Report to Congressional Committees 

United States General Accounting Office 

GAO 

April 2003 BIOTERRORISM

Preparedness Varied 

across State and Local 

Jurisdictions 

GAO-03-373 
State and local officials reported varying levels of preparedness to respond 

to a bioterrorist attack. Officials reported deficiencies in capacity, 

communication, and coordination elements essential to preparedness and 

response, such as workforce shortages, inadequacies in disease surveillance 

and laboratory systems, and a lack of regional coordination and compatible 

communications systems. Some elements, such as those involving 

coordination efforts and communication systems, were being addressed 

more readily, whereas others, such as infrastructure and workforce issues, 

were more resource-intensive and therefore more difficult to address. Cities 

with more experience in dealing with public health emergencies were 

generally better prepared for a bioterrorist attack than other cities, although 

deficiencies remain in every city. 

 

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

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

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

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

adequately prepared. The need for federal guidance has continued to be an 

issue as states have proceeded in their planning and preparedness activities 

with funding from HHS. For example, in their progress reports to HHS in late 

2002 two states reported that they were seeking guidance from HHS on 

assessing vulnerabilities for foodborne or waterborne diseases and 

preparedness steps they should take for these hazards. One of these states 

has declared that it could not make further efforts on testing for these types 

of diseases until it receives more guidance. 

State officials also expressed a desire for more sharing of best practices. 

Officials stated that, while each jurisdiction might need to adapt procedures 

to its own circumstances, time could be saved and needless duplication of 

effort avoided if there were better mechanisms for sharing strategies across 

jurisdictions. They stated that HHS was better positioned to know about 

different strategies that states were pursuing and they want information on 

the best practices. 

Much of the response to a 

bioterrorist attack would occur at 

the local level. Many local areas 

and their supporting state agencies, 

however, may not be adequately 

prepared to respond to such an 

attack. In the Public Health 

Improvement Act that was passed 

in 2000, Congress directed GAO to 

examine state and local 

preparedness for a bioterrorist 

attack. In this report GAO provides 

information on state and local 

preparedness and state and local 

concerns regarding the federal role 

in funding and improving 

preparedness. To gather this 

information, GAO visited seven 

cities and their respective state 

governments, reviewed documents, 

and interviewed officials. Cities are 

not identified because of the 

sensitive nature of this issue. 

GAO recommends that the 

Department of Health and Human 

Services (HHS), in consultation 

with the Department of Homeland 

Security, 

• develop specific benchmarks 

that define adequate 

preparedness for a bioterrorist 

attack and can be used by 

jurisdictions to guide their 

preparedness efforts; and 

• develop a mechanism for 

evaluating and sharing useful 

solutions to problems among 

jurisdictions. 

HHS and the Department of 

Homeland Security concurred with 

the recommendations. 

www.gao.gov/cgi-bin/getrpt?GAO-03-373.

To view the full report, including the scope 

and methodology, click on the link above. 

For more information, contact Janet Heinrich 

at (202) 512-7119. 

Highlights of GAO-03-373, a report to the 

Senate Committee on Health, Education, 

Labor, and Pensions; the Senate and 

House Committees on Appropriations; and 

the House Committee on Energy and 

Commerce 

April 2003

BIOTERRORISM

Preparedness Varied across State and 

Local Jurisdictions 
Page i GAO-03-373 State and Local Bioterrorism Preparedness 

Letter 1

Results in Brief 4

Background 6

State and Local Officials Reported Varying Levels of Bioterrorism 

Preparedness 14

State and Local Jurisdictions and Response Organizations Made 

Progress in Developing Preparedness Plans, but Regional Plans 

Remained Undeveloped 25

State and Local Officials Expressed Concerns regarding Federal 

Funding and Lack of Guidance 28

Conclusions 33

Recommendations for Executive Action 34

Agency Comments 34

Appendix I Bioterrorism Preparedness in Seven Case Cities 37 

Appendix II Scope and Methodology 40 

Appendix III Comments from the Department of Health and 

Human Services 42 

Appendix IV GAO Contact and Staff Acknowledgments 46 

GAO Contact 46

Acknowledgments 46

Related GAO Products 47 

Table 

Table 1: Bioterrorism Preparedness Elements for the Seven Cities 

We Visited, December 2001 through March 2002 37

Contents 
Page ii GAO-03-373 State and Local Bioterrorism Preparedness 

Figure 

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

the Covert Release of a Biological Agent 8

Abbreviations 

CDC Centers for Disease Control and Prevention 

DOJ Department of Justice 

Epi-X Epidemic Information Exchange 

FEMA Federal Emergency Management Agency 

HAN Health Alert Network 

HHS Department of Health and Human Services 

HRSA Health Resources and Services Administration 

MMRS Metropolitan Medical Response System 

OER Office of Emergency Response 

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Page 1 GAO-03-373 State and Local Bioterrorism Preparedness 

April 7, 2003 

Congressional Committees 

Since the terrorist attacks of September 11, 2001, and the subsequent 

anthrax incidents, there has been great concern about bioterrorism1

 in the 

United States. With this concern, there is growing recognition that the 

unique characteristics of a bioterrorist attack, in contrast to a 

conventional attack, would require additional response preparation and 

coordination. Much of the response to a bioterrorist attack would occur at 

the local level. The intentional release of a biological agent by a terrorist 

might not be recognized for several days, during which time a 

communicable disease could be spread to those who were not initially 

exposed. Hospitals and their emergency departments, as well as private 

physicians and nurses, would most likely be the first responders, as 

victims began to seek treatment of their symptoms. 

In order to be adequately prepared for a bioterrorist attack, state and local 

response organizations2

 need to have several basic capabilities, whether 

they possess them directly or have access to them through regional 

agreements. Health care providers, including emergency medical 

personnel, need to be trained to recognize symptoms of diseases caused 

by biological agents likely to be used in a bioterrorist attack (such as 

anthrax and smallpox). Public health departments need to have the 

 1

Bioterrorism is the threatened or intentional release of biological agents (viruses, bacteria, 

or their toxins) for the purpose of influencing the conduct of government or intimidating or 

coercing a civilian population. These agents can be released by way of the air (as aerosols), 

food, water, or insects. 

2

In this report, the term response organizations refers to any organization or individual that 

would respond to a bioterrorist incident. These include physicians, hospitals, laboratories, 

public health departments, emergency medical services, emergency management agencies, 

fire departments, and law enforcement agencies. 

United States General Accounting Office

Washington, DC 20548 
Page 2 GAO-03-373 State and Local Bioterrorism Preparedness 

appropriate infrastructure,3 including disease surveillance systems,4 in 

place at the state and local levels to detect clusters of suspicious 

symptoms or diseases in order to facilitate early detection of an attack and 

treatment of victims. Laboratories need to have adequate capacity and 

necessary staff to test clinical and environmental samples in order to 

identify an agent promptly so that proper treatment can be started and 

infectious diseases prevented from spreading. Hospitals need to have 

adequate facilities and necessary staff to appropriately treat patients. All 

organizations involved in the response must be able to communicate easily 

with one another as events unfold and critical information is acquired. In 

addition, plans that describe how state and local officials would manage 

and coordinate an emergency response need to be in place and to have 

been tested in an exercise, both at the state and local levels and at the 

regional level. 

It has been suggested, however, that many state and local areas may not 

be adequately prepared to respond to and manage a bioterrorist attack.5

For example, it has been reported that there is an ongoing shortage of 

intensive care unit beds and isolation rooms, where infectious disease 

patients are treated.6

 In addition, a recent report has identified problems 

with the public health infrastructure, particularly at the local level, and 

stated that public health departments have generally been poorly funded.7

 3

Public health infrastructure is the foundation that supports the planning, delivery, and 

evaluation of public health activities and is composed of a well-trained public health 

workforce, effective program and policy evaluation, sufficient epidemiology and 

surveillance capability to detect outbreaks and monitor incidence of diseases, appropriate 

response capacity for public health emergencies, effective laboratories, secure information 

systems, and advanced communications systems. 

4

Disease surveillance systems provide for the ongoing collection, analysis, and 

dissemination of health-related data to identify, prevent, and control disease. 

5

National Association of Counties, Counties Secure America: A Survey of County Public 

Health Needs and Preparedness (Washington, D.C.: January 2002) and National 

Association of County and City Health Officials, Research Brief: Assessment of Local 

Bioterrorism and Emergency Preparedness, no. 5 (Washington, D.C.: October 2001). 

6

Amy Smithson and Leslie-Ann Levy, Ataxia: The Chemical and Biological Terrorism 

Threat and the U.S. Response (Washington, D.C.: The Henry L. Stimson Center, October 

2000), 242, 262-263. 

7

Institute of Medicine of the National Academies, The Future of the Public’s Health in the 

21st Century (Washington, D.C.: The National Academies Press, 2003, forthcoming). 
Page 3 GAO-03-373 State and Local Bioterrorism Preparedness 

The Department of Health and Human Services (HHS), the Federal 

Emergency Management Agency (FEMA), and the Department of Justice 

(DOJ) provide assistance to state and local governments in enhancing 

preparedness for bioterrorism and for emergencies of all types.8 In 

November 2002, the President signed the Homeland Security Act of 2002, 

which established the Department of Homeland Security. As a result of 

this legislation, FEMA and certain DOJ and HHS programs with 

preparedness and response functions have been transferred to the new 

department. 

The Public Health Improvement Act directed that we examine state and 

local levels of preparedness for a bioterrorist attack.9

 We have previously 

reported on activities by federal agencies to prepare for and respond to a 

bioterrorist attack.10 In this report, we are providing information on the 

preparedness of state and local jurisdictions for responding to such an 

attack, state and local bioterrorism response planning efforts, and state 

and local concerns regarding the federal role in funding and improving 

state and local preparedness. 

To address our objectives, we conducted multiday site visits to seven 

cities and their respective state governments from December 2001 through 

March 2002, at a time when states were intensively planning for their 

response to a future potential bioterrorist attack following the anthrax 

incidents of the previous fall. Cities were selected to provide wide 

variation in geographic location, population size, and experience with 

natural disasters and large exercises. (See app. I for an overview of each 

city we visited, including comparisons across several elements of 

preparedness.) We do not identify these cities in this report because of the 

sensitive nature of this issue. During the site visits, we interviewed 

officials from state and local public health departments, local emergency 

medical services, state and local emergency management agencies, local 

fire and law enforcement agencies, and hospitals. For each city we visited, 

we also reviewed copies of the state’s spring 2002 application for 

bioterrorism-related funding through cooperative agreements with HHS’s 

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

 8

See, for example, U.S. General Accounting Office, Bioterrorism: Federal Research and 

Preparedness Activities, GAO-01-915 (Washington, D.C.: Sept. 28, 2001). 

9

Pub. L. No. 106-505, § 102, 114 Stat. 2314, 2323 (2000). 

