This is the accessible text file for GAO report number GAO-03-373 
entitled 'Bioterrorism: Preparedness Varied across State and Local 
Jurisdictions' which was released on April 07, 2003.



This text file was formatted by the U.S. General Accounting Office 

(GAO) to be accessible to users with visual impairments, as part of a 

longer term project to improve GAO products’ accessibility. Every 

attempt has been made to maintain the structural and data integrity of 

the original printed product. Accessibility features, such as text 

descriptions of tables, consecutively numbered footnotes placed at the 

end of the file, and the text of agency comment letters, are provided 

but may not exactly duplicate the presentation or format of the printed 

version. The portable document format (PDF) file is an exact electronic 

replica of the printed version. We welcome your feedback. Please E-mail 

your comments regarding the contents or accessibility features of this 

document to Webmaster@gao.gov.



Report to Congressional Committees:



United States General Accounting Office:



GAO:



April 2003:



BIOTERRORISM:



Preparedness Varied across State and Local Jurisdictions:



State and Local Bioterrorism Preparedness:



GAO-03-373:



GAO Highlights:



Highlights of GAO-03-373, a report to the Senate Committee on Health, 

Education, Labor, and Pensions; the Senate and House Committees on 

Appropriations; and the House Committee on Energy and Commerce



Why GAO Did This Study:



Much of the response to a bioterrorist attack would occur at the local 

level. Many local areas and their supporting state agencies, however, 

may not be adequately prepared to respond to such an attack. In the 

Public Health Improvement Act that was passed in 2000, Congress 

directed GAO to examine state and local preparedness for a bioterrorist 

attack. In this report GAO provides information on state and local 

preparedness and state and local concerns regarding the federal role in 

funding and improving preparedness. To gather this information, GAO 

visited seven cities and their respective state governments, reviewed 

documents, and interviewed officials. Cities are not identified because 

of the sensitive nature of this issue.



What GAO Found



State and local officials reported varying levels of preparedness to 

respond to a bioterrorist attack. Officials reported deficiencies in 

capacity, communication, and coordination elements essential to 

preparedness and response, such as workforce shortages, inadequacies in 

disease surveillance and laboratory systems, and a lack of regional 

coordination and compatible communications systems. 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. Cities with more experience in dealing with 

public health emergencies were generally better prepared for a 

bioterrorist attack than other cities, although deficiencies remain in 

every city.



State and local officials reported a lack of adequate guidance from the 

federal government on what it means to be prepared for bioterrorism. 

They said they needed specific standards (such as how large an area a 

response team should be responsible for) to indicate what they should 

be doing to be adequately prepared. The need for federal guidance has 

continued to be an issue as states have proceeded in their planning and 

preparedness activities with funding from HHS. For example, in their 

progress reports to HHS in late 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 of diseases until it 

receives more guidance.



State officials also expressed a desire for more sharing of best 

practices. Officials stated that, while 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 stated that HHS was 

better positioned to know about different strategies that states were 

pursuing and they want information on the best practices.



What GAO Recommends:



GAO recommends that the Department of Health and Human Services (HHS), 

in consultation with the Department of Homeland Security, 

* develop specific benchmarks that define adequate preparedness for a 

bioterrorist attack and can be used by jurisdictions to guide their 

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.



[End of section]



Contents:



Letter:



Results in Brief:



Background:



State and Local Officials Reported Varying Levels of Bioterrorism 

Preparedness:



State and Local Jurisdictions and Response Organizations Made Progress 

in Developing Preparedness Plans, but Regional Plans Remained 

Undeveloped:



State and Local Officials Expressed Concerns regarding Federal Funding 

and Lack of Guidance:



Conclusions:



Recommendations for Executive Action:



Agency Comments:



Appendix I: Bioterrorism Preparedness in Seven Case Cities:



Appendix II: Scope and Methodology:



Appendix III: Comments from the Department of Health and 

Human Services:



Appendix IV: GAO Contact and Staff Acknowledgments:



GAO Contact:



Acknowledgments:



Related GAO Products:



Table:



Table 1: Bioterrorism Preparedness Elements for the Seven Cities We 

Visited, December 2001 through March 2002:



Figure:



Figure 1: Local, State, and Federal Entities Involved in Response to 

the Covert Release of a Biological Agent:



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:



This is a work of the U.S. Government and is not subject to copyright 

protection in the United States. It may be reproduced and distributed 

in its entirety without further permission from GAO. It may contain 

copyrighted graphics, images or other materials. Permission from the 

copyright holder may be necessary should you wish to reproduce 

copyrighted materials separately from GAO’s product.



