparedness. Officials from response
                             organizations in every state we visited reported a lack of guidance from
Preparedness and Sharing     the federal government on what it means to be prepared for bioterrorism.
of Best Practices            In the past, CDC has made efforts to develop guidance for state and local
                             public health officials on bioterrorism preparedness. For example, in its
                             core capacity project of 2001, CDC developed criteria to provide guidance



                             45
                              In 1991, which was the formal end of the recession, state budget shortfalls were 6.2
                             percent of total state general fund revenues. In 1992, shortfalls were 6.5 percent of
                             revenues. Fiscal year 2002 state budget shortfalls are estimated to be 7.8 percent of
                             estimated total general fund revenues.
                             46
                              Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving
                             Weapons of Mass Destruction, Fourth Annual Report, v.
                             47
                              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 30                            GAO-03-373 State and Local Bioterrorism Preparedness
on developing the bioterrorism preparedness capacity of state and local
public health systems. However, these criteria were broad and
nonspecific. State and local officials told us they needed specific
benchmarks (such as how large an area a response team should be
responsible for) to indicate what they should be doing to be adequately
prepared. Local officials were turning to state officials for guidance, and
state officials wanted to be able to turn to the federal government.

Response organizations have been hindered in their efforts to prepare for
bioterrorism because they do not know what agents pose the most
credible threat, which makes it difficult to know when they are prepared.
There have been federal efforts to devise lists of threats, but as we
reported,48 these efforts have been fragmented, as is evident in the
different biological agent threat lists that were developed by federal
departments and agencies. In addition, medical organizations have
historically not been recipients of intelligence regarding threat
information. The Institute of Medicine and the National Research Council
have stated that this practice needs to be changed.49

The need for federal guidance has continued to be an issue as states have
proceeded in their planning and preparedness activities using the HHS
funding. For example, in their progress reports to HHS in late 2002, two of
the states we visited reported that they were seeking guidance from HHS
on assessing vulnerabilities for foodborne or waterborne diseases and
preparedness steps they should take for these hazards. One of these states
declared that it could not make further efforts on testing for waterborne or
agricultural diseases until it received more guidance. States also reported
needing guidance in such areas as using the CDC emergency notification
systems.

State and local officials were interested in receiving detailed guidance
from HHS to be able to better assess their progress and develop realistic
time frames. One state we visited wrote in its progress report that CDC’s
development of pre-event guidelines for use of the vaccinia vaccine for
smallpox would be crucial for providing consistent practices nationwide.



48
 GAO-01-915.
49
 Institute of Medicine, Chemical and Biological Terrorism: Research and Development to
Improve Civilian Medical Response (Washington, D.C.: National Academy Press, 1999),
and National Research Council, Making the Nation Safer: The Role of Science and
Technology in Countering Terrorism (Washington, D.C.: National Academies Press, 2002).




Page 31                         GAO-03-373 State and Local Bioterrorism Preparedness
It also wrote that it would be useful to have an approved method for
evaluating laboratory response to ensure that minimum standards were
being met. Two other states wrote that they would like CDC to provide
guidance for developing emergency operation plans.

CDC has begun to provide more detailed guidance in some areas. For
example, it is developing standards for the National Electronic Disease
Surveillance System, which serves as the foundation for many states’
bioterrorism information systems. Under this system, standards are being
developed to ensure uniform data collection and electronic reporting
practices across the nation. Another initiative that is providing guidance
on communication is CDC’s Public Health Information Network. This
network is intended to build on and integrate existing public health
communication systems and will include public health data standards to
ensure the compatibility of the communication systems used by the health
care community and federal, state, and local public authorities. In
addition, CDC has made efforts in developing new laboratory protocols.
One state noted that CDC’s efforts have been of the highest standard, and
the protocols received have been designed for easy implementation at the
state level.