10GAO-01-915. 
Page 4 GAO-03-373 State and Local Bioterrorism Preparedness 

and Services Administration (HRSA). In addition, we reviewed the 

progress reports on the CDC and HRSA cooperative agreements that were 

submitted to HHS in late 2002 from the relevant states, covering the period 

through October 31, 2002. Because of the events of the fall of 2001, and the 

subsequent federal preparedness funding, changes were occurring at the 

state and local levels with regard to bioterrorism preparedness during our 

site visits and subsequent data collection. Changes have continued to 

occur since our visits, and this report may not reflect all these changes. In 

addition to making the state and local site visits and reviewing the 

pertinent documents, we interviewed officials from federal agencies and 

representatives from national public health associations, and we reviewed 

reports, including reports of the Advisory Panel to Assess Domestic 

Response Capabilities for Terrorism Involving Weapons of Mass 

Destruction,11 concerning state and local preparedness for bioterrorism. 

Because our focus was on the public health and medical consequences of 

a bioterrorist event, we do not report on preparedness activities funded by 

DOJ and FEMA in this study. (See app. II for details regarding our scope 

and methodology.) We conducted our work from November 2001 through 

April 2003 in accordance with generally accepted government auditing 

standards. 

Officials in the states and cities we visited reported varying levels of 

preparedness to respond to a bioterrorist attack. They recognized 

deficiencies in preparedness and were beginning to address these gaps 

and weaknesses. The states and cities we visited were generally better 

prepared in certain elements than in others. Some elements, such as those 

involving coordination efforts and communication systems, were being 

addressed more readily, whereas others, such as infrastructure and 

workforce issues, were more resource-intensive and therefore more 

difficult to address. Officials in the seven cities we visited told us of gaps 

and weaknesses in capacity elements essential to preparedness and 

response, such as workforce shortages and inadequate laboratory 

facilities. The level of preparedness varied by city as well as by element. 

 11Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving 

Weapons of Mass Destruction, Third Annual Report to the President and the Congress of 

the Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving 

Weapons of Mass Destruction (Arlington, Va.: RAND, Dec. 15, 2001), and Fourth Annual 

Report to the President and the Congress of the Advisory Panel to Assess Domestic 

Response Capabilities for Terrorism Involving Weapons of Mass Destruction (Arlington, 

Va.: RAND, Dec. 15, 2002). 

Results in Brief 
Page 5 GAO-03-373 State and Local Bioterrorism Preparedness 

Those cities that had multiple prior experiences with public health 

emergencies caused by natural disasters and with preparation for special 

events, such as political conventions, were generally more prepared than 

the other cities, which had little or no such experience prior to our site 

visits. 

State and local jurisdictions and response organizations we visited were 

engaged in planning efforts to address problems in bioterrorism 

preparedness at the state and local levels, but regional planning between 

states was generally lacking. Most of the cities and states we visited had 

emergency operation plans for coordinating the response to emergencies. 

At the time of our site visits, many of these plans had not specifically 

addressed the unique requirements of response to a bioterrorist attack, but 

many officials were beginning to incorporate a bioterrorism response 

component. Preparing the application plans for the CDC and HRSA 

funding helped states to identify problems on which to focus their efforts, 

including the need for increased participation of hospitals in local 

preparedness and the development of regional plans. Although progress 

was made on local planning, regional planning involving multiple 

municipalities, counties, or jurisdictions in neighboring states or a 

neighboring country lagged. A regional response to a bioterrorist attack 

could require participation of officials from neighboring states or a 

neighboring country, yet some states lacked sufficient coordination with 

their neighboring states and country and had not participated in joint 

response planning. 

State and local officials had concerns regarding the distribution and 

sustainability of federal funding for improving state and local bioterrorism 

preparedness programs and the lack of specific standards for determining 

adequacy of preparedness. State and local officials disagreed as to 

whether federal funding should flow through the state or go directly to the 

local jurisdictions, with each group wanting to control the funds. In 

addition, hospital officials reported that federal funding intended to 

enhance emergency preparedness in their cities had not always been 

shared with them in the past. Further, state and local officials stressed that 

sustained funding is a key factor in maintaining the effectiveness of federal 

funds. Officials requested more federal guidance and sharing of best 

practices to assist them in addressing the remaining deficiencies. All types 

of response organizations were asking for federal guidance on what it 

means to be adequately prepared for bioterrorism. State and local officials 

told us that specific benchmarks would help them determine whether they 

were adequately prepared to respond to a bioterrorist attack. State 
Page 6 GAO-03-373 State and Local Bioterrorism Preparedness 

officials also requested that federal agencies do more to identify and share 

best practices to assist in preparedness and avoid duplication of effort. 

We are recommending that HHS, in consultation with the Department of 

Homeland Security, help state and local jurisdictions better prepare for a 

bioterrorist attack by developing specific benchmarks that define 

adequate preparedness for a bioterrorist attack and can be used by state 

and local jurisdictions to assess and guide their preparedness efforts. We 

are also recommending that HHS, in consultation with the Department of 

Homeland Security, develop a mechanism by which solutions to problems 

that have been used in one jurisdiction can be evaluated by HHS and, if 

appropriate, shared with other jurisdictions. 

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

Homeland Security for their review. HHS concurred with our 

recommendations and provided information on measures it is taking to 

address the concerns we identified. The liaison from the Department of 

Homeland Security provided oral comments noting the department’s 

concurrence with the draft report and the recommendations. 

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

bioterrorist attack, is generally a local responsibility that could involve 

multiple jurisdictions in a region, with states providing additional support 

when needed. The federal government could also become involved in 

investigating or responding to an incident. In addition, the federal 

government provides funding and resources to state and local entities to 

support preparedness and response efforts. 

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

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

involved as needed.12 Having the necessary resources immediately 

available at the local level to respond to an emergency can minimize the 

magnitude of the event and the cost of remediation. In the case of a covert 

release of a biological agent, it could be hours or days before exposed 

 12For example, in responding to an overt release of a biological agent, the federal 

government would become involved more quickly. The Federal Bureau of Investigation is 

the federal agency responsible for investigating all terrorist threats and acts within the 

United States and would conduct a criminal investigation concurrent with local public 

health and medical community’s response. 

Background 

Response to a Bioterrorist 

Incident 
Page 7 GAO-03-373 State and Local Bioterrorism Preparedness 

people start exhibiting signs and symptoms of the disease. Figure 1 

presents the probable series of responses to such a bioterrorist incident. 

Just as in a naturally occurring outbreak, exposed individuals would seek 

out local health care providers, such as private physicians or medical staff 

in hospital emergency departments or public clinics. Health care providers 

would report any illness patterns or diagnostic clues that might indicate an 

unusual infectious disease outbreak associated with the intentional 

release of a biologic agent to their state or local health departments. 
Page 8 GAO-03-373 State and Local Bioterrorism Preparedness 

Figure 1: Local, State, and Federal Entities Involved in Response to the Covert Release of a Biological Agent 
Page 9 GAO-03-373 State and Local Bioterrorism Preparedness 

a

Health care providers can also contact state entities directly. 

b

Federal departments and agencies can also respond directly to local and state entities. 
Page 10 GAO-03-373 State and Local Bioterrorism Preparedness 

c

The Strategic National Stockpile, formerly the National Pharmaceutical Stockpile, is a repository of 

pharmaceuticals, antidotes, and medical supplies that can be delivered to the site of a biological (or 

other) attack. 

Local and state health departments would collect and monitor data, such 

as reports from health care providers, for disease trends and outbreaks. 

Clinical samples would be collected for laboratorians13 to test for 

identification of illnesses. Epidemiologists14 in the health departments 

would use the disease surveillance systems to provide for the ongoing 

collection, analysis, and dissemination of data to identify unusual patterns 

of disease. 

The federal government could also become involved, as needed, in 

investigating or responding to an incident. For certain high-risk diseases, 

such as the Ebola virus, sample testing would be done at a federal 

Biosafety Level 4 laboratory15 equipped to handle dangerous and exotic 

biological agents. CDC has one such laboratory for testing of these 

dangerous agents. CDC also provides state and local jurisdictions with 

assistance on epidemiological investigations and treatment advice. Other 

federal agencies may also assist state and local jurisdictions in the 

investigation of and response to bioterrorism and other public health 

emergencies. 

Prior to January 2002, HHS distributed funds for bioterrorism 

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

funded state and local health departments through CDC’s Bioterrorism 

Preparedness and Response Program. From 1996 through 2001 it provided 

funding to local jurisdictions, targeting police, firefighters, emergency 

medical responders, hospitals, and public health agencies through the 

 13A laboratorian is one who works in a laboratory; in the medical and allied health 

professions, a laboratorian examines or performs tests (or supervises such procedures) 

with various types of chemical and biologic materials, chiefly to aid in the diagnosis, 

treatment, and control of disease, or as a basis for health and sanitation practices. 

14An epidemiologist is a specialist in the study of how disease is distributed in populations 

and the factors that influence or determine this distribution. 

15Laboratories are categorized as either Biosafety Level 1, 2, 3, or 4, with Biosafety Level 4 

laboratories providing the highest degree of protection to personnel, the environment, and 

the community. Biosafety levels represent combinations of laboratory practices and 

techniques, safety equipment, and laboratory facilities. Each combination is specifically 

appropriate for the operations performed, the documented or suspected routes of 

transmission of the infectious agents, and the laboratory function or activity. 

HHS Funding for State and 

Local Bioterrorism 

Preparedness 
Page 11 GAO-03-373 State and Local Bioterrorism Preparedness 

Metropolitan Medical Response System (MMRS)16 of the Office of 

Emergency Response (OER), formerly the Office of Emergency 

Preparedness, which was transferred to the Department of Homeland 

Security on March 1, 2003.17 CDC and HRSA are expanding or developing 

programs to help state and local governments, as well as hospitals and 

other health care entities, improve preparedness for and response to 

bioterrorism and other emergencies. 

In January 2002, HHS announced the allocation of $1.1 billion through 

CDC, HRSA, and OER for state and local bioterrorism preparedness.18 This 

funding supports three separate but related efforts—CDC’s Public Health 

Preparedness and Response for Bioterrorism program, HRSA’s 

Bioterrorism Hospital Preparedness Program, and OER’s MMRS program. 

States applying for funding through cooperative agreements under CDC’s 

Public Health Preparedness and Response for Bioterrorism program and 

HRSA’s Bioterrorism Hospital Preparedness Program were required to 

submit bioterrorism preparedness plans to HHS by April 15, 2002. All 50 

states and four major municipalities 19 applied for and received funding 

through these cooperative agreements.20 The noncompetitive cooperative 

agreements provide that CDC and HRSA funds must be used to 

 16The MMRS program is intended to develop or enhance the local response to a public 

health crisis, especially an attack using weapons of mass destruction, by bringing together 

hospital and public health officials, emergency managers, and others to deal with the 

consequences of an attack. Under the MMRS program, OER contracts with cities to 

improve the ability of local jurisdictions to respond to a public health crisis. 