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 

bioterrorism[Footnote 1] 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 organizations[Footnote 2] 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 appropriate infrastructure,[Footnote 3] including disease 

surveillance systems,[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 7]



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.[Footnote 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.[Footnote 9] We 

have previously reported on activities by federal agencies to prepare 

for and respond to a bioterrorist attack.[Footnote 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 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,[Footnote 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.



Results in Brief:



Officials in the states and cities we visited reported varying levels 

of 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. 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 

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.



Background:



Initial response to a public health emergency of any type, including a 

bioterrorist attack, is generally a local responsibility that could 

involve multiple jurisdictions in a region, with states providing 

additional support when needed. 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 Incident:



Response to a release of a biological agent, whether covert or overt, 

would generally begin at the local level, with the federal government 

becoming involved as needed.[Footnote 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 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.



Figure 1: Local, State, and Federal Entities Involved in Response to 

the Covert Release of a Biological Agent:



[See PDF for image]



[A] Health care providers can also contact state entities directly.



[B] Federal departments and agencies can also respond directly to local 

and state entities.



[C] The Strategic National Stockpile, formerly the National 

Pharmaceutical Stockpile, is a repository of pharmaceuticals, 

antidotes, and medical supplies that can be delivered to the site of a 

biological (or other) attack.



[End of figure]



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 

laboratorians[Footnote 13] to test for identification of illnesses. 

Epidemiologists[Footnote 14] 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 laboratory[Footnote 15] 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 Local Bioterrorism Preparedness:



Prior to January 2002, HHS distributed funds for bioterrorism 

preparedness through two main programs. From 1999 to through 2001 it 

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 Metropolitan Medical Response System (MMRS)[Footnote 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.[Footnote 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.[Footnote 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 [Footnote 19] applied for and received funding through 

these cooperative agreements.[Footnote 20] The noncompetitive 

cooperative agreements provide that CDC and HRSA funds must be used to 

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,[Footnote 21] and 

supporting bioterrorism-related research at the National Institutes of 

Health’s National Institute of Allergy and Infectious 

Diseases.[Footnote 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.[Footnote 23],[Footnote 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 respond to 

bioterrorist attacks.[Footnote 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.[Footnote 26] The remaining funds that were allocated for state 

and local preparedness in January 2002 supported OER’s MMRS 

program.[Footnote 27]



State and Local Officials Reported Varying Levels of Bioterrorism 

Preparedness:



State and local officials reported varying levels of preparedness to 

respond to a bioterrorist attack. They recognized deficiencies in 

preparedness and were beginning to address them. We found that the 

states and cities we visited were making greater progress in certain 

elements of preparedness 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. 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 Elements of Preparedness Related to Coordination 

and Communication:



The cities we visited generally made greater progress in coordination 

and communication preparedness than in other elements of preparedness. 

Coordination efforts where progress was made included participation by 

relevant government and private sector officials in meetings to discuss 

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 

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 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.[Footnote 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.



Progress in Improving Preparedness Capacity Lagged:



In contrast to the improvements made in coordination and communication, 

progress related to the response capacity of the 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 the necessary skills will 

take time and require a strategy for building the needed 

workforce.[Footnote 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 veterinarians[Footnote 30] 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 Laboratory Facilities:



State and local officials for the cities we visited recognized and were 

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 

system[Footnote 31] to detect infectious disease outbreaks.[Footnote 

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 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.[Footnote 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.[Footnote 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 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.[Footnote 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.[Footnote 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.[Footnote 

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 public health 

laboratories to Biosafety Level 3 laboratories,[Footnote 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 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,[Footnote 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 Varied across Cities We Visited:



We found that the overall level of bioterrorism preparedness varied by 

city. In the cities we visited, we observed that those cities that had 

recurring experience with public health emergencies, including those 

resulting from natural disasters, or with preparation for National 

Security Special Events, such as political conventions,[Footnote 40] 

were generally more 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.[Footnote 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 