Officials at the state level also expressed a desire for more sharing of best
practices. Officials stated that although each jurisdiction might need to
adapt procedures to its own circumstances, time could be saved and
needless duplication of effort avoided if there were better mechanisms for
sharing strategies across jurisdictions. They contended that HHS was
positioned to know about different strategies that states were pursuing.
For example, one state wrote in its progress report that it would be useful
for HHS to provide information on syndromic surveillance systems that
were operational. In its progress report, another state wrote that it had
requested the portions of other states’ application plans related to risk
communication and health information dissemination. The state wanted to
include its Native American population in preparedness planning and was
looking for best practices on how to involve tribal governments in
planning.

Some officials particularly expressed a desire for increased information
sharing of best practices among state and local jurisdictions on various
types of training. Many jurisdictions were developing training programs to
increase bioterrorism preparedness. One state official told us during our
visit that his agency needed training material on handling incidents, but he
did not want to duplicate others’ efforts by developing his own materials.
In their progress reports, five of the seven states we visited indicated that


Page 32                      GAO-03-373 State and Local Bioterrorism Preparedness
              they would like CDC’s help in obtaining training information. One state
              wrote that establishing national standards for training and training aids for
              laboratories would minimize the need for individual states or regions to
              develop their own materials. Another state requested assistance with
              Strategic National Stockpile and smallpox education and training
              materials, and a third state requested training videos or videos of tabletop
              exercises to study. One state suggested that it would be useful for CDC to
              organize an Internet site and teleconferences among states to facilitate
              information sharing.


              As concerns about bioterrorism and other public health emergencies,
Conclusions   including newly emerging infectious diseases such as West Nile virus, have
              surfaced over the past few years, cities across the nation have been
              working to increase their preparedness for responding to such events. An
              essential first step for cities was to recognize some of the deficiencies that
              existed in their public health infrastructures and how these would affect
              their ability to respond to a bioterrorism event.

              Cities have recognized and begun to work on deficiencies in elements of
              coordination, communication, and capacity necessary for bioterrorism
              preparedness. Progress in addressing capacity issues has lagged behind
              progress in other areas, in part because finding solutions to deficiencies in
              capacity can be complicated by the magnitude of the resource needs. For
              example, the resources that hospitals would require for responding to a
              biological attack would be greater than what are normally needed. Local
              authorities can shift resources between functions and plan for ways to
              expand capacity in an emergency. However, shifting resources between
              functions can cause serious problems if the emergency is an extended one
              and other important responsibilities are not being met. Needs for
              additional capacity for responding to bioterrorism emergencies must be
              balanced with preparedness for all types of emergencies and must not
              detract from meeting the everyday needs of cities for emergency care.
              Regional plans can help address capacity deficiencies by providing for the
              sharing across localities of resources that, while adequate for everyday
              needs, may be in short supply on a local level in an emergency.

              Our observations of state and local preparedness for bioterrorism in
              selected cities bring certain other needs into focus as well. First, there is
              not yet a consensus on what constitutes adequate preparedness for a
              public health emergency, including a bioterrorist incident, at the state and
              local levels. There have been some efforts to provide guidelines for
              hospital preparedness, but specific standards for state and local


              Page 33                      GAO-03-373 State and Local Bioterrorism Preparedness
                      preparedness are lacking. Officials from state and local response
                      organizations expressed a need for specific benchmarks from the federal
                      government, which could lead to consistent standards across all states.
                      This could also facilitate needed regional planning across state
                      boundaries.

                      Second, we noted several instances in which cities found solutions to
                      deficiencies that they identified. For example, cities developed methods
                      for triaging samples during the anthrax incidents. Federal mechanisms for
                      sharing innovations and other resources, such as fact sheets on infectious
                      diseases and training materials, could prevent states and cities from
                      having to develop solutions to common problems individually. The federal
                      government could take additional steps to assist these states and cities in
                      efficiently and effectively increasing their preparedness.