17DOJ and FEMA also provide funding that supports planning, equipment needs, and 

training for traditional emergency responders and for state emergency management 

agencies, respectively. These funds are targeted toward police, firefighters, and emergency 

medical professionals and are intended to help improve coordination and communication 

by encouraging state and local officials to plan and conduct joint exercises for responding 

to terrorist events. State and local governments can use these funds to plan for response to 

terrorist attacks, conduct exercises to test capabilities, purchase equipment, and train 

personnel. 

18The funds were primarily appropriated by the Department of Defense and Emergency 

Supplemental Appropriations for Recovery from and Response to Terrorist Attacks on the 

United States Act, Pub. L. No. 107-117, 115 Stat. 2230, 2314 (2002), and the Departments of 

Labor, Health and Human Services, and Education, and Related Agencies Appropriations 

Act of Fiscal Year 2002, Pub. L. No. 107-116, 115 Stat. 2186, 2198. 

19The four eligible municipalities were Chicago, the District of Columbia, Los Angeles 

County, and New York City. 

20In addition, CDC funded five American territories: American Samoa, Guam, the Northern 

Marianas Islands, Puerto Rico, and the U.S. Virgin Islands. CDC also funded the three freely 

associated states of the Pacific: Marshall Islands, Micronesia, and Palau. 
Page 12 GAO-03-373 State and Local Bioterrorism Preparedness 

supplement and not supplant any current federal, state, and local funds 

that would otherwise be used for bioterrorism and other public health 

preparedness activities and that these activities should be coordinated 

with any MMRS programs in the jurisdiction. Also in 2002, additional 

funding was appropriated for expanding the National Pharmaceutical 

Stockpile, renamed the Strategic National Stockpile,21 and supporting 

bioterrorism-related research at the National Institutes of Health’s 

National Institute of Allergy and Infectious Diseases.22

Of the $1.1 billion, the CDC program provided funding through 

cooperative agreements in fiscal year 2002 totaling $918 million to states 

and municipalities to improve bioterrorism preparedness and response, as 

well as other public health emergency preparedness activities.23, 24 The 

HRSA program provided funding through cooperative agreements in fiscal 

year 2002 of approximately $125 million to states and municipalities to 

enhance the capacity of hospitals and associated health care entities to 

 21The Strategic National Stockpile is a repository of pharmaceuticals, antidotes, and 

medical supplies that can be delivered to the site of a bioterrorist (or other) attack. 

22The funds allocated were appropriated by the Department of Defense and Emergency 

Supplemental Appropriations for Recovery from and Response to Terrorist Attacks on the 

United States Act, 115 Stat. at 2314. 

23To determine eligibility for the funding, CDC required the applicants to submit plans for 

use of the funds in six focus areas: preparedness planning and readiness assessment, 

surveillance and epidemiology capacity, laboratory capacity for biological agents, 

communications and information technology, risk communication and health information 

dissemination, and education and training. Each focus area included critical capacities that 

had to be addressed. These are the core expertise and infrastructure elements that need to 

be in place as soon as possible to enable a public health system to prepare for and respond 

to bioterrorism and other infectious disease outbreaks. An example of a critical capacity 

under the laboratory capacity for biological agents focus area is to develop and implement 

a jurisdiction-wide program to provide rapid and effective laboratory services in support of 

the response to public health threats and emergencies. 

24In November 2002, HHS released supplemental guidance for implementing the new 

National Smallpox Vaccination Program. These guidelines state that recipients are 

encouraged to use funds made available through the CDC cooperative agreements to plan 

and implement this program and should redirect the funding as necessary. 
Page 13 GAO-03-373 State and Local Bioterrorism Preparedness 

respond to bioterrorist attacks.25 The department released the first 20 

percent of these funds to states and the municipalities within weeks of the 

January announcement. HHS identified 17 “critical benchmarks” (14 for 

the CDC funding and 3 for the HRSA funding) that officials were required 

to address in their application plans. HHS used the critical benchmarks to 

screen application plans for approval before it released the remaining 80 

percent of the CDC and HRSA funding. The benchmarks for the CDC 

program included such activities as designating an executive director of 

the state bioterrorism preparedness and response program, developing an 

interim plan to receive and manage items from the Strategic National 

Stockpile, and preparing a time line for the development of regional plans 

to respond to bioterrorism. In addition, CDC is allowing states to use this 

funding to address preparedness efforts between states and in regions that 

border a foreign country. The benchmarks for the HRSA program included 

development of a timeline for developing and implementing a regional 

hospital plan for dealing with a potential epidemic involving at least 500 

patients. HHS requires progress reports from the states at approximately 

6-month intervals to provide oversight of CDC and HRSA programs and to 

determine future funding.26 The remaining funds that were allocated for 

state and local preparedness in January 2002 supported OER’s MMRS 

program.27

 25HRSA’s guidance on the preparation of application plans for funding required states and 

municipalities to lay out their plans for conducting a needs analysis of hospitals, which 

would enable states and municipalities to allocate their resources most effectively to 

improve preparedness. States and municipalities also needed to discuss their developing 

bioterrorism preparedness plans and protocols for hospitals and other health care entities, 

such as community health centers. In addition, states and municipalities were required to 

address four priority-planning areas: medications and vaccines; personal protection, 

quarantine, and decontamination; communications; and biological disaster drills. 

26In addition, a department official told us that the Office of the Inspector General will have 

a role in ensuring that program participants are accountable for their use of the funds. This 

oversight will include reviewing cooperative agreement requirements, examining program 

participants’ performance and financial records for completeness and timeliness, and 

performing pilot reviews of CDC program participants to determine whether bioterrorism 

preparedness funds were used in accordance with the cooperative agreement terms and 

conditions. 

27OER contracts totaling $10 million in fiscal year 2002 were used to establish an MMRS 

capability in 25 additional cities (bringing the total to 122 cities receiving MMRS funding). It 

was expected that by the end of 2002 80 percent of the U.S. population would reside in an 

area covered by an MMRS contract. 
Page 14 GAO-03-373 State and Local Bioterrorism Preparedness 

State and local officials reported varying levels of preparedness to respond 

to a bioterrorist attack. They recognized deficiencies in preparedness and 

were beginning to address them. We found that the states and cities we 

visited were making greater progress in certain elements of preparedness 

than in others. Some elements, such as those involving coordination 

efforts and communication systems, were being addressed more readily, 

whereas others, such as infrastructure and workforce issues, were more 

resource-intensive and therefore more difficult to address. The level of 

preparedness varied across the cities, with jurisdictions that had multiple 

prior experiences with public health emergencies generally being more 

prepared than the other cities, which had little or no such experience prior 

to our site visits. 

The cities we visited generally made greater progress in coordination and 

communication preparedness than in other elements of preparedness. 

Coordination efforts where progress was made included participation by 

relevant government and private sector officials in meetings to discuss 

how to work together in an emergency and participation in joint training 

exercises. Communication efforts included the purchase and 

implementation of new communication systems and development of 

procedures for communicating with the public and the media. Despite 

these advances, deficiencies in coordination and communication 

remained. 

Most of the cities we visited had made efforts to improve coordination 

among the response organizations. Experience from public health 

emergencies, especially the terrorist attacks of September 11, 2001, and 

the subsequent anthrax incidents, provided momentum for local response 

organizations—including fire departments, emergency medical services, 

law enforcement, public health departments, emergency management 

agencies, and hospitals—to improve coordination. Organizations, such as 

hospitals, that previously were not substantially involved increased their 

participation in preparedness meetings and agreements. Further, most of 

the states we visited reported having established better links between the 

public health departments and the hospitals since the September 11, 2001, 

terrorist attacks and the subsequent anthrax incidents than had previously 

existed. For example, after September 11, 2001, a hospital in one of the 

cities reported that the public health department had given it a telephone 

number to reach public health officials 24 hours a day, 7 days a week. 

In many aspects, the anthrax incidents in October 2001 were exercises in 

cooperation between the health care community and traditional first 

responders. Many cities were inundated with calls about suspicious 

State and Local 

Officials Reported 

Varying Levels of 

Bioterrorism 

Preparedness 

Progress Was Made in 

Elements of Preparedness 

Related to Coordination 

and Communication 
Page 15 GAO-03-373 State and Local Bioterrorism Preparedness 

packages and powders. In several of the cities we visited, public health 

officials reported working with police and fire officials to create a system 

to determine which specimens were most suspicious. These triage systems 

greatly reduced the number of costly full-emergency responses. For 

example, during the height of the public’s concern about anthrax, one city, 

which was experiencing as many as 75 to 90 reports of a white powder per 

day, decided against sending out a complete hazardous materials unit for 

every report. Instead it sent a team consisting of a fire official, a hazardous 

materials official, a police official, and a public health official and this 

team made an initial assessment of whether the full team was needed to 

respond. 

Coordination improved not only horizontally, that is, across different 

entities within jurisdictions, but also vertically, that is, between local and 

state agencies. According to their progress reports, all of the states we 

visited used the 2002 federal funding in part to identify needs and 

coordinate and integrate information technology systems. In all of these 

states, emergency management communication systems were integrated 

both vertically between state and local agencies and horizontally between 

local government and hospitals. Only one of these states reported in its 

progress report to HHS that it continued to have major difficulties in 

improving coordination across different governmental levels because its 

communication system was not capable of sending and receiving critical 

health information. 

In addition, we found that officials were beginning to address 

communication problems. For example, six of the seven cities we visited 

were examining how communication would take place in an emergency. 

Many cities have purchased communication systems that allow officials 

from different organizations to communicate with one another in real 

time. Officials in one area told us that the fire and police departments in 

their area had incompatible radio systems and, consequently, were unable 

to communicate directly. This locality intended to install a compatible 

radio system. It was also considering purchasing wireless communication 

and messaging devices because of their success in other jurisdictions on 

September 11, 2001. 

State officials reported that they were beginning to make progress in 

developing procedures for communication. Responding to the anthrax 

incidents revealed a number of communication issues. For example, state 

and local agency officials identified problems with how information about 

the anthrax incidents was given to the public. These problems included 

not always getting facts about anthrax out quickly, not explaining what 
Page 16 GAO-03-373 State and Local Bioterrorism Preparedness 

was occurring, and releasing inconsistent messages. Officials in one city 

told us that they set up an advisory group of retired media personnel to 

help them examine how they could use the media to help convey their 

message. Following a chemical exercise, public health officials in the same 

city realized that better lines of communication were needed. In response, 

members of the core bioterrorism team were issued pagers so that they 

could be contacted more easily. In addition, two states we visited reported 

to HHS that the outbreaks of West Nile virus in summer 2002 provided 

successful tests of their communication capabilities. 

In addition to these improvements, the state and local health agencies 

were working with CDC to build the Health Alert Network (HAN), an 

information and communication system. The nationwide HAN program 

has provided funding to establish infrastructure at the local level to 

improve the collection and transmission of information related to a 

bioterrorism incident as well as other emergency health events and 

disease surveillance. Goals of the HAN program include providing highspeed Internet connectivity, broadcast capacity for emergency 

communication, and distance-learning infrastructure for training. 

Despite these improvements, deficiencies in communication and 

coordination remained. For example, while four of the states we visited 

said in their progress reports that they had completed integrating all of 

their jurisdictions into HAN, two states had not yet achieved CDC’s goal to 

cover 90 percent of the state’s population.28 One of these states reported 

that, although it had developed a plan for emergency communication with 

the public, local needs were still being assessed. This state reported that 

coordination across multiple governmental levels was problematic and 

time-consuming, and progress in meeting goals for planning was slow. In 

addition, as of November 2002, only two of the states we visited reported 

that they had conducted preparedness exercises that encompassed all 

jurisdictions in the state. According to the states’ progress reports, all 

states we visited intended to conduct exercises on at least some portion of 

their various preparedness plans, such as the plan for receiving and 

distributing the Strategic National Stockpile, in 2003. 

 28The seventh state reported that although 95 percent of the state’s population was covered 

by HAN, all of the jurisdictions in the state were not integrated into the system. 
Page 17 GAO-03-373 State and Local Bioterrorism Preparedness 

In contrast to the improvements made in coordination and 

communication, progress related to the response capacity of the 

workforce, the surveillance and laboratory systems, and hospitals 

generally lagged. Deficiencies in capacity often are not amenable to 

solution in the short term because either they require additional resources 

or the solution takes time to implement. 

At the time of our site visits, shortages in personnel existed in state and 

local public health departments, laboratories, and hospitals and were 

difficult to remedy. Officials from state and local health departments told 

us that staffing shortages were a major concern. One official from a state 

health department said that local health departments in his state were able 

to handle the additional work generated by the anthrax incidents only by 

putting aside their normal daily workload. Local officials also stated that 

their normal daily workload suffered when staff were diverted from their 

usual responsibilities to work on bioterrorism response planning. Local 

officials recognized that diverting staff from their usual duties is 

appropriate in a time of crisis but were concerned about the impact on 

their other public health responsibilities over the longer term. Two of the 

states and cities that we visited were particularly concerned that they did 

not have enough epidemiologists to do the appropriate investigations in an 

emergency. One state department of public health we visited had lost 

approximately one-third of its staff because of budget cuts over the past 

decade. This department had been attempting to hire more 

epidemiologists. Barriers to finding and hiring epidemiologists included 

noncompetitive salaries and a general shortage of people with the 

necessary skills. 

Shortages in laboratory and hospital personnel were also cited. Officials in 

one city noted that they had difficulty filling and maintaining laboratory 

positions. People that accepted the positions often left the health 

department for better-paying positions. Five of the states we visited 

reported shortages of hospital medical staff, including nurses and 

physicians, necessary to increase response capacity in an emergency. 

Increased funding for hiring staff cannot necessarily solve these shortages 

because for many types of positions, such as laboratorians, there are not 

enough trained individuals in the workforce. According to the Association 

of Public Health Laboratories, training laboratorians to provide them with 

Progress in Improving 

Preparedness Capacity 

Lagged 

Workforce 
Page 18 GAO-03-373 State and Local Bioterrorism Preparedness 

the necessary skills will take time and require a strategy for building the 

needed workforce.29

Three states cited ongoing shortages of personnel, which they were 

addressing in their progress reports. Two states had reported that they 

plan to hire veterinarians30 to assist in their preparedness efforts. One of 

these two states also noted difficulties in recruiting personnel when there 

was no guarantee of funding beyond the current year, meaning that 

prospective employees may not be offered permanent positions. Another 

state, however, has had success in hiring epidemiologists. 

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

attempting to address inadequacies in their surveillance systems and 

laboratory facilities. Local officials were concerned that their surveillance 

systems were inadequate to detect a bioterrorist event. Six of the cities we 

visited used a passive surveillance system31 to detect infectious disease 

outbreaks.32 However, passive systems may be inadequate to identify a 

rapidly spreading outbreak in its earliest and most manageable stage 

because, as officials in three states noted, there is chronic underreporting 

and a time lag between diagnosis of a condition and the health 

department’s receipt of the report. To improve disease surveillance, six of 

the states and two of the cities we visited were developing electronic 

surveillance systems. In one city we visited, the public health department 

received clinical information electronically from existing hospital 

 29Association of Public Health Laboratories, “State Public Health Laboratory Bioterrorism 

Capacity,” Public Health Laboratory Issues in Brief: Bioterrorism Capacity (Washington, 

D.C.: October 2002). 

30As we found with the West Nile virus, the links between public and animal health 

agencies are becoming more important. Many emerging diseases affect both animals and 

humans, as do many viruses or other disease-causing agents that might be used in 

bioterrorist attacks. See U.S. General Accounting Office, West Nile Virus Outbreak: 

Lessons for Public Health Preparedness, GAO/HEHS-00-180 (Washington, D.C.: Sept. 11, 

2000). 

31Passive surveillance systems rely on laboratory and hospital staff, physicians, and other 

relevant sources to take the initiative to provide data on illnesses to the health department, 

where officials analyze and interpret the information as it arrives. In contrast, in an active 

disease surveillance system, public health officials contact sources, such as laboratories, 

hospitals, and physicians, to obtain information on conditions or diseases in order to 

identify cases. Active surveillance can provide more complete detection of disease patterns 

than a system that is wholly dependent on voluntary reporting. 

32Officials in one city told us that although it had no local disease surveillance, its state 

maintained a passive disease surveillance system. 

Surveillance Systems and 

Laboratory Facilities 
Page 19 GAO-03-373 State and Local Bioterrorism Preparedness 

databases, which required no additional work by the hospitals. Several 

cities were also evaluating the use of nontraditional data sources, such as 

pharmacy sales, to conduct surveillance. Three of the cities we visited 

were attempting to improve their surveillance capabilities by 

incorporating active surveillance components into their systems.33 For 

example, one city asked six hospitals to participate in a type of active 

system in which the public health department obtains information from 

the hospitals and conducts ongoing analysis of the data to search for 

certain combinations of signs and symptoms.34 The city also had an active 

surveillance system for influenza. 

However, work to improve surveillance systems has proved challenging. 

For example, despite initiatives to develop active surveillance systems, the 

officials in one city considered event detection to be a weakness in their 

system, in part because they did not have authority to access hospital 

information systems. In addition, various local public health officials in 

other cities reported that they lacked the resources to sustain active 

surveillance. 

Officials from all of the states we visited reported problems with their 

public health laboratory systems and said that they needed to be 

upgraded. All states were planning to purchase the equipment necessary 

for rapidly identifying a biological agent. State and local officials in most 

of the areas that we visited told us that the public health laboratory 

systems in their states were stressed, in some cases severely, by the 

sudden and significant increases in workload during the anthrax incidents. 

During these incidents, the demand for laboratory testing was significant 

even in states where no anthrax was found and affected the ability of the 

laboratories to perform their routine public health functions. Following 

the incidents, over 70,000 suspected anthrax samples were tested in 

laboratories across the country. Public health laboratories in some areas 

quickly ran out of space for testing and storing samples. State and local 

officials had to rely on laboratory assistance at the federal level, and CDC 

 33In addition, all of the states we visited were making efforts to improve their disease 

surveillance systems. 

34This type of active surveillance system is sometimes referred to as a syndromic 

surveillance system. One federal official has stated that research examining the usefulness 

of syndromic surveillance needs to continue. See S. Lillibridge, (untitled), in Disease 

Surveillance, Bioterrorism, and Homeland Security, Conference Summary and 

Proceedings Prepared by the Annapolis Center for Science-Based Public Policy (Annapolis, 

Md.: U.S. Medicine Institute for Health Studies, Dec. 4, 2001). 
Page 20 GAO-03-373 State and Local Bioterrorism Preparedness 

received over 6,000 anthrax-related samples and had to operate its 

anthrax-testing laboratory 24 hours a day, 7 days a week and open an 

additional laboratory to test all the samples. Eighty-five percent of state 

and territorial public health laboratories reported that the need to perform 

bioterrorism testing during the anthrax incidents had a negative impact on 

their ability to do routine work, delaying testing for tuberculosis, sexually 

transmitted diseases, and other infectious diseases.35

Further, public health laboratories have a minimal association with private 

laboratories (that is, laboratories that are associated with private hospitals 

or are independent) or sometimes lack ties to laboratories in other states 

that could serve as a backup to ensure timely testing of samples. One state 

we visited had one state public health laboratory, no backup laboratory, 

and no written agreements with neighboring states to provide support. A 

task force of the Association of Public Health Laboratories has written 

that a lack of close ties can lead to a lack of communication and a lack of 

coordination of laboratory testing, both of which are needed to support 

public health interventions.36 All states we visited recognized these 

problems and, in their progress reports to HHS, reported that they were 

using the funds to improve the Laboratory Response Network.37

According to their progress reports, officials in the states we visited were 

working on solutions to their laboratory problems. States were examining 

various ways to manage peak loads, including training additional staff in 

the newest bioterrorism response methods, entering into agreements with 

other states to provide surge capacity, incorporating clinical laboratories 

into cooperative laboratory systems, and purchasing new equipment. One 

state was working to alleviate its laboratory problems by providing 

training on protocols for handling bioterrorist agents, upgrading two local 

 35Association of Public Health Laboratories, 1, 3. 

36J. Witt-Kushner, J.R. Astles, J.C. Ridderhof, and others, “Core Functions and Capabilities 

of State Public Health Laboratories: A Report of the Association of Public Health 

Laboratories,” Morbidity and Mortality Weekly Report, vol. 51, no. RR-14 (2002), 1-8. 

37CDC has established the Laboratory Response Network to maintain state-of-the-art 

capabilities for biological agent identification and characterization. The Laboratory 

Response Network is a multilevel system designed to link state and local public health 

laboratories with advanced capacity clinical, military, veterinary, agricultural, water, and 

food-testing laboratories. 
Page 21 GAO-03-373 State and Local Bioterrorism Preparedness 

public health laboratories to Biosafety Level 3 laboratories,38 and 

establishing agreements with other states to provide backup capacity. 

Another state reported that it was using the funding from CDC to increase 

the number of pathogens the state laboratory could diagnose. The state 

also reported that it has worked to identify laboratories in adjacent states 

that are capable of being reached within 3 hours over surface roads. In 

addition, all of the states reported that their laboratory response plans 

were revised to cover reporting and sharing laboratory results with local 

public health and law enforcement agencies. 

Federal, state, and local officials were concerned that hospitals might not 

have the capacity to accept and treat sudden, large increases in the 

number of patients, as might be seen in a bioterrorist attack. Hospital, 

state, and local officials reported that hospitals needed additional 

equipment and capital improvements—including medical stockpiles, 

personal protective equipment, decontamination facilities, quarantine and 

isolation facilities, and air handling and filtering equipment—to enhance 

preparedness. 