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),[Footnote 42] and all county emergency 

management agencies in the state were linked. 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 Developing Preparedness Plans, but Regional Plans Remained 

Undeveloped:



State and local jurisdictions and response organizations made progress 

in developing plans to improve their preparedness. They had begun to 

include bioterrorism in their agencies’ overall emergency operation 

plans, and preparing the application plans for HHS funding helped 

states focus their planning efforts. In addition, hospitals, which were 

beginning to be seen as part of a local response system, were starting 

to participate in local response planning. While progress was made in 

local planning, regional planning between states lagged. A regional 

response to a bioterrorist attack would potentially require the mutual 

participation of officials from neighboring states or, in several 

instances, a neighboring country, yet some states lacked such 

coordination with their neighboring states and country and had not 

participated in joint response planning.



State and Local Jurisdictions Had Increased Bioterrorism Planning 

Efforts:



At the time of our site visits, although most of the cities and states 

we visited had emergency operation plans, many of these plans did not 

specifically address the unique requirements of response to a 

bioterrorist attack. However, many of the response organizations in 

these cities and 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 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 to Recognize Need for Inclusion in Local 

Planning:



At the time of our site visits, we found that hospitals were beginning 

to coordinate with other local response organizations and collaborate 

with each other in local planning efforts. Hospital officials in one 

city we visited told us that until September 11, 2001, hospitals were 

not seen as part of a response to a terrorist event but that 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.



Regional Planning Was Lacking between States:



Response organization officials were concerned about a lack of planning 

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.



State and Local Officials Expressed Concerns regarding Federal Funding 

and Lack of Guidance:



State and local officials and hospital officials expressed concerns 

about the distribution and sustainability of federal bioterrorism 

preparedness 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 disagreed about whether federal funding for 

bioterrorism preparedness should flow through the state or go directly 

to the local jurisdictions. Hospital officials reported that federal 

funding from OER’s MMRS 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 Related to Distribution and Sustainability:



State and local officials expressed several concerns regarding the 

federal funding provided for state and local bioterrorism preparedness 

both 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.



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.[Footnote 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.[Footnote 44] 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,[Footnote 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.[Footnote 46] We 

have noted previously that federal, state, and local governments have a 

shared responsibility in preparing for terrorist attacks and other 

disasters.[Footnote 47] However, prior to the infusion of federal 

funds, few states were investing in their public health infrastructure.



State and Local Officials Requested Specific Federal Benchmarks for 

Adequate Preparedness and Sharing of Best Practices:



Officials we spoke with at both the state and the local levels 

requested more federal guidance and sharing of best practices to assist 

them in closing the remaining gaps in preparedness. Officials from 

response organizations in every state we visited reported a lack of 

guidance from the federal government on what it means to be prepared 

for bioterrorism. 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 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,[Footnote 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.[Footnote 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. 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 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.



Conclusions:



As concerns about bioterrorism and other public health emergencies, 

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 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.



Recommendations for Executive Action:



To help state and local jurisdictions better prepare for a bioterrorist 

attack, we recommend that the Secretary of Health and Human Services, 

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.



Agency Comments:



We provided a draft of this report to HHS and the Department of 

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 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:



Signed by Janet Heinrich:



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:



[End of section]



Appendix I: Bioterrorism Preparedness in 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:



Context:



City population; City A: Under 300,000; City B: 300,000-1,000,000; City 

C: Over 1,000,000; City D: 300,000-1,000,000; City E: Over 1,000,000; 

City F: 300,000-1,000,000; City G: Under 300,000.



State has a foreign border; City A: Yes; City B: No; City C: No; City 

D: Yes; City E: Yes; City F: No; City G: No.



Metropolitan area has a port; City A: Yes; City B: Yes; City C: Yes; 

City D: Yes; City E: Yes; City F: No; City G: Yes.



City had received funding from the Metropolitan Medical Response System 

(MMRS)[A] program; City A: No; City B: Yes; City C: Yes; City D: Yes; 

City E: Yes; City F: Yes; City G: Yes.



City had responded to suspected anthrax incidents, other public health 

emergencies, or both within previous 5 years; City A: Yes; City B: Yes; 

City C: Yes; City D: Yes; City E: Yes; City F: Yes; City G: Yes.