                      To help state and local jurisdictions better prepare for a bioterrorist
Recommendations for   attack, we recommend that the Secretary of Health and Human Services,
Executive Action      in consultation with the Secretary of Homeland Security,

                  •   develop specific benchmarks that define adequate preparedness for a
                      bioterrorist attack and can be used by state and local jurisdictions to
                      assess and guide their preparedness efforts and
                  •   develop a mechanism by which solutions to problems that have been used
                      in one jurisdiction can be evaluated by HHS and, if appropriate, shared
                      with other jurisdictions.


                      We provided a draft of this report to HHS and the Department of
Agency Comments       Homeland Security. HHS submitted written comments, which are
                      reprinted in appendix III. HHS said the report provides an informative
                      assessment of preparedness for bioterrorism and other public health
                      emergencies at the state and local levels. HHS concurred with our
                      recommendations. The liaison from the Department of Homeland Security
                      provided oral comments noting the department’s concurrence with the
                      draft report and the recommendations.

                      In its comments, HHS stated that it is taking steps to address the concerns
                      we identified. For example, the department noted that both CDC and
                      HRSA will issue guidance that will emphasize coordination of planning on
                      a regional level. HHS also stated that CDC and HRSA will be developing
                      guidelines and templates to assist states in identifying specific
                      benchmarks and that the Office of the Assistant Secretary for Public



                      Page 34                     GAO-03-373 State and Local Bioterrorism Preparedness
Health Emergency Preparedness will be leading an effort to create a
repository of best practices.

HHS noted that it has been a year since our site visits and that during that
period both state and local health departments have made further strides
in their efforts to achieve preparedness for bioterrorism and other public
health emergencies. We noted in the draft report that we include
information obtained from state officials several months after our site
visits. As we also noted in the draft report, we recognize that changes
continue to occur. However, many of the problems we identified will
require sustained efforts, and HHS said that it is now taking steps that are
intended to facilitate further progress.

HHS also provided technical comments, which we incorporated where
appropriate.


We are sending copies of this report to the Secretary of Health and Human
Services and the Secretary of Homeland Security, and other interested
officials. We will also provide copies to others upon request. In addition,
the report will be available at no charge on GAO’s Web site at
http://www.gao.gov.

If you or your staffs have any questions about this report, please call me at
(202) 512-7119. Another contact and key contributors are listed in
appendix IV.




Janet Heinrich
Director, Health Care—Public Health Issues




Page 35                      GAO-03-373 State and Local Bioterrorism Preparedness
List of Committees

The Honorable Judd Gregg
Chairman
The Honorable Edward M. Kennedy
Ranking Minority Member
Committee on Health, Education, Labor, and Pensions
United States Senate

The Honorable Ted Stevens
Chairman
The Honorable Robert C. Byrd
Ranking Minority Member
Committee on Appropriations
United States Senate

The Honorable W.J. “Billy” Tauzin
Chairman
The Honorable John D. Dingell
Ranking Minority Member
Committee on Energy and Commerce
House of Representatives

The Honorable C.W. Bill Young
Chairman
The Honorable David Obey
Ranking Minority Member
Committee on Appropriations
House of Representatives




Page 36                   GAO-03-373 State and Local Bioterrorism Preparedness
                                        Appendix I: Bioterrorism Preparedness in
Appendix I: Bioterrorism Preparedness inSeven Case Cities



Seven Case Cities

                                        Table 1 provides comparisons across several elements of preparedness for
                                        each of the seven cities we visited. The purpose of this table is to provide
                                        additional context for the discussion in the report and some understanding
                                        of the strengths and weaknesses of each city in preparing for a bioterrorist
                                        attack and how these strengths and weaknesses vary among the cities. The
                                        information in this table was obtained from December 2001 through March
                                        2002. The cities have continued to make changes to improve their
                                        bioterrorism preparedness; however, this table does not reflect those
                                        changes.