The resources that hospitals would require for responding to a bioterrorist 

attack with mass casualties are far greater than what are needed for 

everyday performance. Meeting these needs fully would be extremely 

difficult because bioterrorism preparedness is expensive and hospitals are 

reluctant to create capacity that is not needed on a routine basis and may 

never be utilized at a particular facility. Although hospitals may not be able 

to fully meet all preparedness needs, they can take action to increase their 

preparedness by developing plans for their internal emergency response 

operations, and some hospital officials reported taking these initial 

actions. For example, officials at one hospital we visited appointed a 

bioterrorism coordinator and developed plans for taking care of the 

families of hospital staff, transporting patients to the hospital, and 

communicating during an emergency. However, from its assessments of 

hospital capacity, one of the states we visited reported that only 11 

percent of its hospitals could readily increase their capacity for treating 

patients with communicable diseases requiring isolation, such as 

smallpox. Another state reported that most of its hospitals have little or no 

capacity for isolating patients diagnosed with or being tested for 

 38In Biosafety Level 3 laboratories, work is done with indigenous or exotic agents with a 

potential for respiratory transmission, and which may cause serious and potentially lethal 

infection. Biosafety Level 3 laboratories provide the second-highest degree of protection to 

personnel, the environment, and the community. 

Hospitals 
Page 22 GAO-03-373 State and Local Bioterrorism Preparedness 

communicable diseases. A third state was working with the state hospital 

association to provide every hospital in the state with portable 

decontamination units. 

Efforts have been made to assist hospitals in preparing for bioterrorism. 

For example, the hospital association in one city we visited was 

developing a set of recommendations, based on the American Hospital 

Association checklist,39 along with cost estimates, for health care facilities 

to improve their preparedness. The association’s recommendations 

included that each hospital have a 3-day supply of basic personal 

protective equipment (such as gloves, gowns, and shoe covers) on hand 

for staff, a 3-day supply of specified pharmaceuticals, emergency power, a 

loud speaker or other mechanism to communicate with a large group of 

converging casualties outside of the hospital entrance, and an external 

decontamination facility capable of handling 50 victims per hour. These 

guidelines give hospitals criteria by which they can measure their 

preparedness and, in turn, improve their internal emergency response 

operation plans. 

In their progress reports to HHS, all the states we visited discussed a 

number of activities they were undertaking with the HRSA funding to 

increase hospital preparedness. These included hiring state hospital 

bioterrorism program coordinators and medical directors, exploring the 

feasibility of coordinating hospitals’ bioterrorism emergency planning 

across states, and supplying selected hospitals with biohazard suits and 

decontamination systems. 

We found that the overall level of bioterrorism preparedness varied by 

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

recurring experience with public health emergencies, including those 

resulting from natural disasters, or with preparation for National Security 

Special Events, such as political conventions,40 were generally more 

 39A. David Mangelsdorff, Chemical and Bioterrorism Preparedness Checklist (Chicago: 

American Hospital Association, Oct. 3, 2001), 

http://www.hospitalconnect.com/aha/key_issues/disaster_readiness/resources/HospitalRea

dy.html (downloaded Oct. 22, 2002). The checklist was developed to help hospitals 

describe and assess their state of preparedness for chemical and biological incidents. 

40Presidential Decision Directive 62 created a category of special events called National 

Security Special Events, which are events of such significance that they warrant greater 

federal planning and protection than other special events. In addition to major political 

party conventions, such events include presidential inaugurations. 

Level of Preparedness 

Varied across Cities We 

Visited 
Page 23 GAO-03-373 State and Local Bioterrorism Preparedness 

prepared than cities with little or no such experience. Cities that had dealt 

with multiple public health emergencies in the past might have been 

further along because they had learned which organizations and officials 

need to be involved in preparedness and response efforts and moved to 

include all pertinent parties in the efforts. Experience with natural 

disasters raised the awareness of local officials regarding the level of 

public health emergency preparedness in their cities and the kinds of 

preparedness problems they needed to address. For example, in one city 

we visited, officials found that emergency operations center personnel 

became separated from one another during earthquakes and had trouble 

staying in contact. These problems made decision making difficult. The 

officials told us that the personnel needed to learn how to use their radio 

system more effectively. (See app. I for details concerning preparedness 

by city.) 

All the cities we visited had to respond to suspected anthrax incidents in 

fall 2001; however, each city found different deficiencies in its capabilities. 

The anthrax incidents presented challenges for jurisdictions across the 

country, not just in the communities where anthrax was found. Among the 

problems that surfaced during the anthrax incidents, for example, were 

several dealing with coordination across agencies and communication 

among departments and jurisdictions and with the public. A local official 

reported that there was no mechanism to coordinate the public 

information, medical recommendations, and epidemiologic assessments 

throughout the state and neighboring areas and that this created 

considerable confusion and frustration for the public and medical 

community.41 In addition, officials in several states became aware of 

different types of limitations in their state and local communication 

capabilities during the anthrax incidents. For example, in one rural state, 

which had no confirmed anthrax cases but numerous false alarms, the 

state public health department faxed messages containing critical 

information to hospitals throughout the state. Officials in the department 

realized that this one-way system was insufficient because they also 

needed to be able to receive communications rapidly. They were able to 

increase their communication capabilities by setting up a 24-hour toll-free 

telephone number staffed by officials, who could respond to questions 

from hospitals. In another state, public health laboratory officials found 

 41S. Allan, “The Challenges of Local Preparedness for Bioterrorism and Other 

Emergencies,” NACCHO Exchange: Promoting Effective Local Public Health Practice, vol. 

1, no. 1 (2002), 1-5. 
Page 24 GAO-03-373 State and Local Bioterrorism Preparedness 

that it was difficult for many facilities to print files received from CDC 

because their Internet connections were inadequate. Ultimately, the state 

created CD-ROMs containing the protocols describing how to deal with 

suspected anthrax samples, and a state public health official drove more 

than 500 miles across the state to deliver them. 

One of the cities we visited, which had experienced a large natural disaster 

in the late 1990s, was in the early stages of bioterrorism preparedness. 

This city is in a predominantly rural state, which started receiving funds 

for establishing a HAN system for public health information in fiscal year 

2002. There were five epidemiologists at the state level and none at the 

local level, so the city depended on the state to determine when a disease 

investigation was warranted. The state had a limited passive surveillance 

system, with plans for a more elaborate, active surveillance system. 

In contrast, another city we visited was much further along in bioterrorism 

preparedness. In addition to dealing with natural disasters and other 

public health emergencies, the city had also prepared for and hosted a 

National Security Special Event. The state had been receiving funding for 

HAN since 1999. Epidemiologists were employed at the state and local 

levels. The city had a passive surveillance system, and it also had an active 

surveillance system for influenza, which has symptoms similar to those of 

the early stages of diseases attributable to several likely bioterrorist 

agents, such as anthrax. 

Even the cities that were better prepared were not strong in all elements. 

For example, one city had successfully developed an integrated approach 

to preparedness in which multiple organizations, both governmental and 

nongovernmental, examined where terrorist attacks are likely to occur, 

how they could be mitigated, and what resources were necessary. City 

officials also reported that communications had been effective during 

public health emergencies and that the city had an active disease 

surveillance system. However, officials also reported deficiencies in 

laboratory capacity and said that hospitals had not received sufficient 

bioterrorism response training. Another one of the better-prepared cities 

was connected to HAN and the Epidemic Information Exchange (Epi-X),42

and all county emergency management agencies in the state were linked. 

 42Epi-X is a secure, Web-based exchange for public health officials to rapidly exchange 

information on disease outbreaks, exposures to environmental hazards, and other health 

events as they are identified and investigated. 
Page 25 GAO-03-373 State and Local Bioterrorism Preparedness 

However, the state did not have written agreements with its neighboring 

states for responding to an emergency, and a major hospital in the city we 

visited lacked sufficient equipment for a bioterrorism response. 

State and local jurisdictions and response organizations made progress in 

developing plans to improve their preparedness. They had begun to 

include bioterrorism in their agencies’ overall emergency operation plans, 

and preparing the application plans for HHS funding helped states focus 

their planning efforts. In addition, hospitals, which were beginning to be 

seen as part of a local response system, were starting to participate in 

local response planning. While progress was made in local planning, 

regional planning between states lagged. A regional response to a 

bioterrorist attack would potentially require the mutual participation of 

officials from neighboring states or, in several instances, a neighboring 

country, yet some states lacked such coordination with their neighboring 

states and country and had not participated in joint response planning. 

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

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

specifically address the unique requirements of response to a bioterrorist 

attack. However, many of the response organizations in these cities and 

states had begun to develop emergency operation plans that include 

bioterrorism response. Officials from all of these response organizations 

stated that planning for a bioterrorist incident is difficult because they do 

not know what it means to be prepared and therefore are not sure if their 

plans will be adequate. 

At the time of our site visits, all seven states were in the stage of “planning 

to plan” for bioterrorism. While all of these states had previously taken 

steps to assess the readiness levels of their localities, they continued to 

need further assessments. For example, most were doing some 

assessments of capacity, such as assessments of hospital capacity and 

equipment. Although some of these efforts were time-consuming because 

of the need to develop assessment tools, such as surveys, the information 

on needs and current status is essential for the states to be able to plan. 

Preparing the application plans for HHS helped states to identify problems 

in bioterrorism preparedness by requiring them to address specified 

preparedness focus areas. In the application process, states were required 

State and Local 

Jurisdictions and 

Response 

Organizations Made 

Progress in 

Developing 

Preparedness Plans, 

but Regional Plans 

Remained 

Undeveloped 

State and Local 

Jurisdictions Had 

Increased Bioterrorism 

Planning Efforts 
Page 26 GAO-03-373 State and Local Bioterrorism Preparedness 

to assess their capabilities in the focus areas and discuss how they 

planned to address their deficiencies. For example, under the surveillance 

and epidemiologic capacity focus area in its application plan for CDC 

funding, one state we visited identified a lack of adequate staffing, 

expertise, and resources. Officials reported in the plan that the department 

of public health was developing regional medical epidemiology teams, 

each of which would include a part-time practicing physician and a fulltime epidemiologist, with enough teams to cover all the regions in the 

state. These teams would establish ongoing relationships with area 

hospital infection control programs, emergency departments, and other 

health care providers. Another state reported in its HRSA application plan 

that it did not have the capability to track resources, supplies, and the 

distribution of patients at the regional level. It planned to expand an 

existing electronic tracking system to track each hospital’s capacity, 

resources, and patient distribution on a real-time basis. 

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

coordinate with other local response organizations and collaborate with 

each other in local planning efforts. Hospital officials in one city we visited 

told us that until September 11, 2001, hospitals were not seen as part of a 

response to a terrorist event but that the city had come to realize that the 

first responders to a bioterrorism incident could be a hospital’s medical 

staff. Officials from the state began to emphasize the need for a local 

approach to hospital preparedness. They said, however, that it was 

difficult to impress the importance of cooperation on hospitals because 

hospitals had not seen themselves as part of a local response system. The 

local government officials were asking them to create plans that integrated 

the city’s hospitals and addressed such issues as off-site triage of patients 

and off-site acute care. 

