Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
State and Local Bioterrorism Preparedness 
JANET REHNQUIST 
INSPECTOR GENERAL 
DECEMBER 2002 
OEI-02-01-00550  O I G
FFICE OF  NSPECTOR  ENERAL

http://www.oig.hhs.gov/ 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, 
is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as 
the health and welfare of beneficiaries served by those programs.  This statutory mission is carried out 
through a nationwide network of audits, investigations, and inspections conducted by the following 
operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of HHS programs and operations in 
order to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout the 
Department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and the 
public.  The findings and recommendations contained in the inspections reports generate rapid, accurate, 
and up-to-date information on the efficiency, vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigative efforts of OI lead to criminal convictions, administrative sanctions, or civil 
monetary penalties.  The OI also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support in OIGs internal 
operations.  The OCIG imposes program exclusions and civil monetary penalties on health care providers 
and litigates those actions within the Department.  The OCIG also represents OIG in the global settlement 
of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops model compliance plans, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  E X E C U T I V E  S U M M A R Y  
PURPOSE 
To assess State and local health departments capacity to detect and respond to a bioterrorism 
event. 
BACKGROUND 
The Centers for Disease Control and Prevention (CDC) has funded State bioterrorism 
preparedness efforts through cooperative agreements since 1999. More recently, it has 
worked with State and local health departments to develop performance guidance, called the 
Core Capacity Project, for bioterrorism preparedness. The CDC asked the Office of 
Inspector General (OIG) to assess State and local health departments bioterrorism detection 
and response capacity using these core capacities, which are performance measures for 
preparedness. 
Although this inspection was initiated prior to the terrorism events of 2001, the data collection 
was conducted in the wake of those events. When we met with State and local health 
departments in December 2001 and January 2002, many jurisdictions were in the process of 
re-evaluating and upgrading their bioterrorism programs. 
In conducting this inspection, we selected a purposive sample of 12 States and 36 local health 
departments (3 within each State).  Using the core capacities as benchmarks, we assessed each 
health departments preparedness. 
FINDINGS 
The State and local public health infrastructure is under-prepared to detect and 
respond to bioterrorism 
The capacity of a State, county, or city to detect and respond to bioterrorism depends both on 
the strength of its public health infrastructure and on the ability of its public health department to 
work with emergency response partners. Our review of 12 State and 36 local health 
departments identified vulnerabilities in their infrastructure that leave them not fully prepared for 
a bioterrorism event. 
Surveillance and epidemiologic investigation.  State and local health departments rely on 
surveillance systems and epidemiologic investigations to detect and define bioterrorism events. 
In 3 State and 10 local health departments, communicable disease reports used for surveillance 
are not always submitted timely or consistently by providers.  Further, 9 State and 26 local 
health departments do not fully validate the reports they 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  receive and only 4 State and 17 local health departments say they have an active surveillance 
system in addition to disease reporting. In addition, 3 State and 15 local health departments 
lack the specialized staff and technology they would need to support epidemiologic 
investigations during an event; 17 local health departments do not have an epidemiologist on 
staff. 
Identification. States also rely on laboratory testing to detect and define the scope of 
bioterrorism events. The Laboratory Response Network is designed to link local level A 
clinical labs with level B labs and the States level C public health lab.  However, it is not fully 
implemented.  Five of 12 States have an incomplete list of level A laboratories, and 7 State 
laboratories lack support from external level B or C laboratories. In three-quarters of our 
sample States, at least one respondent reports that their State laboratory was overwhelmed by 
the many tests requested during recent, relatively small, anthrax events. 
Communication.  Responding to a bioterrorism event requires communicating with response 
partners. Five State and 17 local health departments have questionable capacity to 
communicate on a 24 hour, 7 day a week basis. Also, 9 State and 24 local health departments 
do not have complete risk communication plans. 
Mobilization. Response also involves the mobilization of personnel and supplies. One quarter 
of State and local health departments acknowledge that they lack the equipment, supplies, 
and/or trained staff to independently respond to large-scale bioterrorism events. They say they 
will be dependent on the community, the State, and the National Pharmaceutical Stockpile. 
However, 5 State and 20 local health departments do not have complete plans for receipt and 
deployment of the Stockpile.  Further, 4 State and 21 local health departments have not tested 
their response protocols. 
Public health interventions . Lastly, responding to bioterrorism requires implementing public 
health interventions. Four State and 14 local health departments report that they do not have all 
the laws, rules, and regulations they may need to fully activate and enforce public health 
interventions that are necessary to control a disease outbreak. These interventions include 
quarantine, seizure of property, and restriction of travel. 
In response to recent terrorism events, virtually all public health departments are 
strengthening their bioterrorism preparedness programs 
Recent events have heightened awareness around bioterrorism preparedness.  All State and 32 
local health departments we visited have written or are writing a bioterrorism response plan. 
They have also integrated their preparedness activities with response partners in the community. 
Seven State and ten local health departments say they have received more decision-maker 
support for their bioterrorism programs since the events. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  Recent funding provides an opportunity to strengthen public health 
infrastructure, but concerns remain 
Since February 2002, CDC funding for bioterrorism preparedness increased from $66.7 million 
to $918 million, and the Health Resources and Services Administration (HRSA) implemented a 
new $125 million program for hospital bioterrorism preparedness. Written guidance for these 
programs appears to address many of the vulnerabilities noted above.  However, some issues 
remain unaddressed.  Program guidance gives little or no support for addressing the mental 
health needs of first responders, victims and their families, and anxious members of the public, 
such as those seeking unnecessary medical attention. Further, some health departments raise 
concern about tactical decisions related to response, such as who receives limited equipment 
and supplies and whether or not first responders should be immunized. Some States also stress 
the need for sustained Federal funding to develop and maintain the public health infrastructure. 
CONCLUSION 
The findings in this report show that our public health infrastructure has left us under-prepared 
to detect and respond to bioterrorism.  Not all State and local health departments have 
sufficient staff, surveillance systems, technology, or laboratory capacity to quickly and 
accurately identify an attack.  Some also lack the plans, partnerships, or authorities to 
adequately respond. Since the anthrax attacks in the Fall of 2001, health departments have 
started to reassess their preparedness and the Federal government has substantially increased 
funding to rebuild public health infrastructures. Based on these findings, we conclude that 
further work is needed at the Federal, State, and local levels to ensure that our countrys public 
health system is fully prepared to respond to bioterrorism. 
RECOMMENDATIONS 
First and foremost, CDC should develop a monitoring system to ensure that the 
bioterrorism preparedness funds are being used as intended. In 2002, State and local 
health departments will receive $918 million in cooperative agreement funds to bolster the 
public health infrastructure and improve their capacity to detect and respond to bioterrorism. 
Each of these cooperative agreements outlines a plan for reaching these goals. It is essential 
that CDC closely monitor the progress of State and local health departments in accomplishing 
the goals set forth in these plans. 
The Assistant Secretary for Public Health Emergency Preparedness should work with 
States to develop strategies that sustain the public health infrastructure subsequent to 
the current influx of Federal funding. Although there will be a significant increase in Federal 
support to States, it is essential that infrastructure improvements be maintained in order to 
protect our nation from the effects of future bioterrorism attacks. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  The CDC and the Substance Abuse and Mental Health Services Administration should 
work together to address community mental health needs in its future guidance to 
States. Our review of CDCs new program guidance reveals that it does not fully address the 
mental health components of bioterrorism preparedness. Should a bioterrorism event occur, 
first responders, victims and their families, and anxious members of the public would likely have 
significant mental health needs. 
The CDC should work with States to help them address tactical decisions related to 
bioterrorism response. Respondents raise several of these issues, such as deciding which 
patients would receive limited treatment and immunizing first responders. The CDC should 
provide technical assistance to States to support them in discussing and planning to deal with 
these, and potentially other, tactical decisions. 
AGENCY COMMENT 
The Assistant Secretary for Public Health Emergency Preparedness (ASPHEP), who directs 
and coordinates the HHS activities related to bioterrorism and other public health emergencies, 
commented on the draft report on behalf of the pertinent HHS agencies and offices. In general, 
the ASPHEP concurs with our recommendations. It notes that financial and program 
monitoring systems are being developed for the cooperative agreements. The ASPHEP also 
notes that CDC will include mental health needs in future guidance, as well as provide technical 
assistance to States.  Appendix B contains the full text of the comment. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  T A B L E  O F  C O N T E N T S  
PAGE

EXECUTIVE SUMMARY  .................................................. i

INTRODUCTION ..........................................................  1

FINDINGS 
Public health infrastructure is under-prepared  ....................................8

Virtually all public health departments are strengthening preparedness  ................. 14

Recent funding provides opportunity, but concerns remain .......................... 15

CONCLUSION ...........................................................  17

RECOMMENDATIONS ...................................................  18

APPENDIX 
Appendix A: 2002 Guidance Addresses Key Vulnerabilities .......................19

Appendix B:  Agency Comment  ...........................................21

ACKNOWLEDGMENTS ..................................................  24

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State and Local Bioterrorism Preparedness  OEI-02-01-00550  I N T R O D U C T I O N  
PURPOSE 
To assess State and local health departments capacity to detect and respond to a bioterrorism 
event. 
BACKGROUND 
The Centers for Disease Control and Prevention (CDC) asked the Office of Inspector General 
(OIG) to assess State and local health departments bioterrorism preparedness.  At that time, 
CDC was funding State and local health departments through their Bioterrorism Preparedness 
and Response Cooperative Agreement Program and was participating in the Bioterrorism 
Preparedness and Response Core Capacity Project 2001.  The CDC made this request prior 
to recent terrorism events. 
Bioterrorism 
The anthrax events of 2001 highlighted the important role the public health system plays in 
responding to bioterrorism, that is, the deliberate release of a biological disease agent for the 
purpose of killing or harming people.  Unlike traditional terrorist attacks, a biological attack can 
be covert and, therefore, unnoticed for days, even weeks. The first responders will be health 
care providers and the public health system, not traditional emergency personnel. The recent 
anthrax events caused 18 people to contract the disease, 5 of whom died.  The consequences 
of any future bioterrorism events could be far more widespread, resulting in life-threatening 
illness on a large-scale that could overwhelm the capacity of the current public health system. 
It is the responsibility of State and local health departments to identify and to prepare their 
communities to respond to a bioterrorism event.  They are reliant on both their partnership with 
each other, as well as their partnerships with other government and private entities. In fact, the 
National Association of County and City Health Officials (NACCHO) asserts that, at the local 
level, public health is reliant on the shared responsibility of many entities, organizations, and 
interests in the community. These relationships become especially important during a 
bioterrorism event because public health departments are reliant on assistance from emergency 
response partners to effectively respond. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  The Departments Role in Bioterrorism Preparedness 
The Department of Health and Human Services (HHS) has several agencies involved in 
bioterrorism preparedness. However, the CDC, the Health Resources and Services 
Administration (HRSA), and the Office of Emergency Response (OER), formerly the Office of 
Emergency Preparedness, in the Office of the Assistant Secretary for Public Health Emergency 
Preparedness (ASPHEP) have the primary responsibility to support State and local 
preparedness efforts.  In addition, the newly created ASPHEP directs the Departments efforts 
to prepare for, protect against, respond to, and recover from all acts of bioterrorism and other 
public health emergencies that effect the civilian population. It also serves as the focal point 
within the HHS for these activities. 
The CDC is leading the effort to ensure the public health infrastructure is fully prepared to 
respond to bioterrorism. More specifically, it is leading several bioterrorism preparedness 
initiatives, including the State and Local Bioterrorism Preparedness and Response Cooperative 
Agreement Program, the National Pharmaceutical Stockpile, the Health Alert Network, the 
Laboratory Response Network, and the Bioterrorism Core Capacity Project. 
The HRSA began funding State health departments to improve their bioterrorism hospital 
preparedness programs in February 2002. The purpose of this cooperative agreement 
program is for States to upgrade hospital preparedness by identifying and implementing 
preparedness plans for hospitals. The cooperative agreements are available to all 50 States, 
the District of Columbia, New York City, Los Angeles County, Chicago, and the territories. 
The OER is responsible for managing the medical and public health consequences during public 
health emergencies, including bioterrorism. Specifically, the OER provides start-up funds for a 
planning process, basic equipment, and a pharmaceutical cache for local and regional 
emergency response systems through the Metropolitan Medical Response System Program 
(MMRS) to improve our largest metropolitan areas capacities to provide integrated, unified 
response to a mass casualty event, including bioterrorism. There are currently 122 
municipalities receiving MMRS funding. 
CDCs Role in Bioterrorism Preparedness 
Bioterrorism Preparedness and Response Cooperative Agreement Program. One of 
the primary initiatives CDC has undertaken to improve the public health infrastructures ability 
to respond to bioterrorism is the Bioterrorism Preparedness and Response Program. This 
program, directed by the Office of Terrorism Preparedness and Response, is a cooperative 
agreement program between CDC and each of the 50 States plus the District of Columbia, 
New York City, Los Angeles, Chicago, and the territories.  It is intended to upgrade State and 
local health department preparedness and response 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  capabilities relative to bioterrorism.  The program started in 1999, but all of the States did not 
begin participating until 2001. The awards totaled $66.7 million in FY 2001 and increased to 
$918 million in FY 2002. In addition to the funds, CDC provides ongoing technical assistance 
and planning guidance. 
The cooperative agreements are divided into seven focus areas. Areas A through E have been 
funded since 1999, but few awardees received funding in all five areas until 2002. Focus areas 
F and G are new in 2002. The seven areas are: 
A. 	 Preparedness Planning and Readiness Assessment funds the development and 
implementation of State-specific plans to address public health issues following a 
biologic or chemical terrorist attack. 
B. 	 Surveillance and Epidemiology Capacity enables States to enhance, design, or 
develop systems to rapidly detect unusual disease outbreaks. 
C. 	 Laboratory Capacity - Biologic Agents enables State and a few city public health 
laboratories to have the core diagnostic capabilities for bioterrorism agents. 
D. 	 Laboratory Capacity - Chemical Agents enables States to acquire and maintain 
state-of-the-art diagnostic capabilities for chemical agents. 
E. 	 Health Alert Network/Communications and Information Technology assists 
States and local health departments to develop a communication network (internet or 
fax) that will be used to broadcast and receive key information, such as public health 
alerts and distance-learning offerings. Further, it is intended to ensure electronic data 
exchange and the protection of data, information, and systems. 
F. 	 Communicating Health Risks and Health Information Dissemination ensures 
that State and local public health organizations develop an effective risk 
communications capacity that will provide timely information to the public during a 
bioterrorism event. 
G. 	 Education and Training ensures that State and local health agencies have the capacity 
to (a) assess the training needs of key public health professionals, infectious disease 
specialists, emergency department personnel, and other health care providers related to 
preparedness for the detection of and response to bioterrorism, and (b) ensure effective 
provision of needed education and training to key target audiences. 
National Pharmaceutical Stockpile (NPS) Program. This program, run by CDCs 
National Center for Environmental Health, is a national repository of antibiotics, chemical 
antidotes, antitoxins, life-support medications, intravenous administration and airway 
maintenance supplies, and medical/surgical items.  The stockpile consists of  12-
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  hour push packages and the Vendor Managed Inventory.  The 12-hour push packages 
consist of preassembled sets of supplies, pharmaceuticals, and medical equipment ready for 
quick delivery.  The Vendor Managed Inventory consists of additional pharmaceuticals and/or 
medical supplies that can be tailored to a specific event and shipped within 24 to 36 hours. 
Health Alert Network (HAN). The Health Alert Network is a nationwide program 
established to facilitate communication, information, and distance-learning related to health 
threats, including bioterrorism. When fully established, the network, through a high-speed, 
continuous, and secure connection to the Internet, will link local health departments to one 
another as well as to other components of bioterrorism preparedness and response, such as 
laboratories and State health departments. 
Laboratory Response Network (LRN). The CDC is establishing a network that will link 
laboratories throughout the country to public health laboratories and state-of-the art facilities 
that can analyze biological agents.  The LRN divides laboratories into four levels according to 
their capacity to test biological and chemical terrorism agents. The CDC laboratory is level D, 
the highest level in the network. Next are laboratories at levels B and C with the capacity to 
test for certain biological agents, such as anthrax.  Level A will consist of local clinical 
laboratories that conduct rule-out testing and refer specimens to higher level laboratories. For 
each level, the network describes laboratory responsibilities, and outlines how to access the 
State Public Health Laboratory, CDC, and the FBI to refer or report suspected agents. 
The Bioterrorism Core Capacity Project 
In an effort to further help State and local health departments improve their public health 
systems ability to detect and respond to bioterrorism, the CDC is leading a joint local, State, 
and Federal effort called the Bioterrorism Preparedness and Response Core Capacity Project 
2001 (Core Capacity Project). The primary organizations involved are the National 
Association of County and City Health Officials (NACCHO) and the Association of State and 
Territorial Health Officials (ASTHO). The mission of the project is to develop the capacities of 
State and local public health systems to prepare for and respond to a bioterrorism event. 
During four working sessions, this group developed a document that is intended to provide 
guidance on the highest priority capacities. 
The Core Capacity Project draft document sets forth five goals for a public health system. 
These goals are as follows: 
1. Surveillance and epidemiologic investigation:  The public health system monitors 
community health status to detect the presence of critical bioterrorism agents and, through 
epidemiological investigations, characterizes the public health emergency. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  2. Identification:  The Laboratory Response Network for bioterrorism can rule-out, refer, 
identify, confirm, and characterize biological threat agents. 
3. Communication:  The public health system assures that information is collected, analyzed, 
and communicated effectively among the response community, decision-makers, and the 
general public. 
4. Mobilization: The public health system identifies, coordinates, and deploys public health 
assets to assure an effective emergency response. 
5. Public Health Interventions: The public health system implements emergency health 
measures to control and contain an outbreak. 
METHODOLOGY 
We combined three methods for this inspection, including in-person interviews, self-
administered questionnaires, and document reviews. We limited our review to 12 States in 
order to obtain detailed and comprehensive data on State and local bioterrorism programs. 
Sample 
We selected a purposive sample of 12 States and 3 local health departments in each of these 
States, for a total of 48 sites. We chose the States based on four criteria: 
1) geographic location; 2) population; 3) the amount of funding the State received from 1999 to 
2001 through CDCs Bioterrorism Preparedness and Response Cooperative Agreement 
Program (excluding funding for laboratory capacity for chemical agents); and 4) the relationship 
between the State and the local health departments (decentralized, centralized, mixed, or 
shared).  In decentralized States, the local government runs the local health department.  In 
centralized States, local health departments function directly under the States authority.  Mixed 
States have some decentralized localities and some localities are run by the State. In States 
with a shared system, State and local governments share authority over the local health 
departments. 
The three local health departments we selected in each of the States included: the one serving 
the capital city, the one serving the highest populated city (unless the capital city is the highest 
populated city; in that case we chose another populous city), and one in a suburban or rural 
area.  For the purposes of this report, we define local health department as a city, county, 
regional, or municipal level health department, even in centralized States where these agencies 
are part of the State department of health. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  State Health Department Site Visits 
We conducted an on-site interview with State health department officials in each State and 
discussed their capacity to respond to a bioterrorism event. These interviews were conducted 
during December 2001 and January 2002.  We interviewed various officials responsible for 
preparedness, such as the State epidemiologist, public health laboratory director, bioterrorism 
preparedness coordinator, the Health Alert Network director, and in some cases, staff from 
emergency response agencies. In seven States the director of the department of health was 
present. We designed the interview questionnaire based on the goals of the Core Capacity 
Projects guidance. Specifically, we reviewed each State health departments level of 
bioterrorism preparedness in the following areas: surveillance and epidemiology, identification, 
communication, mobilization, and intervention. 
Local Health Department Site Visits 
We conducted an interview with officials in each of the local health departments about their 
capacity to respond to a bioterrorism event.  All but one of these interviews were conducted 
on-site during the same week as the State health department visit.  We interviewed the officials 
responsible for the public health response to bioterrorism, which generally included the director 
of public health. We again designed the interview questionnaire based on the Core Capacity 
Projects guidance to State and local health departments. We asked about the local health 
departments capacity in each of the following areas:  surveillance and epidemiology, 
identification, communication, mobilization, and intervention. 
Core Capacity Self-Assessment 
We asked respondents at each State and local health department to complete a self-assessment 
of their bioterrorism preparedness. All 12 State and 36 local health departments responded 
between December 2001 and March 2002. The assessment was based on the most detailed 
level of the Core Capacity Projects guidance.  It asked health departments to rate their 
capacity on 277 specific tasks related to bioterrorism preparedness.  For each item, we asked 
the health departments to indicate if they had full capacity, partial capacity, or no capacity. 
(See State and Local Bioterrorism Preparedness: Report Card, OEI-02-01-00552, for more 
information on the results.) 
Review of Bioterrorism Response Plans 
We also asked each State and local health department to submit a copy of their bioterrorism 
emergency response plan, if one existed. We received and reviewed 28 plans. We assessed 
the plans overall structure and content. Specifically, we reviewed each plans organizational 
chart, response procedures, including plan activation procedures, response partner list, and 
NPS plan. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  LIMITATIONS 
There were several limitations to our methodology. First, due to health departments response 
to recent terrorism events, we evaluated a system in transition. Bioterrorism preparedness 
activities are moving swiftly and will have changed from the time of the interviews to the time 
this report is released.  Further, the recently approved increases in funding and new initiatives 
related to bioterrorism preparedness will undoubtedly change the systems we evaluated. 
Second, because we selected a purposive sample of 12 States and 36 local health departments, 
our findings cannot be projected to the entire population of States or local health departments. 
Third, we did not assess State and local health departments capacity to respond to chemical 
attacks or other forms of terrorism, nor did we look at State or local law enforcement agencies 
ability to respond to bioterrorism. Finally, the data we collected were self-reported, and we 
have not independently verified their accuracy. 
This inspection was conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  F I N D I N G S  
Our review of 12 State and 36 local health departments bioterrorism preparedness is based on 
in-depth discussions with public health officials, reviews of their emergency response plans, and 
an analysis of their comprehensive self-assessments. Our review revealed that their public 
health infrastructure is under-prepared to detect and respond to bioterrorism.  However, almost 
all health departments are currently strengthening their bioterrorism preparedness programs. 
Recent increases in HHS funding, while not addressing all concerns, do provide an opportunity 
to strengthen the public health infrastructure. These findings are evidence that further work is 
needed at the Federal, State, and local level to ensure that our countrys public health system is 
fully prepared to respond to bioterrorism. 
State and local public health infrastructure is under-prepared to 
detect and respond to bioterrorism 
The capacity of a State, county, or city to detect and respond to bioterrorism depends both on 
the strength of its public health infrastructure and on the ability of its public health department to 
work with emergency response partners. All of the health departments in our sample report 
vulnerabilities in their public health infrastructure that leave them less than fully prepared for a 
bioterrorism event. Table 1 (on the following page) lists key vulnerabilities based on the 
bioterrorism core capacities. 
The public health infrastructures capacity to detect bioterrorism is weak 
In order for a health department to effectively detect a bioterrorism event, its infrastructure must 
include a strong surveillance system that monitors community health in a timely and accurate 
manner. It must also include sufficient resources to conduct thorough epidemiologic 
investigations and a robust laboratory capacity that can test for bioterrorism agents. 
Surveillance systems are weak. We found that surveillance systems used by State and local 
health departments to identify and define the scope of bioterrorism events are often weak. 
These systems rely on data that are not always timely or submitted consistently by providers. A 
strong surveillance system is particularly important to identify a covert bioterrorism attack, as 
opposed to the announced anthrax events of 2001. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  Table 1 
Key Vulnerabilities in State and Local Bioterrorism Preparedness 
(12 State & 36 local health departments) 
Surveillance and  Surveillance systems are weak: 
Epidemiologic    3 States and 10 locals volunteer that communicable disease reports are 
Investigation  not always submitted or timely 
  9 States and 26 locals do not fully validate the completeness or 
appropriateness of surveillance data 
  Only 4 States and 17 locals have an active surveillance system, in 
addition to disease reporting 
Epidemiologic capacity is limited by lack of resources: 
  17 local health departments have no epidemiologist on staff 
  3 States and 15 locals lack adequate response staff or equipment 
  22 locals will rely on State for assistance with investigations 
Identification  Laboratory capacity is vulnerable: 
  Laboratory Response Network not fully implemented 
<  5 States have an incomplete list of level A labs 
<  No States hold regular meetings with level A labs 
<  In 7 States the State laboratories conduct all level B and C testing 
  States struggled to meet demand during recent anthrax events 
<  In 9 of 12 States respondents report State Lab was overwhelmed 
Communication  Not all necessary communication protocols are in place: 
  5 States and 17 locals do not have a complete current roster of 24-
hour contact information 
  9 States and 24 locals do not have complete risk communication plans 
Mobilization  States and locals have limited ability to mobilize response: 
  3 States and 9 locals volunteer that they have inadequate resources 
  4 States and 21 locals have done no testing of response protocols 
  5 States and 20 locals do not have complete plans for using the NPS 
Public Health  States and locals do not have all legal authority they may need: 
Interventions    4 States and 14 locals do not have all needed laws, rules, regulations 
  Only 7 States can fully activate and enforce quarantine 
  Only 5 States can fully activate and enforce the seizure of property 
  Only 6 States can fully activate and enforce the restriction of travel 
Sources: OEI State and Local Health Department Interviews, December 2001 through January 2002 and 

OEI State and Local Health Department Core Capacity Self-Assessment, December 2001 through March 2002

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State and Local Bioterrorism Preparedness  OEI-02-01-00550  While communicable disease reporting is the most common system that our sample health 
departments use to monitor community health, this system has several limitations.  In general, 
communicable disease reporting requires physicians and laboratories to report communicable 
disease cases to either the State or local health department. Although five local health 
departments use an electronic reporting system, it is more common for local health departments 
to require health care providers to call, fax, or mail their reports. Respondents in 3 States and 
10 local health departments also volunteer that disease reports are not always timely or 
submitted consistently by providers. Further, 9 State and 26 local health departments do not 
fully validate the reports they receive by periodically evaluating their completeness or 
appropriateness.  Lastly, some health departments do not appear to have adequate methods to 
analyze disease reports. In fact, several respondents told us that they only look at reports 
weekly and a few say they do not have the capacity to do any analysis.  For example, one local 
health department says they cannot do any trend analysis because they do not have access to 
historical data maintained by the State. 
Four State and 17 local health departments we visited have surveillance methods in addition to 
communicable disease reporting. The majority of these local health departments are in large 
cities and some receive special funding from CDC. Their active surveillance methods involve 
collecting and analyzing data from sources such as emergency rooms or 911 calls on a regular 
basis. For example, several health departments monitor emergency room diversions, since 
more than one emergency room reaching full capacity may indicate a problem.  One health 
department with no active surveillance reports that it is too costly to implement.  Specifically, an 
official says, We havent had the resources to develop [surveillance] algorithms or 
technologies. Active surveillance also requires the cooperation of outside entities, such as 
hospitals.  One heath department reports that the only local hospital with the ability to provide 
surveillance data refused to do so without reimbursement. 
Epidemiologic capacity is limited by lack of resources.  After identifying an unusual 
disease outbreak through surveillance, a health department must conduct epidemiologic 
investigations to determine the incidence and distribution of the outbreak.  We found that 
sample State and local health departments ability to conduct these investigations is limited. 
Many lack the specialized staff or technology they need. In fact, 3 States and 15 local health 
departments volunteer that they lack adequate staff or equipment. 
Of the 36 local health departments we visited, 17 do not have an epidemiologist on staff. 
Nearly all of the local health departments that do have their own epidemiologist serve large 
urban areas. The smaller localities that do not employ their own epidemiologist appear to be 
the most vulnerable.  They routinely rely on local public health nurses to investigate disease 
outbreaks. 
Many local health departments, even those with their own epidemiologist, say they may not 
have enough trained staff or technology to conduct increased numbers of investigations during 
an event. Seventeen say they would rely on the State to assist their own epidemiologist or 
cross-trained staff to conduct investigations. Five others say they 
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10 
State and Local Bioterrorism Preparedness  OEI-02-01-00550  would have to rely exclusively on the State to conduct investigations. A few local health 
departments say having adequate staff for data entry is also a particular concern, especially 
since specialized epidemiology software packages require specific skills. One local health 
department faced difficulty in finding enough staff to do data entry for all of their recent anthrax 
investigations.  A respondent from another local health department says, Data entry personnel 
is where we are weakest. 
Some State and local health departments have initiatives to strengthen their epidemiologic 
capacity.  In one State, they are planning an epidemiologic interview training class for their staff. 
Another local health department has developed diagnostic algorithms to assist with these 
investigations.  Further, 12 local health departments have mutual aid agreements with other 
agencies, such as local universities or other health departments, to assist with epidemiologic 
investigations during public health emergencies. 
Laboratory capacity is vulnerable. The capacity of the laboratory system that State and 
local health departments rely on to identify bioterrorism agents is limited. This was particularly 
evident when a number of States could not meet the demand for anthrax testing this past fall. 
While the CDC has outlined a Laboratory Response Network (LRN) to strengthen the nations 
ability to identify bioterrorism, it is not fully implemented.  The LRN divides laboratories into 
four levels (A, B, C, and D) according to their capacity to test bioterrorism agents. 
To begin with, not all of our sample States have identified or communicated with the level A 
laboratories in their State. These are local clinical laboratories that conduct rule-out testing and 
if necessary refer specimens to a higher level. Five States have an incomplete list of level A 
laboratories. One State respondent reports that they are still working with CDC to identify 
potential A level labs and approaching them. Another State reports, No labs are currently 
level A.  Further, States are not consistently communicating with level A laboratories.  None 
conduct regular meetings with level A laboratories and only about half offer formal training. 
One State relies on a secure website to communicate with level A laboratories about protocols. 
They report there is no assurance [level A laboratories] are complying with these protocols. 
In seven of the sample States, State laboratories do not have support from an external B or C 
level laboratory. Level B and C laboratories are generally State or city public health 
laboratories that have the capacity to test for certain bioterrorism agents, such as anthrax.  In 
the States without level B and C support, the State public health laboratory is the only 
laboratory with the ability to conduct higher level testing. For example, one respondent reports 
that the lack of a public health laboratory in a large metropolitan area greatly hampers our 
response to a bioterrorism event. A large city also says that they are completely dependent 
on the State lab.  They report difficulty adding level B laboratories to their networks.  A few 
say local private laboratories refuse to perform bioterrorism testing. For example, one 
respondent says the (private) laboratory we outsourced our other clinical lab tests to said no 
(to our request to test for bioterrorism.) 
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11 
State and Local Bioterrorism Preparedness  OEI-02-01-00550  A few others say that their laboratories are willing to upgrade to level B but have been unable 
to because of a lack of funding or reagents. 
Most States struggled to meet the demand for laboratory testing during the recent anthrax 
events and scares. In 9 of our 12 sample States, at least one respondent volunteers that the 
State laboratory was overwhelmed by the testing. In fact, three States and one large local 
health department sent anthrax specimens out of the State to be tested because of a backlog in 
their own laboratory. Further, a State respondent reports, During anthrax we were 
backlogged.  The counties wanted to send (their specimens) elsewhere.  Some health 
departments had to stop other public health testing in order to conduct their anthrax testing. A 
respondent at one State says, Right now, we do all the testing, including rule-out. We had to 
divert normal testing, such as HIV and e-coli, during the anthrax crisis.  A different State 
explains, The number of people in labs dedicated to bioterrorism is limited. Although people 
are cross-trained, it doesnt scale up rapidly. The rest of the work was put on hold. 
Several health departments we interviewed discovered other vulnerabilities in their own 
laboratory procedures while responding to the anthrax testing. First, eight local respondents 
mention that there was some confusion regarding the chain of custody of specimens. One 
respondent says, We didnt know where [the specimens] were collected from or who needed 
to be called. Second, others report experiencing delays reporting the results of anthrax testing. 
Another State says that reporting results was a concern.  Clients complained that we didnt 
contact them. Third, a few health departments mention that working with the Federal Bureau 
of Investigations (FBI) and law enforcement was not always a smooth process. One 
respondent states, The FBI was hesitant to share information, even though we were told that 
public health was the first priority. In practice, this was not the case. Lastly, several 
respondents report that the environmental samples submitted during the events needed to be 
handled differently from human specimens.  As one explains, environmental specimens require a 
higher safety level during testing and are often more difficult to label than human specimens. 
The public health systems capacity to respond to bioterrorism is limited 
Once a health department has identified a disease outbreak, it must take additional steps to 
effectively respond. Specifically, the health department must 1) continuously communicate with 
response partners and the public, 2) identify and mobilize the local, State, and national 
resources available to them, and 3) provide the public health measures necessary to control the 
spread of the disease, such as giving vaccinations. 
Not all necessary communication protocols are in place.  Although all State and local 
health departments appear to have some ability to communicate with their emergency response 
partners during a bioterrorism event, the current system is vulnerable. The majority have 
redundant communication equipment, such as radios, pagers, and cell phones that will enable 
them to communicate with response partners during an emergency.  Although all but one State 
uses the Health Alert Network (HAN) to send 
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12 
State and Local Bioterrorism Preparedness  OEI-02-01-00550  alerts to local health departments, only half of the States have a HAN that allows two-way 
communication.  Further, several State health departments are concerned that not all of their 
local health departments have the capacity to receive and review communications on a 24 hour, 
7 day a week basis.  In fact, 5 State and 17 local health departments do not have a complete 
call-down roster with current 24-hour contact information. 
Accurately and effectively communicating with the public and media is crucial during a 
bioterrorism event. Public health departments use risk communication to prevent inaccurate 
information from being released to the public, therefore preventing a potentially dangerous 
public response. In addition, appropriate risk communication can foster the public trust that 
may be necessary to effectively control the spread of disease. Although 9 State and 24 local 
health departments do not have complete written risk communication plans, most of the health 
departments report they expect to follow the basic principles of risk communication. These 
include having a central point of contact, such as a public information officer, and conveying a 
single consistent message across response partners. 
States and locals have limited ability to mobilize response. State and local health 
departments expressed concerns about their ability to identify, coordinate, and deploy public 
health assets to assure an effective emergency response. In particular, 3 State and 9 local 
health departments say they will not have the trained staff, equipment, and supplies they need to 
respond to a bioterrorism emergency; others say sustaining a response to a large-scale or long 
term event would be difficult.  Further, 4 State and 21 local health departments report that they 
have not tested their response protocols. A few health departments volunteer that they would 
need to rely on Federal support for an adequate response.  One local respondent says, No 
one has the ability to respond to a bioterrorism event. We need to get the rapid response from 
the national level. 
To compensate for these limitations, health departments are taking several steps.  Four State 
and six local health departments plan to rely on cross-trained staff.  Six State and 14 local 
health departments will rely on resources and volunteers from the community or response 
partners.  However, only 3 State and 14 local health departments have conducted training for 
volunteers.  In addition, two State and eight local health departments have begun stockpiling a 
limited number of supplies and pharmaceuticals.  Other initiatives include surveying the 
community to identify available resources and forming mutual aid agreements with potential 
public health response partners or other organizations within the community. 
While State health departments are expecting to receive Federal aid in the form of the National 
Pharmaceutical Stockpile (NPS), they do not all have plans for handling the NPS when it 
arrives.  The NPS push package contains equipment, supplies, and pharmaceuticals that can be 
delivered within the first few hours of an event.  However, 5 State and 20 local health 
departments we interviewed do not have complete plans for receiving, organizing, repackaging, 
securing, and distributing the NPS. 
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13 
State and Local Bioterrorism Preparedness  OEI-02-01-00550  States and locals do not have all legal authority they may need.  To effectively respond 
to bioterrorism, a health department must have the legal authority to implement the necessary 
public health measures to control the spread of disease.  Four State and 14 local health 
departments report not having all of the laws, rules, and regulations that clearly specify the 
authorities they may need to activate and enforce emergency public health and infection control 
measures. These measures, or interventions, could include closure or quarantine of public 
places, isolation of infected persons, restrictions on travel, or seizure of personal belongings or 
property.  Further, some of the departments say they may not have the capacity to enforce 
their legal authority.  For example, only seven States have the capacity to fully activate and 
enforce quarantine. Only five States report that they can fully activate and enforce the seizure 
of personal property and only six States can fully restrict travel.  Several respondents say they 
need to rely on local law enforcement to implement these public health measures. As one 
explains, [The] relationship between public health and law enforcement is key to moving 
effectively and efficiently. 
In response to recent terrorism events, virtually all public health 
departments are strengthening their bioterrorism preparedness 
programs 
Recent events have heightened awareness around bioterrorism preparedness. In fact, all 
sample States and 32 of the 36 local public health departments have written or are currently 
writing a bioterrorism response plan. A review of these plans reveals that most are integrated 
into a wider emergency management plan.  While they typically include an organizational chart 
showing the emergency command structure, a list of response partners, and an outline or 
summary of emergency response procedures, their level of detail varies. Some are more 
comprehensive, such as one plan that includes a detailed algorithm for responding to 
bioterrorism and discusses the legal authorities for public health interventions. Conversely, 
other plans are very broad, with few specific bioterrorism features. 
Four local health departments we interviewed do not have a plan and are not currently writing 
one.  One respondent says they need guidance from the Federal government about what to 
write. Another says, Planning for bioterrorism is not a priority for this health department. 
The local health departments we visited have begun to integrate their public health preparedness 
activities with response partners in their community.  These partners include traditional 
emergency response partners, such as local law enforcement, hospitals, health care providers 
and associations, laboratories, and fire departments. Health departments have also increasingly 
reached out to form relationships with other entities, such as the Red Cross, schools, medical 
examiners, and amateur radio operators. Most health departments are part of terrorism 
taskforces, workgroups, or committees and some also have formal mutual aid agreements. 
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14 
State and Local Bioterrorism Preparedness  OEI-02-01-00550  Seven State and ten local health departments also say they have received more support from 
decision-makers and other stakeholders for their bioterrorism preparedness programs since the 
recent terrorism events. Several report new staff positions were funded to integrate 
bioterrorism preparedness with other activities. Respondents in 5 States and 12 local health 
departments report that political leaders have been attending emergency response planning 
meetings or have started their own taskforce. Three local health departments have also 
received more funding for bioterrorism. 
Recent funding provides an opportunity to strengthen public 
health, but concerns remain 
Guidance from recent funding requires States to address most vulnerabilities 
In 2002, the Department significantly increased funding to State and local health departments 
through two cooperative agreement programs. First, CDCs Bioterrorism Preparedness and 
Response Cooperative Agreement Program has increased from $66.7 million in 2001 to $918 
million in 2002. Second, in February 2002, HRSA announced a new $125 million cooperative 
agreement program with State health departments to upgrade hospital preparedness. 
Detection.  Recent funding appears to target a number of the weaknesses in disease 
surveillance and epidemiology.  As noted earlier, health departments are relying on 
communicable disease reports that are not always timely or submitted consistently by providers. 
Further, almost half of the local health departments do not have an epidemiologist to investigate 
these reports.  As shown in Appendix A, CDCs cooperative agreement guidance provides 
State health departments with opportunity to improve their capacity to detect bioterrorism by 
strengthening their disease reporting system and requiring one epidemiologist in each 
Metropolitan Statistical Area with a population over 500,000. 
Recent funding also addresses several weaknesses in laboratory capacity.  As we noted above, 
about half of the States have not identified all level A clinical laboratories and some have 
concerns about their relationship with law enforcement. As discussed in Appendix A, CDCs 
new cooperative agreement funding gives State health departments an opportunity to improve 
these weaknesses by writing plans and procedures that include all laboratories in their 
jurisdiction and by improving relations with the FBI and level A laboratories. 
Response. Recent funding also presents several opportunities for State health departments to 
improve their response and communication capacity, as illustrated in Appendix A. First, health 
departments will be funded to plan for the use of the NPS. Second, States will enhance their 
communication capacity by expanding the Health Alert Network, developing a risk 
communication plan, and helping local health departments to have 24 hours per day, 7 days per 
week communication systems. Third, States are 
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15 
State and Local Bioterrorism Preparedness  OEI-02-01-00550  required to examine their statutes, regulations, and ordinances to determine whether they 
provide authority to perform emergency public health measures.  Lastly, recent funding also 
requires States to improve their ability to protect the personal safety of responders, including 
health care providers. This concern has been raised by several of our respondents, especially 
regarding vaccinating first responders. 
Some concerns remain 
Some respondents raise concerns that go beyond the scope of recent funding. To begin with, 
some health departments noted that sustained Federal funding for both bioterrorism 
preparedness and the public health infrastructure is critical.  For example, some respondents 
believe they cannot hire and maintain professional staff, such as epidemiologists and laboratory 
technicians, without a commitment of sustained funding. Others comment that bioterrorism 
preparedness initiatives will be less effective without the support of a strong public health 
infrastructure. For example, one respondent states, Money to do specific things such as 
laboratory capacity wont help us respond without public health nurses. 
The mental health component of response is not adequately addressed by CDCs recent 
funding guidance. One respondent, stressing the importance of mental health services, says, 
Mental health services should be better prioritized. Several respondents believe that the 
public, first responders, and victims and their families will have significant mental health needs 
during a bioterrorism event. Further, anxious members of the public seeking unnecessary 
medical attention could quickly overwhelm the health care system during a bioterrorism event. 
Although HRSA funding guidance discusses mental health, the CDC cooperative agreement 
guidance does not address mental health issues. For example, while CDC requires States to 
establish a bioterrorism advisory committee with representation from other State and local 
agencies, it does not identify mental health agencies as required members. 
Additionally, some health departments report that difficult tactical decisions may complicate 
their ability to respond to bioterrorism. Several officials note that during a large-scale event 
resources would be limited, meaning that difficult ethical decisions will need to be made, such as 
deciding which patients receive treatment and which do not.  For instance, one respondent is 
concerned that there are only a small number of ventilators in her county.  If there were ever a 
smallpox outbreak, she volunteers, someone would need to decide which patients were given 
the ventilators and which were denied or perhaps taken off their equipment. At least one health 
department is beginning to address these difficult issues by initiating a series of bioethical 
seminars for its staff. 
Lastly, we found that hospital laboratories can play an important role in the laboratory response 
system.  Although HRSAs cooperative agreement addresses hospital preparedness and 