Table 1: Bioterrorism Preparedness Elements for the Seven Cities We Visited, December 2001 through March 2002

                            City A    City B         City C         City D         City E         City F         City G
Context
City population             Under     300,000-       Over           300,000-       Over           300,000-       Under
                            300,000   1,000,000      1,000,000      1,000,000      1,000,000      1,000,000      300,000
State has a foreign         Yes       No             No             Yes            Yes            No             No
border
Metropolitan area has a     Yes       Yes            Yes            Yes            Yes            No             Yes
port
City had received           No        Yes            Yes            Yes            Yes            Yes            Yes
funding from the
Metropolitan Medical
Response System
(MMRS)a program
City had responded to       Yes       Yes            Yes            Yes            Yes            Yes            Yes
suspected anthrax
incidents, other public
health emergencies, or
both within previous 5
years
City prepared and           No        No             Yes            Yes            Yes            No             No
hosted a National
                        b
Security Special Event
within previous 5 years
Disease surveillance,
follow-up, and agent
identification
Statewide passive           Yes       Yes            Yes            Yes            Yes            Yes            Yes
disease surveillance
        c
system
Statewide active disease    Yes       Yes            No             No             Yes            No             Yes
                    d
surveillance system
Local active disease        No        Noe            Noe            Yes            Yes            No             No
                    d
surveillance system
One or more                 No        Yes            Yes            Yes            Yes            Yes            Yes
epidemiologists in local
public health agency




                                        Page 37                           GAO-03-373 State and Local Bioterrorism Preparedness
                                        Appendix I: Bioterrorism Preparedness in
                                        Seven Case Cities




                              City A   City B        City C         City D         City E         City F         City G
 One or more                  Yes      Yes           Yes            Yes            Yes            Yes            Yes
 epidemiologists in state
 public health agency
 One or more Biosafety        Yes      Yes           Yes            Yes            Yes            Yes            Yes
 Level 3 laboratories in
           f
 the state
 Treatment capacity
 Drug stockpile               No       Yes           Yes            Yes            Yes            No             Yes
                     g
 maintained by city
 Drug stockpile               Yes      Yes           Yes            Yes            Yes            No             Yes
                          h
 maintained by hospital
 Hospital had sufficient      No       No            No             No             No             No             No
 bioterrorism response
 training, per self-report
 Hospital had sufficient      No       No            No             No             No             No             No
 equipment for
 bioterrorism response,
 per self-reporti
 Responder
 communications
 Communications               No       No            No              No            Yes            No             No
 between emergency
 responders had been
 effective during public
 health emergencies, per
 self-report
 City had compatible          Yes      Yes           Yes            Yes            Yes            No             Yes
 radio system
 State public health
 resources
 State had a plan for         Yesj     Yesj          Yes            Yes            Yesj           Yes            Yesj
 using the Strategic
 National Stockpile
 State public health office   No       Yes           No             Yes            Yes            No             Yes
 used Health Alert
 Network (HAN)k
 Local public health office   No       Yes           No             Yes            Yes            No             Yes
 used HANk
 Cooperation among
 responders
 Written agreements exist     Yes      No            Yes            No             No             Yes            No
 to cooperate with
 neighboring state(s)
 Coordination with            No       NAl           NAl            Yes            No             NAl            NAl
 neighboring country
 Local officials had          No       No            No             No             Yesm           No             No
 developed a system for
 triaging samples prior to
 the 2001 anthrax
 incidents

Source: GAO.