City prepared and hosted a National Security Special Event[B] within 

previous 5 years; City A: No; City B: No; City C: Yes; City D: Yes; 

City E: Yes; City F: No; City G: No.



Disease surveillance, follow-up, and agent identification:



Statewide passive disease surveillance system[C]; City A: Yes; City B: 

Yes; City C: Yes; City D: Yes; City E: Yes; City F: Yes; City G: Yes.



Statewide active disease surveillance system[D]; City A: Yes; City B: 

Yes; City C: No; City D: No; City E: Yes; City F: No; City G: Yes.



Local active disease surveillance system[D]; City A: No; City B: No[E]; 

City C: No[E]; City D: Yes; City E: Yes; City F: No; City G: No.



One or more epidemiologists in local public health agency; City A: No; 

City B: Yes; City C: Yes; City D: Yes; City E: Yes; City F: Yes; City 

G: Yes.



One or more epidemiologists in state public health agency; City A: Yes; 

City B: Yes; City C: Yes; City D: Yes; City E: Yes; City F: Yes; City 

G: Yes.



One or more Biosafety Level 3 laboratories in the state[F]; City A: 

Yes; City B: Yes; City C: Yes; City D: Yes; City E: Yes; City F: Yes; 

City G: Yes.



Treatment capacity:



Drug stockpile maintained by city[G]; City A: No; City B: Yes; City C: 

Yes; City D: Yes; City E: Yes; City F: No; City G: Yes.



Drug stockpile maintained by hospital[H]; City A: Yes; City B: Yes; 

City C: Yes; City D: Yes; City E: Yes; City F: No; City G: Yes.



Hospital had sufficient bioterrorism response training, per self-

report; City A: No; City B: No; City C: No; City D: No; City E: No; 

City F: No; City G: No.



Hospital had sufficient equipment for bioterrorism response, per self-

report[I]; City A: No; City B: No; City C: No; City D: No; City E: No; 

City F: No; City G: No.



Responder communications:



Communications between emergency responders had been effective during 

public health emergencies, per self-report; City A: No; City B: No; 

City C: No; City D: No; City E: Yes; City F: No; City G: No.



City had compatible radio system; City A: Yes; City B: Yes; City C: 

Yes; City D: Yes; City E: Yes; City F: No; City G: Yes.



State public health resources:



State had a plan for using the Strategic National Stockpile; City A: 

Yes[J]; City B: Yes[J]; City C: Yes; City D: Yes; City E: Yes[J]; City 

F: Yes; City G: Yes[J].



State public health office used Health Alert Network (HAN)[K]; City A: 

No; City B: Yes; City C: No; City D: Yes; City E: Yes; City F: No; City 

G: Yes.



Local public health office used HAN[K]; City A: No; City B: Yes; City 

C: No; City D: Yes; City E: Yes; City F: No; City G: Yes.



Cooperation among responders:



Written agreements exist to cooperate with neighboring state(s); City 

A: Yes; City B: No; City C: Yes; City D: No; City E: No; City F: Yes; 

City G: No.



Coordination with neighboring country; City A: No; City B: NA[L]; City 

C: NA[L]; City D: Yes; City E: No; City F: NA[L]; City G: NA[L].



Local officials had developed a system for triaging samples prior to 

the 2001 anthrax incidents; City A: No; City B: No; City C: No; City D: 

No; City E: Yes[M]; City F: No; City G: No.



Source: GAO.



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.



[End of table]



[End of section]



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.



We reviewed reports from the Advisory Panel to Assess Domestic Response 

Capabilities for Terrorism Involving Weapons of Mass 

Destruction[Footnote 50] 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.[Footnote 51] 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.



[End of section]



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



MAR 27 2003:



Ms. Janet Heinrich:



Director, Health Care - Public Health Issues United States General:



Accounting Office Washington, D.C. 20548:



Dear Ms. Heinrich:



Enclosed are the department’s comments on your draft report entitled, 

“Bioterrorism: Preparedness Varied across State and Local 

Jurisdictions.” The comments represent the tentative position of the 

department and are subject to reevaluation when the final version of 

this report is received.



The department also provided several technical comments directly to 

your staff.



The department appreciates the opportunity to comment on this draft 

report before its publication.



