INFECTIOUS 

DISEASE THREATS

Funding and 

Performance of Key 

Preparedness and 

Capacity-Building 

Programs

Report to Congressional Committees

May 2018

GAO-18-362

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-362, a report to

congressional committees.

Date

May 2018

INFECTIOUS DISEASE THREATS

Funding and Performance of Key Preparedness and 

Capacity-Building Programs

What GAO Found

The Department of Health and Human Services (HHS) has three key 

preparedness and capacity-building programs—Epidemiology and Laboratory 

Capacity for Infectious Diseases (ELC), the Hospital Preparedness Program 

(HPP), and Public Health Emergency Preparedness (PHEP). These three 

programs awarded about $21.2 billion to states and other jurisdictions from 2002

through 2017 to carry out public health preparedness and response efforts, 

including those related to infectious diseases, natural disasters, or terrorist 

events. Of this amount, $18.4 billion were awards funded from annual 

appropriations. The remaining was funded from supplemental appropriations to 

respond to specific infectious disease threats, including Zika, Ebola, and H1N1 

pandemic influenza. HHS officials and non-federal stakeholders told GAO that 

supplemental appropriations were important for supporting necessary surges in 

capacity, but the timing of additional awards can limit response.

HHS’s Three Key Preparedness and Capacity-Building Programs: ELC, HPP, and 

PHEP

Program Purpose of awards provided to states and other 

jurisdictions

Epidemiology and 

Laboratory Capacity for 

Infectious Diseases (ELC)

Supports epidemiologists, surveillance systems, and 

laboratory facilities to build state and local capacity to 

combat domestic infectious disease threats.

Hospital Preparedness 

Program (HPP)

Improves medical surge capacity by enhancing community 

and health system preparedness for various public health 

threats, including infectious disease threats.

Public Health Emergency 

Preparedness (PHEP) 

Strengthens state and local public health departments’ 

ability to prepare for a variety of public health threats, 

including infectious disease threats.

Source: GAO summary of the Department of Health and Human Services’ (HHS) program information. | GAO-18-362

HHS’s three key preparedness and capacity-building programs measure 

performance in four areas that directly relate to infectious disease preparedness 

capacity—electronic lab reporting, epidemiology capacity, laboratory capacity, 

and responder protection. The majority of awardees (states and other 

jurisdictions) met targets for all nine measures in the responder protection area, 

which measures activities related to safety and coordination for responders. 

However, awardee performance in the other three areas was mixed. 

• Electronic lab reporting. One of two measures was met in this area. This area

relates to the sending of laboratory reports to public health agencies via 

electronic means (as opposed to traditional, paper reports). 

• Epidemiology capacity. One of three measures was met in this area. This 

area relates to awardees’ ability to identify and respond to infectious disease 

outbreaks.

• Laboratory capacity. Five of six measures were met in this area. This area

relates to both laboratory testing of certain pathogens, and communication 

between laboratories and other public entities.

HHS reviewed a copy of this report and provided technical comments, which 

GAO incorporated as appropriate.

View GAO-18-362. For more information, 

contact Marcia Crosse at (202) 512-7114 or 

crossem@gao.gov

Why GAO Did This Study

An infectious disease threat is unique 

because of the transmissibility of 

diseases and the mobility of human 

populations, among other reasons. 

Infectious disease threats in recent 

years—such as Zika and Ebola

outbreaks—have heightened the 

United States’ attention to future 

potential threats, and raised questions 

about the nation’s preparedness and 

response capabilities.

A congressional report included a 

provision for GAO to report on the U.S. 

public health system’s current capacity 

to respond to infectious disease 

threats. This report describes (1)

funding HHS has made available to 

awardees—states and other 

jurisdictions—through its key 

preparedness and capacity-building 

programs—ELC, HPP, and PHEP; and

(2) these programs’ performance 

measurement data on the awardees’

infectious disease preparedness 

capacity. 