                                        Page 38                           GAO-03-373 State and Local Bioterrorism Preparedness
Appendix I: Bioterrorism Preparedness in
Seven Case Cities




Note: GAO analysis of information obtained from visits to each of the cities.
a
 The MMRS program is an Office of Emergency Response (OER) program intended to develop or
enhance the local response to a public health crisis, especially an attack using weapons of mass
destruction. It takes a comprehensive local approach by assembling hospitals, emergency managers,
the public health establishment, and others to deal with the consequences of an attack. Cities enter
into contracts with OER for a predetermined period. For more information on the MMRS program, see
U.S. General Accounting Office, Bioterrorism: Federal Research and Preparedness Activities,
GAO-01-915 (Washington, D.C.: Sept. 28, 2001).
b
 Presidential Decision Directive 62 created a category of special events called National Security
Special Events, which are events of such significance that they warrant greater federal planning and
protection than other special events. Such events include presidential inaugurations and major
political party conventions.
c
 Passive disease surveillance systems rely on laboratory and hospital staff, physicians, and other
relevant sources to take the initiative to provide data on illnesses to health departments, where
officials analyze and interpret the information as it comes in.
d
 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.
e
 City had implemented an active disease surveillance system in the past for a public health
emergency or special event but had discontinued the system.
f
 Biosafety levels represent combinations of laboratory practices and techniques, safety equipment,
and laboratory facilities. Each combination is specifically appropriate for the operations performed,
the documented or suspected routes of transmission of the infectious agents, and the laboratory
function or activity. In Biosafety Level 3 facilities, work is done with indigenous or exotic agents with a
potential for respiratory transmission, and which may cause serious and potentially lethal infection.
Level 3 laboratories provide the second-highest degree of protection to personnel, the environment,
and the community.
g
 The drug stockpile is maintained by the local responders (not including individual hospitals). These
city stockpiles are independent of the federal Strategic National Stockpile, a repository of
pharmaceuticals, antidotes, and medical supplies that can be delivered to the site of a bioterrorist (or
other) attack.
h
 A “yes” entry indicates that officials from at least one hospital that we spoke with in that city gave a
positive response. These hospital stockpiles are independent of the federal Strategic National
Stockpile.
i
    Equipment includes personal protective gear or decontamination equipment.
j
    The state had a draft plan or was developing a plan.
k
HAN is a Centers for Disease Control and Prevention program that supports the exchange of key
public health information over the Internet and other communication methods, such as two-way radio.
l
    NA means not applicable; this state has no foreign borders.
m
    During the anthrax incidents of 2001, the locality built on the existing triage system.




Page 39                                    GAO-03-373 State and Local Bioterrorism Preparedness
              Appendix II: Scope and Methodology
Appendix II: Scope and Methodology


              We visited seven cities selected to provide wide variation in geographic
              location, population size, and experience with natural disasters and large
              exercises. Recommendations from experts, including officials from the
              Department of Health and Human Services (HHS) Office of Emergency
              Response and the National Association of County and City Health
              Officials, were also considered in the selection of cities. We also visited
              each city’s state government. The cities visited are not identified in this
              report because of the sensitive nature of the issue.

              During the multiday site visits, which we conducted from December 2001
              through March 2002, we interviewed officials from state and local public
              health departments, local emergency medical services, state and local
              emergency management agencies, local fire and law enforcement
              agencies, and hospitals and national public health care associations. We
              asked them about their activities related to preparing for and responding
              to bioterrorism, lessons learned from past natural disasters and the
              anthrax incidents in October 2001, past and current federal funding for
              helping state and local agencies prepare for bioterrorism, and gaps and
              weaknesses as well as strengths and successes in their readiness for
              bioterrorism. We reviewed copies of the bioterrorism preparedness plans
              states sent to HHS in spring 2002 for cooperative agreement funding from
              the Centers for Disease Control and Prevention (CDC) and the Health
              Resources and Services Administration (HRSA). In addition, to update our
              data, we obtained follow-up information from state and local officials and
              reviewed the 6-month progress reports on the CDC and HRSA cooperative
              agreements that were submitted to HHS in late 2002 from the relevant
              states, covering the period through October 31, 2002. Because our focus
              was on the public health and medical consequences of a bioterrorist event,
              we do not report on preparedness efforts funded by the Department of
              Justice and the Federal Emergency Management Agency in this study.