Sincerely,



Dennis J. Duquette:



Acting Principal Deputy Inspector General:



Signed by Dennis J. Duquette:



Enclosure:



The Office of Inspector General (OIG) is transmitting the department’s 

response to this draft report in our capacity as the department’s 

designated focal point and coordinator for General Accounting Office 

reports. The OIG has not conducted an independent assessment of these 

comments and therefore expresses no opinion on them.



Comments of the Department of Health and Human Services on the General 

Accounting Office’s Draft Report, “Bioterrorism: Preparedness 

Varied across State and Local Jurisdictions” (GAO-03-373):





General Comments:



The Department of Health and Human Services (department) appreciates 

the opportunity to review and comment on the draft report of the 

General Accounting Office (GAO) entitled Bioterrorism: Preparedness 

Varied Across State and Local Jurisdictions. The department commends 

the GAO for an informative assessment of preparedness for bioterrorism 

and other public health emergencies at the state and local levels. The 

GAO’s findings for the seven cities and states probably are 

representative to a considerable extent of the situation across the 

country at that time. Having said that, the department would like to 

reinforce the point made in the report that changes have continued to 

take place since the GAO site visits and this report does not reflect 

all such changes. Indeed, it has been a year since the completion of 

the GAO site visits and, in that period of time, both state and local 

health departments have made further strides in their efforts to 

achieve preparedness for bioterrorism and other public health 

emergencies.



GAO Recommendations for Executive Action:



To help state and local jurisdictions better prepare for a bioterrorist 

attack, we recommend that the Secretary of Health and Human Services, 

in consultation with the Secretary of Homeland Security:



* develop specific benchmarks that define adequate preparedness for a 

bioterrorist attack and which can be used by state and local 

jurisdictions to assess and guide their preparedness efforts,



* 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.



Department Response:



The department would like to respond to some of the principal findings 

in the report and provide additional information on measures it is 

taking to address the concerns identified by GAO.



Regional Planning. We recognize that since public health emergencies, 

including bioterrorist attacks, do not respect geopolitical lines, 

preparedness planning and implementation must be carried out on a 

regional basis (regions defined to include geographical areas that 

cover not only multiple counties within a state but also those 

involving two or more states and those that cross international 

borders). To that end, the guidances to be issued this year by both the 

Centers for Disease Control and Prevention (CDC) and the Health 

Resources and Services Administration (HRSA) will reinforce our 

emphasis on coordination of planning on a regional level.



Workforce Shortages. This is a concern we are addressing through 

several different mechanisms. Both the CDC and HRSA guidances this year 

will continue to focus on the education and training needed to prepare 

for and respond to bioterrorism and other public health emergencies. 

For state and local health departments that do not have sufficient 

fiscal resources at this time for hiring, an effort is being made to 

advance necessary funding from the CDC and HRSA FY 2003 cooperative 

agreements to meet this need as well as others that may be creating 

impediments to achieving state and local public health emergency 

preparedness.



This year HRSA is also mounting a new $28 million initiative on 

continuing education and curriculum development for clinical providers 

who may be involved in the triage, diagnosis, treatment or definitive 

care of terrorist victims. With respect to the longer term challenge of 

creating an adequate public health workforce, we have already awarded a 

cooperative agreement to the Association of Schools of Public Health 

with the intent of having 19 Schools of Public Health develop and 

implement a curriculum to train personnel specifically in the array of 

skills needed by state and local health departments to respond to 

bioterrorism and other public health emergencies.



Laboratory Capacity. Laboratories play a critical role in the detection 

and diagnosis of illnesses resulting from exposure to either biological 

or chemical agents. No therapy or prophylaxis can be initiated without 

laboratory identification and confirmation of the agent in question. 

Therefore, discussion of state and local efforts in laboratory capacity 

building should not be consolidated with discussion of surveillance 

activities. We recommend that these two topics each be accorded its own 

section in the report.



Specific Benchmarks and Detailed Guidance. In response to the concern 

articulated by various state and local health departments that they 

need more specific benchmarks and more detailed guidance, we are in 

fact including a larger number of specific benchmarks in this year’s 

guidance. Furthermore, both CDC and HRSA will be developing additional 

guidelines as well as templates that will be shared with all awardee 

jurisdictions. Every effort will be made to ensure that these 

guidelines will allow states to better assess their progress toward 

achieving an adequate level of preparedness and to determine when they 

have achieved that level.