capacity, it does not currently address the role and capacity of hospital-based laboratories in 
States Laboratory Response Networks. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  C O N C L U S I O N  
The findings in this report show that our public health infrastructure has left us under-prepared 
to detect and respond to bioterrorism.  Not all State and local health departments have 
sufficient staff, surveillance systems, technology, or laboratory capacity to quickly and 
accurately identify an attack.  Some also lack the plans, partnerships, or authorities to 
adequately respond. Since the anthrax attacks in the Fall of 2001, health departments have 
started to reassess their preparedness and the federal government has substantially increased 
funding to rebuild public health infrastructures. Based on these findings, we conclude that 
further work is needed at the Federal, State, and local levels to ensure that our countrys public 
health system is fully prepared to respond to bioterrorism. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  R E C O M M E N D A T I O N S  
First and foremost, CDC should develop a monitoring system to ensure that the 
bioterrorism preparedness funds are being used as intended. In 2002, State and local 
health departments will receive $918 million in cooperative agreement funds to bolster the 
public health infrastructure and improve their capacity to detect and respond to bioterrorism. 
Each of these cooperative agreements outlines a plan for reaching these goals. It is essential 
that CDC closely monitor the progress of State and local health departments in accomplishing 
the goals set forth in these plans. 
The Assistant Secretary for Public Health Emergency Preparedness should work with 
States to develop strategies that sustain the public health infrastructure subsequent to 
the current influx of Federal funding. Although there will be a significant increase in Federal 
support to States, it is essential that infrastructure improvements be maintained in order to 
protect our nation from the effects of future bioterrorism attacks. 
The CDC and the Substance Abuse and Mental Health Services Administration should 
work together to address community mental health needs in its future guidance to 
States. Our review of CDCs new program guidance reveals that it does not fully address the 
mental health components of bioterrorism preparedness. Should a bioterrorism event occur, 
first responders, victims and their families, and anxious members of the public would likely have 
significant mental health needs. 
The CDC should work with States to help them address tactical decisions related to 
bioterrorism response. Respondents raise several of these issues, such as deciding which 
patients would receive limited treatment and immunizing first responders. The CDC should 
provide technical assistance to States to support them in discussing and planning to deal with 
these, and potentially other, tactical decisions. 
AGENCY COMMENT 
The Assistant Secretary for Public Health Emergency Preparedness (ASPHEP), who directs 
and coordinates the HHS activities related to bioterrorism and other public health emergencies, 
commented on the draft report on behalf of the pertinent HHS agencies and offices. In general, 
the ASPHEP concurs with our recommendations. It notes that financial and program 
monitoring systems are being developed for the cooperative agreements. The ASPHEP also 
notes that CDC will include mental health needs in future guidance, as well as provide technical 
assistance to States.  Appendix B contains the full text of the comment. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  APPENDIX A 
2002 CDC and HRSA Cooperative Agreement Guidance 
Requires States to Address Key Vulnerabilities 
Area of Vulnerability  Guidance Addressing Key Vulnerabilities 
Surveillance and    States must have a highly functioning, mandatory reportable 
Epidemiologic  disease surveillance system with timely reporting by  providers 
Vulnerabilities  and laboratories. 
  States must prepare a timeline for developing a system to 
receive and evaluate these reports on a 24/7 basis. 
  States should consider providing education for laboratories and 
providers about reporting requirements. 
  States should pursue active surveillance of outside data sources 
after fulfilling the basis capacities. 
  States must write a plan to provide one epidemiologist for each 
Metropolitan Statistical Area with a population greater than 
500,000. 
Identification    States must create an integrated response plan (that includes 
Vulnerabilities  results reporting) for laboratories within their jurisdiction. 
  States must develop operational plans and protocols that 
include transporting specimens, training of personnel, triage 
procedures for prioritizing intake and testing of specimens. 
  States must establish operational relationships with local 
Hazardous Material (HAZMAT) teams, first responders, and the 
FBI. 
  States must prepare a timeline for ensuring effective working 
relationships and communication between level A (clinical) 
laboratories and higher level laboratories. 
Continued 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  Communication    States must prepare a timeline for a plan that ensures 90 percent 
Vulnerabilities  of the population is covered by the Health Alert Network. 
  States must develop an interim plan for risk communication and 
information dissemination to the public. 
  States must work with local health departments to ensure that 
they establish and maintain a system for 24/7 notification. 
Mobilization    States must develop an interim plan to receive and manage items 
Vulnerabilities  from the National Pharmaceutical Stockpile and other sources (and 
identify personnel to be trained for these functions). 
Public Health    States must prepare a timeline for assessment of statutes, 
Interventions  regulations, and ordinances within the state that provide for 
Vulnerabilities  executing emergency public health measures. 
  States must develop and expand their capacity to address 
worker health and safety issues related to bioterrorism, with a 
primary focus on protection of emergency response workers, 
remediation workers, and exposed occupational groups. 
  States should assess the need for protection of clinicians 
(vaccination, antibiotic prophylaxis, personal protective equipment, 
education) to ensure their availability in an epidemic. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  APPENDIX B 
Agency Comment 
In this appendix, we present in full the comment from the Assistant Secretary for Public Health 
Emergency Preparedness. 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550   _____ 
22 
State and Local Bioterrorism Preparedness  OEI-02-01-00550   _____ 
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State and Local Bioterrorism Preparedness  OEI-02-01-00550  A C K N O W L E D G M E N T S  
This report was prepared in New York under the direction of John I. Molnar, Regional Inspector 
General for Evaluation and Inspections, and Jodi D. Nudelman, Assistant Regional Inspector General. 
Other principal Office of Evaluation and Inspections staff who contributed include: 
Demetra Arapakos, Team Leader  Joseph Rutherford, Program Specialist

Miriam Gareau, Project Leader  Genevieve Nowolinski, Program Specialist

Patricia Banta, Program Analyst

Judy Kellis, Program Analyst

Christi Macrina, Program Analyst

Ellen Vinkey, Program Analyst

Thomas Zimmermann, Program Analyst

Tricia Fields, Program Analyst - Kansas City

Kristen Masse, Program Analyst - Chicago

Pamela Minniear, Program Analyst - San Francisco 

Clark Thomas, Program Analyst - Dallas

Deborah Walden, Program Analyst - Kansas City

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State and Local Bioterrorism Preparedness  OEI-02-01-00550