Government officials, health care association representatives, and hospital 

officials in many of the areas that we visited stated that hospitals had 

become more interested in these issues and more involved in planning 

efforts than prior to September 11, 2001. They noted that health care 

providers in hospitals gained an awareness of the seriousness of the threat 

of bioterrorism and began to ask for information, lectures, and 

presentations of their cities’ emergency plans. Hospital representatives, as 

well as state and local officials, told us that hospital personnel were more 

interested in attending training on biological agents and that hospitals had 

formed better connections with local public health departments in many 

areas. We also found that some hospitals were starting to collaborate with 

one another on planning efforts. 

Hospitals Were Beginning 

to Recognize Need for 

Inclusion in Local Planning 
Page 27 GAO-03-373 State and Local Bioterrorism Preparedness 

Response organization officials were concerned about a lack of planning 

for regional coordination between states. As called for by the guidance for 

the cooperative agreements, all of the states we visited organized their 

planning on a regional basis, assigning local areas to particular regions for 

planning purposes. However, the state-defined regions encompassed areas 

within the state only. A concern for response organization officials was the 

lack of planning for regional coordination between states and with a 

neighboring country of the public health response to a bioterrorist attack. 

With regard to coordination efforts between states, a hospital official in 

one city we visited said that state lines presented a “real wall” for planning 

purposes. Hospital officials in one state reported that they had no 

agreements with other states to share physicians. However, one local 

official reported that he had been discussing border issues and had drafted 

mutual aid agreements for hospitals and emergency medical services. 

Public health officials from several states reported developing working 

relationships with officials from other states to provide backup laboratory 

capacity. 

States varied with regard to the intensity of their coordination efforts with 

a neighboring country. Officials in one state told us that the state lacked 

the needed coordination with the foreign country that it borders, but they 

reported in the state’s CDC application plan that workforce plans and 

infectious disease surveillance and reporting are the two priorities for the 

state with the neighboring country. The emergency management officials 

in the city we visited in that state reported that the border guards knew 

and informally coordinated with one another. Officials in this state 

reported in the state’s CDC application plan that some of the state’s 

hospitals employed people from the foreign country and so hospital 

staffing could be problematic if borders were closed during an emergency. 

However, officials in another state that we visited reported good regional 

partnerships with the foreign country that it borders. In fact, the state 

officials noted that the needs of a metropolitan area in the neighboring 

country would be evaluated and integrated into the state plan. In addition, 

the state reported in its progress report that it was developing an 

agreement with the neighboring country to provide laboratory surge 

capacity. 

Regional Planning Was 

Lacking between States 
Page 28 GAO-03-373 State and Local Bioterrorism Preparedness 

State and local officials and hospital officials expressed concerns about 

the distribution and sustainability of federal bioterrorism preparedness 

funding, as well as about a lack of guidance on what it means to be 

prepared for a bioterrorism event. State and local officials we met with 

disagreed about whether federal funding for bioterrorism preparedness 

should flow through the state or go directly to the local jurisdictions. 

Hospital officials reported that federal funding from OER’s MMRS 

program in their cities had not always been shared with them in the past. 

In addition, state and local officials reported that sustainability in funding 

over several years would be beneficial to all jurisdictions. State and local 

officials requested more specific federal guidance on what constitutes 

adequate preparedness. State officials also requested more sharing of best 

practices to assist them in closing the remaining gaps in preparedness. 

State and local officials expressed several concerns regarding the federal 

funding provided for state and local bioterrorism preparedness both 

before and after September 11, 2001. These concerns were related to the 

distribution and sustainability of these funds. 

State and local officials we met with disagreed about whether federal 

funding for bioterrorism preparedness should flow through the state or go 

directly to the local jurisdictions. Local officials suggested that some 

funding should be allocated directly to local governments because it 

would be more efficient since the state would not withhold a percentage 

for its own use. However, state officials told us that if funds went directly 

to the local level, it would be difficult for them to direct the funding to the 

areas of greatest need within the states. In addition, state officials reported 

that when money flows through the states they can control purchases of 

emergency response equipment to ensure compatibility across regions of 

the state. 

Progress reports to HHS from the seven states we visited showed great 

variability in the speed with which the states committed funds provided 

through the CDC cooperative agreements, in part because of the differing 

state requirements for distribution. Two of the states had obligated more 

than 70 percent of the funding they received from HHS as of fall 2002, 

while two other states had obligated only about 20 percent of their funds 

as of the same time, with the remaining three states obligating percentages 

between these figures. Some states reported that they needed to arrange 

for grants or take other actions before they could transfer any of the funds 

to local jurisdictions. 

State and Local 

Officials Expressed 

Concerns regarding 

Federal Funding and 

Lack of Guidance 

Funding Concerns Were 

Related to Distribution and 

Sustainability 

Distribution
Page 29 GAO-03-373 State and Local Bioterrorism Preparedness 

Hospital officials also raised concerns about the distribution of federal 

funding for preparedness. In a national survey, 62 percent of hospital 

officials said that a lack of awareness of federally sponsored preparedness 

programs was a factor in not participating in preparedness programs.43 In 

addition, hospital officials that we spoke with in two cities added that 

federal funding from OER’s MMRS program in their cities had not been 

shared with hospitals in the past. The HRSA program may help alleviate 

these problems. It has led to increased coordination among government 

agencies, which may lead to an increased awareness of the funding 

opportunity it provides. In addition, the HRSA guidance on funding under 

the cooperative agreement requires that approximately three-quarters of 

the funding be spent directly on or in hospitals, community health clinics, 

and other health care systems. HRSA also requires states to undertake 

certain initial state-level tasks that would not involve costs to the 

hospitals, including designating a hospital bioterrorism preparedness 

coordinator, establishing a statewide advisory committee, and conducting 

a needs assessment. In their progress reports to HHS, all states we visited 

reported that the HRSA funding was being used primarily to support such 

initial state-level activities, including conducting assessments, developing 

plans, and hiring state-level personnel. HHS recently stated that most, if 

not all, states have now determined how funding will be awarded to 

hospitals, community health clinics, and other health care systems. 

During our site visits, state officials also expressed concerns in light of the 

budget shortfalls and cuts they were experiencing. Officials from one state 

expressed concern that the 2002 funding from HHS might be used to 

supplant state funding instead of supplementing it, because of general 

budgetary cutbacks in the state, although such use is expressly prohibited 

by the funding agreements. An official from another state told us that the 

funding that its state public health laboratory received in 2002 from CDC 

for bioterrorism preparedness was not enough to offset the general cuts in 

the state budget for the public health laboratory. We were not able to 

determine whether any of the state funds were supplanted by the HHS 

funding. 

The public health infrastructure depends on sustained and consistent 

investment, yet in the past the funding has been viewed as unsystematic.44

 43Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving 

Weapons of Mass Destruction, Third Annual Report, G-7-9. 

44Institute of Medicine of the National Academies, xi. 

Sustainability
Page 30 GAO-03-373 State and Local Bioterrorism Preparedness 

In fiscal year 2002, states were experiencing budget shortfalls (as a 

percentage of general fund revenues) that were worse than after the 

recession of the early 1990s ended,45 and shortfalls in 2003 were expected 

to be even worse. The influx of federal funds for bioterrorism 

preparedness made it possible for jurisdictions to undertake new efforts in 

this area, at a time when other public health programs were experiencing 

cutbacks. 

State and local officials told us that sustained funding would be necessary 

to address one important need—hiring and retaining needed staff. They 

told us they would be reluctant to hire additional staff unless they were 

confident that the funding would be sustained and staff could be retained. 

These statements are consistent with the findings of the Advisory Panel to 

Assess Domestic Response Capabilities for Terrorism Involving Weapons 

of Mass Destruction, which recommended that federal support for state 

and local public health preparedness and infrastructure building be 

sustained at an annual rate of $1 billion for the next 5 years to have a 

material impact on state and local governments’ preparedness for a 

bioterrorist event.46 We have noted previously that federal, state, and local 

governments have a shared responsibility in preparing for terrorist attacks 

and other disasters.47 However, prior to the infusion of federal funds, few 

states were investing in their public health infrastructure. 

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

more federal guidance and sharing of best practices to assist them in 

closing the remaining gaps in preparedness. Officials from response 

organizations in every state we visited reported a lack of guidance from 

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

In the past, CDC has made efforts to develop guidance for state and local 

public health officials on bioterrorism preparedness. For example, in its 

core capacity project of 2001, CDC developed criteria to provide guidance 

 45In 1991, which was the formal end of the recession, state budget shortfalls were 6.2 

percent of total state general fund revenues. In 1992, shortfalls were 6.5 percent of 

revenues. Fiscal year 2002 state budget shortfalls are estimated to be 7.8 percent of 

estimated total general fund revenues. 

46Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving 

Weapons of Mass Destruction, Fourth Annual Report, v. 

47See U.S. General Accounting Office, Homeland Security: Effective Intergovernmental 

Coordination Is Key to Success, GAO-02-1013T (Washington, D.C.: Aug. 23, 2002). 

State and Local Officials 

Requested Specific Federal 

Benchmarks for Adequate 

Preparedness and Sharing 

of Best Practices 
Page 31 GAO-03-373 State and Local Bioterrorism Preparedness 

on developing the bioterrorism preparedness capacity of state and local 

public health systems. However, these criteria were broad and 

nonspecific. State and local officials told us they needed specific 

benchmarks (such as how large an area a response team should be 

responsible for) to indicate what they should be doing to be adequately 

prepared. Local officials were turning to state officials for guidance, and 

state officials wanted to be able to turn to the federal government. 

Response organizations have been hindered in their efforts to prepare for 

bioterrorism because they do not know what agents pose the most 

credible threat, which makes it difficult to know when they are prepared. 

There have been federal efforts to devise lists of threats, but as we 

reported,48 these efforts have been fragmented, as is evident in the 

different biological agent threat lists that were developed by federal 

departments and agencies. In addition, medical organizations have 

historically not been recipients of intelligence regarding threat 

information. The Institute of Medicine and the National Research Council 

have stated that this practice needs to be changed.49

The need for federal guidance has continued to be an issue as states have 

proceeded in their planning and preparedness activities using the HHS 

funding. For example, in their progress reports to HHS in late 2002, two of 

the states we visited reported that they were seeking guidance from HHS 

on assessing vulnerabilities for foodborne or waterborne diseases and 

preparedness steps they should take for these hazards. One of these states 

declared that it could not make further efforts on testing for waterborne or 

agricultural diseases until it received more guidance. States also reported 

needing guidance in such areas as using the CDC emergency notification 

systems. 

State and local officials were interested in receiving detailed guidance 

from HHS to be able to better assess their progress and develop realistic 

time frames. One state we visited wrote in its progress report that CDC’s 

development of pre-event guidelines for use of the vaccinia vaccine for 

smallpox would be crucial for providing consistent practices nationwide. 

 48GAO-01-915. 

49Institute of Medicine, Chemical and Biological Terrorism: Research and Development to 

Improve Civilian Medical Response (Washington, D.C.: National Academy Press, 1999), 

and National Research Council, Making the Nation Safer: The Role of Science and 

Technology in Countering Terrorism (Washington, D.C.: National Academies Press, 2002). 
Page 32 GAO-03-373 State and Local Bioterrorism Preparedness 

It also wrote that it would be useful to have an approved method for 

evaluating laboratory response to ensure that minimum standards were 

being met. Two other states wrote that they would like CDC to provide 

guidance for developing emergency operation plans. 

CDC has begun to provide more detailed guidance in some areas. For 

example, it is developing standards for the National Electronic Disease 

Surveillance System, which serves as the foundation for many states’ 

bioterrorism information systems. Under this system, standards are being 

developed to ensure uniform data collection and electronic reporting 

practices across the nation. Another initiative that is providing guidance 

on communication is CDC’s Public Health Information Network. This 

network is intended to build on and integrate existing public health 

communication systems and will include public health data standards to 

ensure the compatibility of the communication systems used by the health 

care community and federal, state, and local public authorities. In 

addition, CDC has made efforts in developing new laboratory protocols. 

One state noted that CDC’s efforts have been of the highest standard, and 

the protocols received have been designed for easy implementation at the 

state level. 

Officials at the state level also expressed a desire for more sharing of best 

practices. Officials stated that although each jurisdiction might need to 

adapt procedures to its own circumstances, time could be saved and 

needless duplication of effort avoided if there were better mechanisms for 

sharing strategies across jurisdictions. They contended that HHS was 

positioned to know about different strategies that states were pursuing. 

For example, one state wrote in its progress report that it would be useful 

for HHS to provide information on syndromic surveillance systems that 

were operational. In its progress report, another state wrote that it had 

requested the portions of other states’ application plans related to risk 

communication and health information dissemination. The state wanted to 

include its Native American population in preparedness planning and was 

looking for best practices on how to involve tribal governments in 

planning. 

Some officials particularly expressed a desire for increased information 

sharing of best practices among state and local jurisdictions on various 

types of training. Many jurisdictions were developing training programs to 

increase bioterrorism preparedness. One state official told us during our 

visit that his agency needed training material on handling incidents, but he 

did not want to duplicate others’ efforts by developing his own materials. 

In their progress reports, five of the seven states we visited indicated that 
Page 33 GAO-03-373 State and Local Bioterrorism Preparedness 

they would like CDC’s help in obtaining training information. One state 

wrote that establishing national standards for training and training aids for 

laboratories would minimize the need for individual states or regions to 

develop their own materials. Another state requested assistance with 

Strategic National Stockpile and smallpox education and training 

materials, and a third state requested training videos or videos of tabletop 

exercises to study. One state suggested that it would be useful for CDC to 

organize an Internet site and teleconferences among states to facilitate 

information sharing. 

As concerns about bioterrorism and other public health emergencies, 

including newly emerging infectious diseases such as West Nile virus, have 

surfaced over the past few years, cities across the nation have been 

working to increase their preparedness for responding to such events. An 

essential first step for cities was to recognize some of the deficiencies that 

existed in their public health infrastructures and how these would affect 

their ability to respond to a bioterrorism event. 

Cities have recognized and begun to work on deficiencies in elements of 

coordination, communication, and capacity necessary for bioterrorism 

preparedness. Progress in addressing capacity issues has lagged behind 

progress in other areas, in part because finding solutions to deficiencies in 

capacity can be complicated by the magnitude of the resource needs. For 

example, the resources that hospitals would require for responding to a 

biological attack would be greater than what are normally needed. Local 

authorities can shift resources between functions and plan for ways to 

expand capacity in an emergency. However, shifting resources between 

functions can cause serious problems if the emergency is an extended one 

and other important responsibilities are not being met. Needs for 

additional capacity for responding to bioterrorism emergencies must be 

balanced with preparedness for all types of emergencies and must not 

detract from meeting the everyday needs of cities for emergency care. 

Regional plans can help address capacity deficiencies by providing for the 

sharing across localities of resources that, while adequate for everyday 

needs, may be in short supply on a local level in an emergency. 

Our observations of state and local preparedness for bioterrorism in 

selected cities bring certain other needs into focus as well. First, there is 

not yet a consensus on what constitutes adequate preparedness for a 

public health emergency, including a bioterrorist incident, at the state and 

local levels. There have been some efforts to provide guidelines for 

hospital preparedness, but specific standards for state and local 

Conclusions 
Page 34 GAO-03-373 State and Local Bioterrorism Preparedness 

preparedness are lacking. Officials from state and local response 

organizations expressed a need for specific benchmarks from the federal 

government, which could lead to consistent standards across all states. 

This could also facilitate needed regional planning across state 

boundaries. 

Second, we noted several instances in which cities found solutions to 

deficiencies that they identified. For example, cities developed methods 

for triaging samples during the anthrax incidents. Federal mechanisms for 

sharing innovations and other resources, such as fact sheets on infectious 

diseases and training materials, could prevent states and cities from 

having to develop solutions to common problems individually. The federal 

government could take additional steps to assist these states and cities in 

efficiently and effectively increasing their preparedness. 

To help state and local jurisdictions better prepare for a bioterrorist 

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

in consultation with the Secretary of Homeland Security, 

• develop specific benchmarks that define adequate preparedness for a 

bioterrorist attack and can be used by state and local jurisdictions to 

assess and guide their preparedness efforts and 

• develop a mechanism by which solutions to problems that have been used 

in one jurisdiction can be evaluated by HHS and, if appropriate, shared 

with other jurisdictions. 

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

Homeland Security. HHS submitted written comments, which are 

reprinted in appendix III. HHS said the report provides an informative 

assessment of preparedness for bioterrorism and other public health 

emergencies at the state and local levels. HHS concurred with our 

recommendations. The liaison from the Department of Homeland Security 

provided oral comments noting the department’s concurrence with the 

draft report and the recommendations. 

In its comments, HHS stated that it is taking steps to address the concerns 

we identified. For example, the department noted that both CDC and 

HRSA will issue guidance that will emphasize coordination of planning on 

a regional level. HHS also stated that CDC and HRSA will be developing 

guidelines and templates to assist states in identifying specific 

benchmarks and that the Office of the Assistant Secretary for Public 

Recommendations for 

Executive Action 

Agency Comments 
Page 35 GAO-03-373 State and Local Bioterrorism Preparedness 

Health Emergency Preparedness will be leading an effort to create a 

repository of best practices. 

HHS noted that it has been a year since our site visits and that during that 

period both state and local health departments have made further strides 

in their efforts to achieve preparedness for bioterrorism and other public 

health emergencies. We noted in the draft report that we include 

information obtained from state officials several months after our site 

visits. As we also noted in the draft report, we recognize that changes 

continue to occur. However, many of the problems we identified will 

require sustained efforts, and HHS said that it is now taking steps that are 

intended to facilitate further progress. 

HHS also provided technical comments, which we incorporated where 

appropriate. 

We are sending copies of this report to the Secretary of Health and Human 

Services and the Secretary of Homeland Security, and other interested 

officials. We will also provide copies to others upon request. In addition, 

the report will be available at no charge on GAO’s Web site at 

http://www.gao.gov. 

If you or your staffs have any questions about this report, please call me at 

(202) 512-7119. Another contact and key contributors are listed in 

appendix IV. 

Janet Heinrich 

Director, Health Care—Public Health Issues 
Page 36 GAO-03-373 State and Local Bioterrorism Preparedness 

List of Committees 

The Honorable Judd Gregg 

Chairman 

The Honorable Edward M. Kennedy 

Ranking Minority Member 

Committee on Health, Education, Labor, and Pensions 

United States Senate 

The Honorable Ted Stevens 

Chairman 

The Honorable Robert C. Byrd 

Ranking Minority Member 

Committee on Appropriations 

United States Senate 

The Honorable W.J. “Billy” Tauzin 

Chairman 

The Honorable John D. Dingell 

Ranking Minority Member 

Committee on Energy and Commerce 

House of Representatives 

The Honorable C.W. Bill Young 

Chairman 

The Honorable David Obey 

Ranking Minority Member 

Committee on Appropriations 

House of Representatives 
Appendix I: Bioterrorism Preparedness in 

Seven Case Cities 

Page 37 GAO-03-373 State and Local Bioterrorism Preparedness 

Table 1 provides comparisons across several elements of preparedness for 

each of the seven cities we visited. The purpose of this table is to provide 

additional context for the discussion in the report and some understanding 

of the strengths and weaknesses of each city in preparing for a bioterrorist 

attack and how these strengths and weaknesses vary among the cities. The 

information in this table was obtained from December 2001 through March 

2002. The cities have continued to make changes to improve their 

bioterrorism preparedness; however, this table does not reflect those 

changes. 

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

 City A City B City C City D City E City F City G 

Context 

City population Under 

300,000 

300,000- 

1,000,000 

Over 

1,000,000 

300,000-

1,000,000 

Over 

1,000,000 

300,000-

1,000,000 

Under 

300,000 

State has a foreign 

border 

Yes No No Yes Yes No No 

Metropolitan area has a 

port 

Yes Yes Yes Yes Yes No Yes 

City had received 

funding from the 

Metropolitan Medical 

Response System 

(MMRS)a program 

No Yes Yes Yes Yes Yes Yes 

City had responded to 

suspected anthrax 

incidents, other public 

health emergencies, or 

both within previous 5 

years 

Yes Yes Yes Yes Yes Yes Yes 

City prepared and 

hosted a National 

Security Special Eventb

within previous 5 years 

No No Yes Yes Yes No No 

Disease surveillance, 

follow-up, and agent 

identification 

 

Statewide passive 

disease surveillance 

systemc

Yes Yes Yes Yes Yes Yes Yes 

Statewide active disease 

surveillance systemd

Yes Yes No No Yes No Yes 

Local active disease 

surveillance systemd

No Noe

 Noe Yes Yes No No 

One or more 

epidemiologists in local 

public health agency 

No Yes Yes Yes Yes Yes Yes 

Appendix I: Bioterrorism Preparedness in 

Seven Case Cities 
Appendix I: Bioterrorism Preparedness in 

Seven Case Cities 

Page 38 GAO-03-373 State and Local Bioterrorism Preparedness 

 City A City B City C City D City E City F City G 

One or more 

epidemiologists in state 

public health agency 

Yes Yes Yes Yes Yes Yes Yes 

One or more Biosafety 

Level 3 laboratories in 

the statef

Yes Yes Yes Yes Yes Yes Yes 

Treatment capacity 

Drug stockpile 

maintained by cityg

No Yes Yes Yes Yes No Yes 

Drug stockpile 

maintained by hospitalh

Yes Yes Yes Yes Yes No Yes 

Hospital had sufficient 

bioterrorism response 

training, per self-report 

No No No No No No No 

Hospital had sufficient 

equipment for 

bioterrorism response, 

per self-reporti

No No No No No No No 

Responder 

communications 

 

Communications 

between emergency 

responders had been 

effective during public 

health emergencies, per 

self-report 

No No No No Yes No No 

City had compatible 

radio system 

Yes Yes Yes Yes Yes No Yes 

State public health 

resources 

 

State had a plan for 

using the Strategic 

National Stockpile 

Yesj Yesj Yes Yes Yesj Yes Yesj

State public health office 

used Health Alert 

Network (HAN)k

No Yes No Yes Yes No Yes 

Local public health office 

used HANk

No Yes No Yes Yes No Yes 

Cooperation among 

responders 

 

Written agreements exist 

to cooperate with 

neighboring state(s) 

Yes No Yes No No Yes No 

Coordination with 

neighboring country 

No NAl NAl Yes No NAl NAl

Local officials had 

developed a system for 

triaging samples prior to 

the 2001 anthrax 

incidents 

No No No No Yesm No No 

Source: GAO. 
Appendix I: Bioterrorism Preparedness in 

Seven Case Cities 

Page 39 GAO-03-373 State and Local Bioterrorism Preparedness 

Note: GAO analysis of information obtained from visits to each of the cities. 

a

The MMRS program is an Office of Emergency Response (OER) program intended to develop or 

enhance the local response to a public health crisis, especially an attack using weapons of mass 

destruction. It takes a comprehensive local approach by assembling hospitals, emergency managers, 

the public health establishment, and others to deal with the consequences of an attack. Cities enter 

into contracts with OER for a predetermined period. For more information on the MMRS program, see 

U.S. General Accounting Office, Bioterrorism: Federal Research and Preparedness Activities, 

GAO-01-915 (Washington, D.C.: Sept. 28, 2001). 

b

Presidential Decision Directive 62 created a category of special events called National Security 

Special Events, which are events of such significance that they warrant greater federal planning and 

protection than other special events. Such events include presidential inaugurations and major 

political party conventions. 

c

Passive disease surveillance systems rely on laboratory and hospital staff, physicians, and other 

relevant sources to take the initiative to provide data on illnesses to health departments, where 

officials analyze and interpret the information as it comes in. 

d

In an active disease surveillance system, public health officials contact sources, such as laboratories, 

hospitals, and physicians, to obtain information on conditions or diseases in order to identify cases. 

e

City had implemented an active disease surveillance system in the past for a public health 

emergency or special event but had discontinued the system. 

f

Biosafety levels represent combinations of laboratory practices and techniques, safety equipment, 

and laboratory facilities. Each combination is specifically appropriate for the operations performed, 

the documented or suspected routes of transmission of the infectious agents, and the laboratory 

function or activity. In Biosafety Level 3 facilities, work is done with indigenous or exotic agents with a 

potential for respiratory transmission, and which may cause serious and potentially lethal infection. 

Level 3 laboratories provide the second-highest degree of protection to personnel, the environment, 

and the community. 

g

The drug stockpile is maintained by the local responders (not including individual hospitals). These 

city stockpiles are independent of the federal Strategic National Stockpile, a repository of 

pharmaceuticals, antidotes, and medical supplies that can be delivered to the site of a bioterrorist (or 

other) attack. 

h

A “yes” entry indicates that officials from at least one hospital that we spoke with in that city gave a 

positive response. These hospital stockpiles are independent of the federal Strategic National 

Stockpile. 

i

Equipment includes personal protective gear or decontamination equipment. 

j

The state had a draft plan or was developing a plan. 

k

HAN is a Centers for Disease Control and Prevention program that supports the exchange of key 

public health information over the Internet and other communication methods, such as two-way radio. 

l

NA means not applicable; this state has no foreign borders. 

m

During the anthrax incidents of 2001, the locality built on the existing triage system. 
Appendix II: Scope and Methodology 

Page 40 GAO-03-373 State and Local Bioterrorism Preparedness 

We visited seven cities selected to provide wide variation in geographic 

location, population size, and experience with natural disasters and large 

exercises. Recommendations from experts, including officials from the 

Department of Health and Human Services (HHS) Office of Emergency 

Response and the National Association of County and City Health 

Officials, were also considered in the selection of cities. We also visited 

each city’s state government. The cities visited are not identified in this 

report because of the sensitive nature of the issue. 

During the multiday site visits, which we conducted from December 2001 

through March 2002, we interviewed officials from state and local public 

health departments, local emergency medical services, state and local 

emergency management agencies, local fire and law enforcement 

agencies, and hospitals and national public health care associations. We 

asked them about their activities related to preparing for and responding 

to bioterrorism, lessons learned from past natural disasters and the 

anthrax incidents in October 2001, past and current federal funding for 

helping state and local agencies prepare for bioterrorism, and gaps and 

weaknesses as well as strengths and successes in their readiness for 

bioterrorism. We reviewed copies of the bioterrorism preparedness plans 

states sent to HHS in spring 2002 for cooperative agreement funding from 

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

Resources and Services Administration (HRSA). In addition, to update our 

data, we obtained follow-up information from state and local officials and 

reviewed the 6-month progress reports on the CDC and HRSA cooperative 

agreements that were submitted to HHS in late 2002 from the relevant 

states, covering the period through October 31, 2002. Because our focus 

was on the public health and medical consequences of a bioterrorist event, 

we do not report on preparedness efforts funded by the Department of 

Justice and the Federal Emergency Management Agency in this study. 

The results of our visits cannot be generalized to the entire country. In 

addition, the hospitals we included in our site visits were chosen based on 

recommendations of local public health officials and hospital associations. 

This resulted in a mix of private and public hospitals, but because of the 

selection method, the results cannot be generalized to all hospitals in the 

areas we visited. 

We interviewed officials from HHS’s Office of the Assistant Secretary for 

Public Health Emergency Preparedness regarding its efforts to improve 

state and local preparedness for responding to a bioterrorist incident. 

Appendix II: Scope and Methodology 
Appendix II: Scope and Methodology 

Page 41 GAO-03-373 State and Local Bioterrorism Preparedness 

We reviewed reports from the Advisory Panel to Assess Domestic 

Response Capabilities for Terrorism Involving Weapons of Mass 

Destruction1

 and reports from several associations, including the American 

Hospital Association, the National Association of County and City Health 

Officials, and the American College of Emergency Physicians. We 

conducted interviews with representatives from several associations, 

including the American Hospital Association, the Association of State and 

Territorial Health Officials, and the National Governors Association. We 

also reviewed a report by the U.S. Conference of Mayors about local costs 

associated with bioterrorism preparedness.2

 In addition, we examined the 

President’s budget request for bioterrorism preparedness for fiscal year 

2003. 

Because of the events of the fall of 2001, and the subsequent federal 

preparedness funding, changes were occurring at the state and local levels 

with regard to bioterrorism preparedness during our site visits and 

subsequent data collection. Changes have continued to occur and this 

report may not reflect all these changes. 

We conducted our work from November 2001 through April 2003 in 

accordance with generally accepted government auditing standards. 

 1

Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving 

Weapons of Mass Destruction, Third Annual Report to the President and the Congress of 

the Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving 

Weapons of Mass Destruction (Arlington, Va.: RAND, Dec. 15, 2001), and Fourth Annual 

Report to the President and the Congress of the Advisory Panel to Assess Domestic 

Response Capabilities for Terrorism Involving Weapons of Mass Destruction (Arlington, 

Va.: RAND, Dec. 15, 2002). 

2

The United States Conference of Mayors, The Cost of Heightened Security in America’s 

Cities: A 192-City Survey (Washington, D.C.: City Policy Associates, January 2002). 
Appendix III: Comments from the Department of Health and Human Services 

Page 42 GAO-03-373 State and Local Bioterrorism Preparedness 

Appendix III: Comments from the 

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

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

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

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

Acknowledgments 

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

Marcia Crosse, (202) 512-7119 

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

Robert Copeland, Deborah Miller, and Roseanne Price made key 

contributions to this report. 

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Acknowledgments 
Related GAO Products 

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

Chemical and Biological Defense: Observations on DOD’s Risk 

Assessment of Defense Capabilities. GAO-03-137T. Washington, D.C.: 

October 1, 2002. 

Anthrax Vaccine: GAO’s Survey of Guard and Reserve Pilots and 

Aircrew. GAO-02-445. Washington, D.C.: September 20, 2002. 

Homeland Security: New Department Could Improve Coordination but 

Transferring Control of Certain Public Health Programs Raises 

Concerns. GAO-02-954T. Washington, D.C.: July 16, 2002. 

Homeland Security: New Department Could Improve Biomedical R&D 

Coordination but May Disrupt Dual-Purpose Efforts. GAO-02-924T. 

Washington, D.C.: July 9, 2002. 

Homeland Security: New Department Could Improve Coordination but 

May Complicate Priority Setting. GAO-02-893T. Washington, D.C.: 

June 28, 2002. 

Homeland Security: New Department Could Improve Coordination but 

May Complicate Public Health Priority Setting. GAO-02-883T. 

Washington, D.C.: June 25, 2002. 

Bioterrorism: The Centers for Disease Control and Prevention’s Role in 

Public Health Protection. GAO-02-235T. Washington, D.C.: November 15,

2001. 

Bioterrorism: Review of Public Health Preparedness Programs. GAO-02-

149T. Washington, D.C.: October 10, 2001. 

Bioterrorism: Public Health and Medical Preparedness. GAO-02-141T. 

Washington, D.C.: October 9, 2001. 

Bioterrorism: Coordination and Preparedness. GAO-02-129T. 

Washington, D.C.: October 5, 2001. 

Bioterrorism: Federal Research and Preparedness Activities. GAO-01-

915. Washington, D.C.: September 28, 2001. 

Chemical and Biological Defense: Improved Risk Assessment and 

Inventory Management Are Needed. GAO-01-667. Washington, D.C.: 

September 28, 2001. 

Related GAO Products 
Related GAO Products 

Page 48 GAO-03-373 State and Local Bioterrorism Preparedness 

West Nile Virus Outbreak: Lessons for Public Health Preparedness. 

GAO/HEHS-00-180. Washington, D.C.: September 11, 2000. 

Combating Terrorism: Need for Comprehensive Threat and Risk 

Assessments of Chemical and Biological Attacks. GAO/NSIAD-99-163. 

Washington, D.C.: September 14, 1999. 

Chemical and Biological Defense: Program Planning and Evaluation 

Should Follow Results Act Framework. GAO/NSIAD-99-159. Washington, 

D.C.: August 16, 1999. 

Combating Terrorism: Observations on Biological Terrorism and Public 

Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16, 

1999. 

(290087) 
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