Sharing ofBest Practices. This is a goal that we strongly endorse. In 

fact, the Office of the Assistant Secretary for Public Health Emergency 

Preparedness, working closely with CDC and HRSA, will be leading an 

effort to create a repository of “best practices,” that could include, 

but not be limited to readiness assessment, 24/7 disease reporting, 

laboratory proficiency testing, risk communication or Information 

Technology interoperability. Such “best practices” will be identified, 

validated and then shared with state and local health departments. This 

project will reduce the duplication of time, effort and resources that 

take place when each jurisdiction tries to “reinvent the wheel.” We 

intend to initiate this project by no later than early summer.



Last year at its first annual meeting with recipients of its 

cooperative agreements, HRSA highlighted a number of best practices in 

areas that would be beneficial to state health departments attempting 

to address hospital preparedness. As HRSA begins to plan for this 

year’s annual meeting of its grantees, the sharing of best practices 

will be considered a high priority agenda item.



On a related effort, HRSA will be publishing very shortly a Federal 

Register Notice announcing an initiative that will provide funding to 

relevant national professional organizations to collaborate on the 

development of core competencies essential for hospital leadership and 

for clinical care to be provided by hospital-based personnel in 

bioterrorism, radiological, or chemical disasters.



Thank you for a valuable report. It adds to and reinforces what we 

already know about the activities/concerns of state and local health 

departments as they go about preparing for and responding to 

bioterrorism and other public health emergencies.



[End of section]



Appendix IV: GAO Contact and Staff Acknowledgments:



GAO Contact:



Marcia Crosse, (202) 512-7119:



Acknowledgments:



In addition to the contact named above, George Bogart, Barbara Chapman, 

Robert Copeland, Deborah Miller, and Roseanne Price made key 

contributions to this report.



[End of section]



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.



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.



[End of section]



FOOTNOTES



[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. 



[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).



[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.



[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).



[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.



[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.



[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.



[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.



[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.



[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.



[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.



[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).



[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. 



[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.



[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/HospitalReady.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.



[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.



[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.



[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.



[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).



[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).



[50] 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).



[51] 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).



GAO’s Mission:



The General Accounting Office, the investigative arm of Congress, 

exists to support Congress in meeting its constitutional 

responsibilities and to help improve the performance and accountability 

of the federal government for the American people. GAO examines the use 

of public funds; evaluates federal programs and policies; and provides 

analyses, recommendations, and other assistance to help Congress make 

informed oversight, policy, and funding decisions. GAO’s commitment to 

good government is reflected in its core values of accountability, 

integrity, and reliability.



Obtaining Copies of GAO Reports and Testimony:



The fastest and easiest way to obtain copies of GAO documents at no 

cost is through the Internet. GAO’s Web site ( www.gao.gov ) contains 

abstracts and full-text files of current reports and testimony and an 

expanding archive of older products. The Web site features a search 

engine to help you locate documents using key words and phrases. You 

can print these documents in their entirety, including charts and other 

graphics.



Each day, GAO issues a list of newly released reports, testimony, and 

correspondence. GAO posts this list, known as “Today’s Reports,” on its 

Web site daily. The list contains links to the full-text document 

files. To have GAO e-mail this list to you every afternoon, go to 

www.gao.gov and select “Subscribe to daily E-mail alert for newly 

released products” under the GAO Reports heading.



Order by Mail or Phone:



The first copy of each printed report is free. Additional copies are $2 

each. A check or money order should be made out to the Superintendent 

of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 

more copies mailed to a single address are discounted 25 percent. 

Orders should be sent to:



U.S. General Accounting Office



441 G Street NW,



Room LM Washington,



D.C. 20548:



To order by Phone: 	



	Voice: (202) 512-6000:



	TDD: (202) 512-2537:



	Fax: (202) 512-6061:



To Report Fraud, Waste, and Abuse in Federal Programs:



Contact:



Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov



Automated answering system: (800) 424-5454 or (202) 512-7470:



Public Affairs:



Jeff Nelligan, managing director, NelliganJ@gao.gov (202) 512-4800 U.S.



General Accounting Office, 441 G Street NW, Room 7149 Washington, D.C.



20548: