Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANET REHNQUIST 

INSPECTOR GENERAL 

DECEMBER 2002 

OEI-02-01-00550 

State and Local Bioterrorism Preparedness 
OFFICE OF INSPECTOR GENERAL

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 OIG’s 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. 
EXECUTIVE SUMMARY 

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 department’s 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 i 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 State’s 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 ii 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 country’s 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 iii 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 CDC’s 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 iv OEI-02-01-00550 
TABLE OF CONTENTS 

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 v OEI-02-01-00550 
INTRODUCTION 

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 1 OEI-02-01-00550 
The Department’s 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 Department’s 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. 

CDC’s Role in Bioterrorism Preparedness 

Bioterrorism Preparedness and Response Cooperative Agreement Program. One of 

the primary initiatives CDC has undertaken to improve the public health infrastructure’s 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 2 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 CDC’s 

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 3 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 4 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, selfadministered 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 CDC’s 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 State’s 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 5 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 

Project’s guidance. Specifically, we reviewed each State health department’s 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 

Project’s guidance to State and local health departments. We asked about the local health 

department’s 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 Project’s 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 plan’s organizational 

chart, response procedures, including plan activation procedures, response partner list, and 

NPS plan. 

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State and Local Bioterrorism Preparedness 6 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 President’s Council on Integrity and Efficiency. 

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State and Local Bioterrorism Preparedness 7 OEI-02-01-00550 
FINDINGS 

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 country’s 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 infrastructure’s 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 8 OEI-02-01-00550 
Table 1 

Key Vulnerabilities in State and Local Bioterrorism Preparedness 

(12 State & 36 local health departments) 

Surveillance and 

Epidemiologic 

Investigation 

Surveillance systems are weak: 

• 3 States and 10 locals volunteer that communicable disease reports are 

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 

Interventions 

States and locals do not have all legal authority they may need: 

• 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 9 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 haven’t 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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State and Local Bioterrorism Preparedness 10 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 nation’s 

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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State and Local Bioterrorism Preparedness 11 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 doesn’t 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 didn’t 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 didn’t 

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 system’s 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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State and Local Bioterrorism Preparedness 12 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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State and Local Bioterrorism Preparedness 13 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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State and Local Bioterrorism Preparedness 14 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, CDC’s 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, CDC’s 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, CDC’s 

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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State and Local Bioterrorism Preparedness 15 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 won’t help us respond without public health nurses.” 

The mental health component of response is not adequately addressed by CDC’s 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 HRSA’s 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 16 OEI-02-01-00550 
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 country’s public 

health system is fully prepared to respond to bioterrorism. 

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State and Local Bioterrorism Preparedness 17 OEI-02-01-00550 
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. 

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 CDC’s 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 18 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 

Epidemiologic 

Vulnerabilities 

• States must have a “highly functioning, mandatory reportable 

disease surveillance system” with timely reporting by providers 

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 

Vulnerabilities 

• States must create an integrated response plan (that includes 

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 19 OEI-02-01-00550 
Communication 

Vulnerabilities 

• States must prepare a timeline for a plan that ensures 90 percent 

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 

Vulnerabilities 

• States must develop an interim plan to receive and manage items 

from the National Pharmaceutical Stockpile and other sources (and 

identify personnel to be trained for these functions). 

Public Health 

Interventions 

Vulnerabilities 

• States must prepare a timeline for assessment of statutes, 

regulations, and ordinances within the state that provide for 

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 20 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 21 OEI-02-01-00550 
 _____ 

State and Local Bioterrorism Preparedness 22 OEI-02-01-00550 
 _____ 

State and Local Bioterrorism Preparedness 23 OEI-02-01-00550 
ACKNOWLEDGMENTS 

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 24 OEI-02-01-00550