              The results of our visits cannot be generalized to the entire country. In
              addition, the hospitals we included in our site visits were chosen based on
              recommendations of local public health officials and hospital associations.
              This resulted in a mix of private and public hospitals, but because of the
              selection method, the results cannot be generalized to all hospitals in the
              areas we visited.

              We interviewed officials from HHS’s Office of the Assistant Secretary for
              Public Health Emergency Preparedness regarding its efforts to improve
              state and local preparedness for responding to a bioterrorist incident.




              Page 40                         GAO-03-373 State and Local Bioterrorism Preparedness
Appendix II: Scope and Methodology




We reviewed reports from the Advisory Panel to Assess Domestic
Response Capabilities for Terrorism Involving Weapons of Mass
Destruction1 and reports from several associations, including the American
Hospital Association, the National Association of County and City Health
Officials, and the American College of Emergency Physicians. We
conducted interviews with representatives from several associations,
including the American Hospital Association, the Association of State and
Territorial Health Officials, and the National Governors Association. We
also reviewed a report by the U.S. Conference of Mayors about local costs
associated with bioterrorism preparedness.2 In addition, we examined the
President’s budget request for bioterrorism preparedness for fiscal year
2003.

Because of the events of the fall of 2001, and the subsequent federal
preparedness funding, changes were occurring at the state and local levels
with regard to bioterrorism preparedness during our site visits and
subsequent data collection. Changes have continued to occur and this
report may not reflect all these changes.

We conducted our work from November 2001 through April 2003 in
accordance with generally accepted government auditing standards.




1
 Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving
Weapons of Mass Destruction, Third 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, 2001), and 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).
2
The United States Conference of Mayors, The Cost of Heightened Security in America’s
Cities: A 192-City Survey (Washington, D.C.: City Policy Associates, January 2002).




Page 41                         GAO-03-373 State and Local Bioterrorism Preparedness
             Appendix III: Comments from the Department of Health and Human Services
Appendix III: Comments from the
Department of Health and Human Services




             Page 42                         GAO-03-373 State and Local Bioterrorism Preparedness
Appendix III: Comments from the Department of Health and Human Services




Page 43                         GAO-03-373 State and Local Bioterrorism Preparedness
Appendix III: Comments from the Department of Health and Human Services




Page 44                         GAO-03-373 State and Local Bioterrorism Preparedness
Appendix III: Comments from the Department of Health and Human Services




Page 45                         GAO-03-373 State and Local Bioterrorism Preparedness
                  Appendix IV: GAO Contact and Staff
Appendix IV: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Marcia Crosse, (202) 512-7119
GAO Contact
                  In addition to the contact named above, George Bogart, Barbara Chapman,
Acknowledgments   Robert Copeland, Deborah Miller, and Roseanne Price made key
                  contributions to this report.




                  Page 46                         GAO-03-373 State and Local Bioterrorism Preparedness
             Related GAO Products
Related GAO Products


             Chemical and Biological Defense: Observations on DOD’s Risk
             Assessment of Defense Capabilities. GAO-03-137T. Washington, D.C.:
             October 1, 2002.

             Anthrax Vaccine: GAO’s Survey of Guard and Reserve Pilots and
             Aircrew. GAO-02-445. Washington, D.C.: September 20, 2002.

             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.

             Chemical and Biological Defense: Improved Risk Assessment and
             Inventory Management Are Needed. GAO-01-667. Washington, D.C.:
             September 28, 2001.



             Page 47                    GAO-03-373 State and Local Bioterrorism Preparedness
           Related GAO Products




           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.

           Chemical and Biological Defense: Program Planning and Evaluation
           Should Follow Results Act Framework. GAO/NSIAD-99-159. Washington,
           D.C.: August 16, 1999.

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




(290087)
           Page 48                    GAO-03-373 State and Local Bioterrorism Preparedness
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