1 GAO/HEHS-00-142R West Nile Virus

United States General Accounting Office

Washington, DC 20548

Health, Education, and

Human Services Division

B-285709

June 23, 2000

The Honorable Daniel Patrick Moynihan

The Honorable Charles E. Schumer

United States Senate

The Honorable Gary L. Ackerman

The Honorable Joseph Crowley

The Honorable Eliot L. Engel

The Honorable Vito J. Fossella

The Honorable Carolyn B. Maloney

The Honorable Jerrold L. Nadler

The Honorable Major R. Owens

The Honorable Charles B. Rangel

The Honorable Jose E. Serrano

The Honorable Edolphus Towns

The Honorable Anthony D. Weiner

House of Representatives

Subject: West Nile Virus: Preliminary Information on Lessons Learned

At your request we are performing a review of the lessons learned from the 1999

outbreak of West Nile virus in New York City and surrounding areas, for bioterrorism

preparedness and related public health policies. This letter, as requested by your office,

provides information on our progress to date and our preliminary findings.

We are currently completing fieldwork for this assignment, including interviews with and

documentation gathering from key officials and agencies involved in the identification of

and response to the outbreak last fall. These parties include: the infectious disease

physician in northern Queens who first reported the unusual illnesses; city and state

health department and emergency preparedness officials who responded to the report;

Centers for Disease Control and Prevention (CDC) epidemiological, emergency

preparedness and other officials involved in the outbreak; federal, state, and academic

laboratories contributing to the identification of the virus including the laboratories of the

Department of Agriculture, the Department of the Army, and the University of

California, Irvine; wildlife and zoo officials who tracked the virus’s impact on birds, and

others. Our work is designed to provide information on
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 The significant events and communications that occurred between key involved

parties and agencies throughout the crisis, from the first doctors who diagnosed the

illness to the federal officials mounting a response, and

 The lessons learned from these events for bioterrorism preparedness and related

public health policies.

Information collected to date indicates that many officials and experts believe aspects of

the outbreak investigation went very quickly and very well. These include the

physician’s reporting of the initial unusual symptoms and the role the local health

department epidemiologists played in quickly mobilizing a broad-based outbreak

investigation. Further, particular aspects of the communications between involved parties

were considered useful for disseminating information. For example, throughout much of

the crisis, daily conference calls on the status of events were conducted involving

officials from as many as 18 different local, state, federal and other agencies. Finally,

experts also point out that, while the virus was initially incorrectly diagnosed as another

related virus, the misdiagnosis did not affect the appropriate treatments for patients or the

public health response.

Most parties interviewed to date also believe there are lessons to be learned from the

events, particularly related to communication and infrastructure issues, that may be

relevant in designing future preparedness measures. Even though this was a relatively

small outbreak, it consumed the time of dozens if not hundreds of officials from local,

state, and federal public health and other agencies and organizations, and greatly strained

available resources. Many involved officials believe that the outbreak was another

“wake-up call” that public health officials must anticipate and be better prepared to

respond to such surprises. Officials also believe that the outbreak illustrates the need for

a better public health infrastructure at the local, state, and national level to control

infectious diseases, particularly those that are vector-borne. Work to date indicates that

any problems identified are likely to revolve around such things as the following:

• Communication between and among local, state, and federal public health agencies.

Rapid and reliable communication between public health agencies is considered essential

to preparedness and coordination—as the ability to disseminate and share information

rapidly among public health officials helps ensure that decisions are made with the most

current information available. Officials involved in the West Nile events indicated that

the communications that occurred (for example, the daily conference calls and phone

conversations between agency and organization officials) helped update involved parties

as the investigation unfolded. However, some key officials indicated to us that they

believed this means of sharing information was time-consuming and inefficient and that

alternatives for communicating detailed information were needed so they could use their

expertise and skills to conduct the investigation. Some people also indicated that there

was much confusion during the course of events about “who to call” for various types of

information or to handle various responsibilities or who within each agency could be

considered a responsible spokesperson and information source.
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• Communication between public health agencies and other organizations with relevant

information, such as animal health experts. Livestock animals and wildlife are often

considered sentinels, providing an early warning device for diseases that could harm

people. Assessments of the West Nile events and many officials we interviewed said that

the events highlighted the need for better integration and communication between

animal/wildlife health communities and public health. Since the initial outbreak, CDC,

state wildlife veterinarians, and an expanding group of federal and other agencies are

using deaths in crows as sentinel events to define the current geographic distribution of

mosquitoes and birds infected with West Nile virus.

• The adequacy of epidemiological capacity and local level disease surveillance systems.

The outbreak was initially identified because an astute physician reported two unusual

cases of illness to the City Health Department, and active surveillance in New York City

confirmed 62 human cases of the disease. Physicians are required to report encephalitis

cases to the Health Department; however, the West Nile investigation confirmed that

such reporting often did not occur. During the West Nile investigation, the six New York

City Health Department staff who normally track over 50 reportable infectious diseases

in the city—along with several others detailed to assist from other divisions and

agencies—worked long hours seven days a week to contact relevant officials at 70

hospitals to identify potential cases, interview patients and families, track cases, and

ensure laboratory samples were shipped to appropriate parties, among other duties.

Officials indicated that the availability of even the small number of trained staff in New

York City was critical to the quick response to the initial outbreak. Such capacity at the

local level is thought to be lacking in many other locations.

• The adequacy of laboratory capacity—especially “surge capacity” to allow a quick

response to an unexpected crisis. A frequent theme of discussions and assessments has

been the adequacy of laboratory infrastructure at the state and federal levels for

performing timely and thorough laboratory analyses. Officials pointed out that there are

only two federal laboratories capable of handling those infectious agents considered of

most concern. Further, most laboratories, including veterinary laboratories, are not

equipped to identify diseases that are rarely seen. Inadequate “surge capacity,” the ability

to deal with a sudden increase in needed testing, was another cited concern. According

to officials we spoke with, laboratory capacity for performing the tests needed to identify

the West Nile virus and to diagnose which people had the virus was consumed quickly by

this relatively small outbreak.

• Potential problems in distinguishing between a naturally occurring biological outbreak

and one that is intentionally caused. While the West Nile virus outbreak is thought to

have been a naturally-occurring event and officials interviewed indicated that the

investigation did not find otherwise, at one point there was speculation in media reports

that the outbreak might have had an unnatural (bioterrorist) origin. Because of this,

experts indicate that this episode does illustrate the potential problems in distinguishing

natural disease from an intentional attack. The source of the disease (whether natural or

intentional) would not change the process to diagnose and treat patients. However, if

local health officials are informed of a bioterrorist incident or threat, or if a health

department or CDC investigation determines that an event is likely a bioterrorist one,

then additional organizations would need to become involved to carry out a criminal

investigation. Current recommended protocols are to notify the Federal Bureau of
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Investigation and law enforcement officials, who would also seek to determine whether

terrorists had targeted additional locations for release of the disease.

We will be providing a final report of our findings in early September 2000, including

more detailed information and agency comments. As agreed, unless you publicly

announce the contents of this letter earlier, we plan no further distribution of it until 3

days from the date of this letter. At that time, we will send copies to the Honorable

Jeffrey P. Koplan, Director of CDC, the Honorable Dan Glickman, Secretary of

Agriculture, and other interested parties. We will make copies available to others upon

request. If you or your staffs have any questions, please contact me at (202) 512-7119.

Other major contributors to this letter included Linda Bade, Marcia Crosse, Katherine

Iritani, Anita Kay, and Deborah Miller.

Janet Heinrich

Associate Director, Health Financing and

Public Health Issues

(201062)