Summary

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

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

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Implemented" or "Not implemented" based on our follow up work.

Recommendations for Executive Action