To do this work, GAO analyzed HHS’s 

data on awards provided to awardees

through the three key programs using 

annual and supplemental 

appropriations, and interviewed HHS 

officials and non-federal stakeholders 

about such funding. GAO identified 

non-federal stakeholders representing 

medical and public health associations, 

research centers, and others through a

review of relevant literature, as well as 

prior GAO work. GAO also reviewed

the most recently available data on 

awardee performance on 20 measures

directly related to infectious disease 

preparedness collectively used by the

three programs. GAO categorized 

these 20 measures into four 

preparedness capacity areas.
Page i GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Letter 1

Background 5

HHS Awarded $21.2 Billion to States through Key Programs; 

Stakeholders Stated That Available Funding Assisted Capacity 

Surges, but They Also Cited Challenges 10

Majority of Awardees Met Targets for All Responder Protection 

Measures, but Performance Was Mixed Across Other Areas 19

Agency Comments 29

Appendix I Non-Federal Stakeholders’ Views on Factors to Consider for an 

Emergency Response Fund 30

Appendix II GAO Contact and Staff Acknowledgments 32

Tables

Table 1: Performance Measures Used by HHS’s Three Key 

Preparedness and Capacity-Building Programs, by 

Preparedness Capacity Area 20

Table 2: Awardee Performance on Responder Protection 

Performance Measures, by Program 22

Table 3: Awardee Performance on Laboratory Capacity 

Performance Measures, by Program 24

Table 4: Awardee Performance on Electronic Lab Reporting 

Performance Measures 26

Table 5: Awardee Performance on Epidemiology Capacity 

Performance Measures, by Program 27

Table 6: Six Factors That May Be Considered for an Emergency 

Response Fund, According to Non-Federal Stakeholders 30

Figures

Figure 1: Awards Provided to States and Other Jurisdictions 

through Three Key HHS Preparedness and CapacityBuilding Programs, Annual Appropriations, Fiscal Years 

2002-2017 11

Figure 2: Awards Provided through Epidemiology and Laboratory 

Capacity for Infectious Diseases (ELC), Annual and 

Supplemental Appropriations, Fiscal Years 2002-2017 12

Contents
Page ii GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Figure 3: Awards Provided through the Hospital Preparedness 

Program (HPP), Annual and Supplemental 

Appropriations, Fiscal Years 2002-2017 13

Figure 4: Awards Provided through Public Health Emergency 

Preparedness (PHEP), Annual and Supplemental

Appropriations, Fiscal Years 2002-2017 14
Page iii GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Abbreviations

ASPR Office of the Assistant Secretary for Preparedness and

 Response

CDC Centers for Disease Control and Prevention

ELC Epidemiology and Laboratory Capacity for Infectious

 Diseases

HHS Department of Health and Human Services

HPP Hospital Preparedness Program 

NOFO notice of funding opportunity

PHEF Public Health Emergency Fund

PHEP Public Health Emergency Preparedness

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Page 1 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

441 G St. N.W.

Washington, DC 20548

May 24, 2018

The Honorable Roy Blunt

Chairman

The Honorable Patty Murray

Ranking Member

Subcommittee on Labor, Health and Human Services, Education, and 

Related Agencies 

Committee on Appropriations

United States Senate

The Honorable Tom Cole

Chairman

The Honorable Rosa DeLauro

Ranking Member

Subcommittee on Labor, Health and Human Services, Education, and 

Related Agencies 

Committee on Appropriations

House of Representatives

An infectious disease threat is unique because of the transmissibility of 

diseases, the universal susceptibility of the world’s population to 

pathogens that have not previously circulated, and the mobility of human 

populations. Infectious disease threats in recent years—such as Zika, 

Ebola, and H1N1 pandemic influenza—have heightened the United 

States’ attention to future potential infectious disease threats and raised 

questions about the nation’s preparedness and response capabilities. The 

Department of Health and Human Services (HHS) is the lead federal 

agency for public health and medical preparedness for, and response to, 

infectious disease threats. HHS provides funding to states, localities, 

territories, and freely associated states to aid capacity building and 

preparedness for infectious disease threats and other public health 

threats, such as natural disasters or terrorist events, through three key 

programs: (1) Epidemiology and Laboratory Capacity for Infectious 

Diseases (ELC), (2) the Hospital Preparedness Program (HPP), and (3) 

Public Health Emergency Preparedness (PHEP). The Centers for 

Disease Control and Prevention (CDC) administers ELC and PHEP, while 

the HHS Office of the Assistant Secretary for Preparedness and 

Response (ASPR) administers HPP. These three key programs routinely 

Letter
Page 2 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

monitor select aspects of state and local preparedness capacity through 

certain performance measures.1

State and local governments typically lead the domestic response to an 

infectious disease threat. If a threat is severe enough that state and local 

response capabilities—including those supported by ELC, HPP, and 

PHEP—are overwhelmed, state and local governments become reliant on 

additional support from the federal government. For example, during 

recent infectious disease threats, HHS received supplemental 

appropriations to respond to Zika in 2016, Ebola in 2014, and H1N1 

pandemic influenza in 2009.2 These recent threats have generated 

discussions about states’ and other jurisdictions’ preparedness and 

response capacity, as well as federal funding to support such capacity.

A Senate Report accompanying the 2017 Consolidated Appropriations 

Act included a provision for GAO to study the U.S. public health system’s 

capacity to respond to infectious disease threats.3 This report describes

1. the funding that HHS has made available to awardees—states and 

other jurisdictions—through the three key programs that aid states’ 

infectious disease preparedness capacity, and

2. these programs’ performance measurement data on the awardees’ 

infectious disease preparedness capacity.

To describe the funding that HHS has made available to awardees 

through the three key preparedness and capacity-building programs, we 

obtained data from ASPR and CDC on the amount of awards that the 

 1

Throughout this report, we use the term “preparedness capacity” to refer to preparedness 

activities, such as identifying and coordinating with partners involved in a response, as 

well as capacity-building activities that are critical to a response, such as laboratory 

services and public health surveillance.

2

A supplemental appropriation is an act appropriating funds in addition to those already 

provided in an annual appropriation act. Supplemental appropriations provide additional 

budget authority usually in cases where the need for funds is considered too urgent to be 

postponed until enactment of the next regular annual appropriation bill. For Zika 

supplemental appropriations to HHS, see the Zika Response and Preparedness Act, Pub. 

L. No. 114-223, div. B tit. I, 130 Stat. 857, 901. For Ebola supplemental appropriations to 

HHS, see the Consolidated and Further Continuing Appropriations Act, 2015, Pub. L. No. 

113-235, div. G, tit. VI., 128 Stat. 2130, 2520. For H1N1 pandemic influenza supplemental 

appropriations to HHS see the Supplemental Appropriations Act, 2009, Pub. L. No. 111-

32, tit. VIII, 123 Stat. 1859, 1884.

3

See Pub. L. No. 115-31, § 4, 131 Stat. 135, 137; 163 Cong. Rec. H3949 (Daily ed. May 

3, 2017); S. Rep. No. 114-274, at 80 (2016).
Page 3 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

agencies made through ELC, HPP, and PHEP to states and other 

jurisdictions in the form of cooperative agreements from fiscal years 2002 

through 2017.4 We analyzed these data to determine the amount of 

awards made by CDC (through ELC and PHEP) and ASPR (through 

HPP) with funding from annual appropriations, as well as awards made 

with funding from supplemental appropriations provided to respond to

specific infectious disease threats. We assessed the reliability of the 

award data we obtained by comparing these data to data in published 

reports, such as agency budget justifications; following up with agency 

officials regarding any discrepancies in the data; and gathering 

information from agencies on the internal checks they use when 

maintaining their data. Based on these steps, we determined that the data 

were reliable for our reporting purposes. We also reviewed 

documentation and interviewed ASPR and CDC officials, as well as nonfederal stakeholders, to gather information on how awards to states and 

other jurisdictions have aided responses to recent infectious disease 

threats (Zika, Ebola, and H1N1 pandemic influenza). We identified the 

non-federal stakeholders to interview by reviewing relevant literature on 

infectious disease preparedness and response funding, as well as our 

prior work.5 We selected and interviewed 10 non-federal stakeholders 

representing medical associations, public health associations, academic 

research centers, and organizations with emergency preparedness and 

response experience. The perspectives from non-federal stakeholders 

presented in our findings are those that the stakeholders generally agreed 

on, and when available, we present alternative stakeholder perspectives. 

While we attempted to gather similar information from all non-federal 

stakeholders, there were cases in which all stakeholders did not provide a 

perspective on each issue presented. The views of the 10 non-federal 

stakeholders are not generalizable beyond these stakeholders; however, 

 4

For purposes of this report, we use the term “award,” which could also be referred to as 

an obligation—a definite commitment by a federal entity that creates a legal liability to

make payments immediately or in the future. A cooperative agreement is a legal 

instrument used to provide financial support when substantial interaction is expected 

between a federal agency and a state, local government, or other recipient carrying out 

the funded activity.

5

See, for example, GAO, Emerging Infections Diseases: Actions Needed to Address the 

Challenges of Responding to Zika Virus Disease Outbreaks, GAO-17-445 (Washington, 

D.C.: May 23, 2017); National Preparedness: Improvements Needed for Measuring 

Awardee Performance in Meeting Medical and Public Health Preparedness Goals, 

GAO-13-278 (Washington, D.C.: Mar. 22, 2013); and Influenza Pandemic: Lessons 

Learned from the H1N1 Pandemic Should Be Incorporated into Future Planning, 

GAO-11-632 (Washington, D.C.: June 27, 2011). 
Page 4 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

they provide insights on how federal funding has aided the response to 

certain infectious disease threats.

To describe the three key programs’ performance measurement data on 

awardees’ infectious disease preparedness capacity, we obtained and 

reviewed data from ASPR and CDC on awardee performance. 

Specifically, we reviewed data for a total of 20 performance measures: 8 

measures from ELC, 5 measures from HPP, and 7 measures from PHEP. 

For each measure, we reviewed the most recently available, agencyvalidated data (from 2015 to 2017, depending on the measure). The 20 

measures we reviewed are a subset of measures used by the three 

programs that directly relate to infectious disease preparedness capacity. 

HPP and PHEP are programs that support “all-hazards” preparedness 

capacity, meaning they help states and other jurisdictions build capacities 

to respond to a range of public health threats, including, but not limited to, 

infectious diseases. Although many of the “all hazards” performance 

measures used by the programs could indirectly relate to infectious 

disease preparedness capacity, our review focused on those measures 

directly related to infectious disease preparedness capacity, as we 

determined through consultation with ASPR and CDC officials.6

Through our review of agency performance measure documentation and 

interviews with agency officials, we determined that the 20 performance 

measures fell into four areas of preparedness capacity: (1) electronic lab 

reporting, (2) epidemiology capacity, (3) laboratory capacity, and (4) 

responder protection. For our analysis, we grouped the performance 

measures into these four areas, with consultation from ASPR and CDC 

officials. In general, the majority of awardees reported data for each of the 

20 measures in our review. Reasons for not reporting data included a 

measure not applying to the awardee or the awardee did not conduct an 

 6

An example of a measure that indirectly relates to infectious disease preparedness 

capacity is the PHEP measure that asks if public health officials have procedures in place 

to manage volunteers supporting a public health or medical incident. Centers for Disease 

Control and Prevention, Public Health Emergency Preparedness Cooperative Agreement 

Budget Period 1 Performance Measure Specifications and Implementation Guidance, July 

1, 2017 – June 30, 2018 (Washington, D.C.).
Page 5 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

exercise necessary to determine their performance on a measure.7 We 

calculated the percentage of awardees that achieved a performance 

target for each measure based on the number of awardees that reported 

data on the measure and to which the measure applied.

To assess the reliability of the performance measure data, we reviewed 

agency documentation, such as performance measure implementation 

guidance provided to awardees; interviewed knowledgeable ASPR and 

CDC officials about their data systems and data validation processes; and 

performed checks of the data for consistency and completeness. Based 

on these steps, we determined that the data for the 20 performance 

measures included in our review were sufficiently reliable for our reporting 

purposes. One limitation of performance measure data is that these data 

are self-reported by the awardees. ASPR and CDC officials conduct data 

checks to mitigate this limitation, such as looking for outliers in the data 

and conducting validation calls with awardees.

We conducted this performance audit from June 2017 to May 2018 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and

conclusions based on our audit objectives.

ELC, HPP, and PHEP are the three key HHS programs through which the 

department provides annual awards to states and other jurisdictions to aid 

capacity building and preparedness for public health threats, including 

infectious disease threats, natural disasters, or terrorist events. ELC was 

established in 1995 and currently has 64 awardees—all 50 states, 6 

 7

A measure did not apply to an awardee when the measure referred to an entity, such as

an Ebola treatment center, that did not exist within the awardee’s jurisdiction. An Ebola 

treatment center is a hospital that is prepared to provide comprehensive care to people 

diagnosed with Ebola virus disease for the duration of a patient’s illness, as designated by 

states and localities with CDC input. Awardees that were provided less funding, such as 

localities and U.S. territories, may not have been required to report data on certain 

measures, according to CDC officials.

Background
Page 6 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

localities, and 8 territories and freely associated states.8 HPP and PHEP 

were established in 2002 and currently have 62 awardees—all 50 states, 

4 localities, and 8 territories and freely associated states.9 ASPR and 

CDC provide awards through the three programs using cooperative 

agreements.

Federal support through ELC, HPP, and PHEP helps states and other 

jurisdictions build and strengthen their abilities to effectively respond to 

public health threats before they occur. While ELC primarily supports 

public health infectious disease prevention and control capacity, HPP and 

PHEP are programs that support “all-hazards” preparedness capacity, 

meaning they help build capacities to respond to a range of public health 

threats, including infectious diseases, natural disasters, or terrorist 

events. According to ASPR and CDC documentation, each program has 

a distinct goal:

• ELC’s goal is to support capacity building to combat domestic 

infectious disease threats. The program funds epidemiologists and 

activities that support surveillance systems, modernize laboratory 

facilities, and develop integrated information networks at local and 

state levels, among other disease detection and response activities. 

Two primary classes of ELC funding include (1) flexible, non-diseasespecific funding (generally referred to as “cross-cutting” funding) to 

address high-priority needs related to epidemiology, laboratory, and 

health information systems; and (2) disease-specific, categorical 

funding that targets specific infectious diseases and other related 

public health threats, including antimicrobial-resistant bacteria, 

arboviral and tickborne diseases (e.g., Lyme, West Nile, Zika), 

foodborne disease and illnesses, healthcare-associated infections, 

influenza, and waterborne diseases.10

 8

ELC’s 64 awardees are the 50 states; 6 localities, which are Chicago, the District of 

Columbia, Houston, Los Angeles County, New York City, and Philadelphia; and 8 

territories and freely associated states—American Samoa, Federated States of 

Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico, and 

the U.S. Virgin Islands. See 42 U.S.C. § 247d-3a (authorizing awards made by ELC).

9

HPP’s and PHEP’s 62 awardees are the same as the ELC awardees with the exception 

of 2 localities, Houston and Philadelphia. See 42 U.S.C. §§ 247d-3a, 247-3b (authorizing 

awards made by HPP and PHEP).

10Arbovirus, or arthropod-borne virus, refers to a virus that is transmitted via arthropods, 

such as mosquitoes and ticks. Other diseases in this category include chikungunya, 

dengue fever, Rocky Mountain spotted fever, and tularemia. 

ELC, HPP, and PHEP 

Goals and Activities
Page 7 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

• HPP’s goal is to improve patient outcomes and medical surge

capacity by enhancing community and health care system 

preparedness for health consequences of various public health 

threats, including infectious disease threats. The program funds the 

development of health care coalitions—networks of health care 

entities and response organizations that can provide medical services, 

resources, or support during a public health threat. Working through 

these coalitions, HPP funds activities such as establishing electronic 

coordination and situational awareness systems to track available 

hospital beds and other resources, engaging with other responders 

through interoperable communications systems, maintaining or 

enhancing medical caches to protect health care workers and patients 

during a response, and developing and improving preparedness plans 

through regional exercises.11

• PHEP’s goal is to develop effective public health emergency 

management and response programs nationwide. PHEP strengthens

the capabilities of state, local, and territorial public health departments 

to prepare for, and respond to, evolving public health threats, 

including infectious disease threats. Activities funded include 

developing and exercising plans to receive, store, distribute, and 

dispense life-saving medicines and emergency medical supplies to 

the public during a response to a public health threat, and 

coordinating emergency operations activities during a public health 

response to limit the health effects of life-threatening emergencies. 

PHEP funding also supports building epidemiological surveillance 

systems and laboratory capability for detecting, testing, and identifying 

harmful pathogens and reporting results to CDC, and conducting drills 

and exercises to test response capabilities.

 11A medical cache is a storage of medical supplies and medications that can be deployed 

in an emergency.
Page 8 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Awards to states and other jurisdictions through ELC, HPP, and PHEP 

are generally funded from annual appropriations.12 Specifically,

• ELC awards are funded by annual appropriations to CDC, as well as 

amounts made available to the Prevention and Public Health Fund;

13

• HPP awards are funded by annual appropriations to the Public Health 

and Social Services Emergency Fund;14 and

• PHEP awards are funded by annual appropriations to CDC.

In addition, ASPR and CDC have, at times, provided awards to states and 

other jurisdictions through these programs in response to specific 

infectious disease threats with funding from supplemental appropriations 

provided by Congress to HHS. Supplemental appropriations provide 

budget authority for government activities, in addition to funding provided 

in annual appropriations or continuing resolutions.15

ELC, HPP, and PHEP awardees must fulfill certain application, financial, 

and reporting requirements as part of the terms of the programs’ 

 12When regular annual appropriations are not completed before the beginning of the fiscal 

year, funding may be provided by continuing resolutions for the full year, up to a specified 

date, or until regular appropriations are enacted. ELC awards are determined by a 

competitive technical and objective review process. HPP and PHEP annual awards are 

based on a formula that includes a base amount for each awardee plus population-based 

funding. 

13Section 4002 of the Patient Protection and Affordable Care Act established the 

Prevention and Public Health Fund in 2010 to “provide for expanded and sustained 

national investment in prevention and public health programs to improve health and help 

restrain the rate of growth in private and public health care costs,” and made 

appropriations to the fund for fiscal year 2010 and each year thereafter. Pub. L. No. 111-

148, §§ 4002,10401(b), 124 Stat. 119, 541, 974 (2010) (codified as amended at 42 U.S.C. 

§ 300u-11). Since 2010, CDC has used Prevention and Public Health Fund resources to 

fund ELC awards for “cross-cutting” activities, as well as other public health programs and 

activities. For information on activities funded by Prevention and Public Health Fund in 

fiscal years 2010 and 2011, see GAO, Prevention and Public Health Fund: Activities 

Funded in Fiscal Years 2010 and 2011, GAO-12-788 (Washington, D.C.: Sept. 13, 2012).

14The Public Health and Social Services Emergency Fund is an HHS budget account that 

funds authorized ASPR and other HHS office operations and activities to support the 

nation’s ability to prepare for, respond to, and recover from the health consequences of 

naturally occurring and manmade threats.

15Budget authority authorizes an agency to enter into financial obligations that will result in 

outlays of federal government funds.

Funding for ELC, HPP, 

and PHEP Awards

ELC, HPP, and PHEP 

Performance Measures
Page 9 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

cooperative agreements. As part of these reporting requirements, 

awardees are required to report on performance measures, which can 

number 35 or more across all three programs.16 For example, PHEP 

awardees must report on the percentage of volunteers that were 

deployed for an exercise or actual public health threat within a determined 

time frame, and HPP awardees are subject to several measures to 

assess the extent to which they have appropriate preparedness and 

response plans in place. Reporting on performance measures helps the 

agencies gauge awardees’ progress on discrete activities related to 

preparedness capacity, as well as to determine where additional technical 

assistance and other resources to support awardees are needed. Further, 

agency officials stated that performance measures can have targets that 

are intended to continuously challenge awardees to meet high standards. 

The 20 performance measures included in this report (i.e., those that are 

directly related to infectious disease preparedness capacity) constitute a 

subset of the programs’ measures. We reported in March 2013 that many 

other performance measures used by HPP and PHEP did not have 

targets and recommended that HHS develop targets for such measures.17

We also recommended that HPP and PHEP performance measures 

remain consistent over time. Since our 2013 report, PHEP’s measures 

have generally remained consistent in recent years, but some of these 

measures lack targets. HPP implemented new measures for the 2017 to 

2022 project period that are not consistent with those from prior years. As 

of February 2018, more than half of these new measures lacked targets. 

ASPR officials told us that they expect measures to change over time to 

allow HPP to adapt to evolving public health threats, and agency 

guidance notes that targets may be set at a later date after establishing 

awardees’ baseline scores.

 16See Centers for Disease Control and Prevention, Public Health Emergency 

Preparedness Cooperative Agreement Budget Period 1 Performance Measure 

Specifications and Implementation Guidance, July 1, 2017–June 30, 2018 (Atlanta, Ga.); 

Instructions for Preparing Annual Performance Report /Continuation Application: 

Epidemiology and Laboratory Capacity for Infectious Diseases, Funding Opportunity 

Announcement Number: CK14-140104PPHF17 (Atlanta, Ga.); and Epidemiology and 

Laboratory Capacity for Infectious Diseases Cooperative Agreement Performance 

Measures Guidance for Domestic Ebola Supplement, Project Period March 31, 2015 to 

March 30, 2018, Version 5 (Atlanta, Ga.: September 2017). See also Office of the 

Assistant Secretary for Preparedness and Response, 2017–2022 Hospital Preparedness 

Program Performance Measures Implementation Guidance (Washington, D.C.); and 

Hospital Preparedness Program Measure Manual: Implementation Guidance for Ebola 

Preparedness Measures (Washington, D.C.: July 2015).

17See GAO-13-278. 
Page 10 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

From fiscal years 2002 through 2017, a total of about $21.2 billion was

awarded by ASPR and CDC to states and other jurisdictions through 

ELC, HPP, and PHEP to carry out public health preparedness and 

response efforts, including those related to infectious diseases, natural 

disasters, or terrorist events.18 The vast majority of this amount—about 86

percent, or $18.4 billion—was provided from annual appropriations. The 

amount of awards from annual appropriations was mostly made by CDC 

through PHEP, which totaled about $11.4 billion over the time period. The 

amount of awards made by ASPR through HPP and by CDC through ELC 

totaled about $5.6 billion and $1.5 billion, respectively.

The combined amount of awards provided through the three programs’ 

annual appropriations has generally decreased, from about $1.4 billion in 

fiscal year 2003 (which was when the total awards were at the highest 

level) to about $1.0 billion in fiscal year 2017, though funding trends 

between the three programs have varied over time. Specifically, the 

amount of awards provided through ELC from annual appropriations 

almost doubled, from about $0.1 billion in fiscal year 2002 to about $0.2 

billion in fiscal year 2017. The amount of awards provided through HPP 

and PHEP from annual appropriations generally decreased, though the 

 18The nominal value of awards is presented in this report. Due to rounding, certain award 

amounts presented in this section may not sum to total award amounts reported.

HHS Awarded $21.2 

Billion to States 

through Key 

Programs; 

Stakeholders Stated 

That Available 

Funding Assisted 

Capacity Surges, but 

They Also Cited 

Challenges

HHS’s Three Key 

Programs Awarded $21.2 

Billion to States and Other 

Jurisdictions from Fiscal 

Years 2002 through 2017; 

Supplemental Awards 

Played a Large Role in 

Certain Years
Page 11 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

amount of awards has remained relatively constant in recent years. 

Overall, from its high in fiscal year 2003 to fiscal year 2017, HPP award 

amounts decreased about 54 percent. PHEP award amounts decreased 

about 33 percent from its high in fiscal year 2002 to fiscal year 2017. (See 

fig. 1.)

Figure 1: Awards Provided to States and Other Jurisdictions through Three Key HHS Preparedness and Capacity-Building 

Programs, Annual Appropriations, Fiscal Years 2002-2017

Note: The Department of Health and Human Services (HHS) provides funding to states, localities, 

territories, and freely associated states to aid capacity building and preparedness for public health 

threats, including infectious disease threats, natural disasters, or terrorist events through three key 

programs: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), the Hospital 

Preparedness Program (HPP), and Public Health Emergency Preparedness (PHEP). This figure 

includes data on annual awards to states and other jurisdictions provided through these three 

programs with funding from annual appropriations to address preparedness for public health threats 

that include, but are not limited to, infectious disease threats.
Page 12 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

In addition, from fiscal years 2002 through 2017, a total of about $2.9 

billion in awards has been made through the three programs from 

supplemental appropriations, and these awards have been a large 

percentage of the total award amounts provided in certain years.19 For 

example, award amounts provided through ELC from supplemental 

appropriations in fiscal years 2015 through 2017 to respond to Ebola and 

Zika ranged between about 30 and 50 percent of the total award amounts 

during those years. (See fig. 2.)

Figure 2: Awards Provided through Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), Annual and 

Supplemental Appropriations, Fiscal Years 2002-2017

Note: Awards provided to respond to Zika in fiscal year 2016 were provided using funding that CDC 

reprogrammed away from other programs prior to supplemental appropriations being enacted. In this 

figure, these awards are included as awards provided from supplemental appropriations.

 19This amount includes about $0.3 billion through ELC, $0.4 billion through HPP, and $2.2 

billion in awards through PHEP.
Page 13 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Similarly, in fiscal years 2015 through 2017, awards were provided 

through HPP from supplemental appropriations to respond to Ebola, and 

in fiscal year 2015 these awards made up a large percentage of awards 

provided through HPP. Specifically, these award amounts totaled 

approximately $0.2 billion in 2015, which was about 44 percent of the 

total award amounts (about $0.4 billion) provided through HPP in that 

year. (See fig. 3.)

Figure 3: Awards Provided through the Hospital Preparedness Program (HPP), Annual and Supplemental Appropriations, 

Fiscal Years 2002-2017

Awards from supplemental appropriations were also provided through 

PHEP in certain years, including in fiscal years 2009 and 2010 to respond 

to H1N1 pandemic influenza. The fiscal year 2009 award amounts for 

H1N1 pandemic influenza totaled close to $1.4 billion—66 percent of the 

total award amounts provided through PHEP in that year (about $2 

billion). (See fig. 4.)
Page 14 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Figure 4: Awards Provided through Public Health Emergency Preparedness (PHEP), Annual and Supplemental 

Appropriations, Fiscal Years 2002-2017

Note: Awards provided to PHEP awardees from supplemental appropriations in fiscal years 2009 and 

2010 to respond to H1N1 pandemic influenza were made through a separate granting mechanism—

the Public Health Emergency Response Grant for H1N1 Influenza Pandemic. Awards provided to 

PHEP awardees from supplemental appropriations in fiscal year 2017 to respond to Zika were made 

through a separate granting mechanism—the Public Health Preparedness and Response 

Cooperative Agreement for All-Hazards Public Health Emergencies.
Page 15 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

According ASPR and CDC officials, as well as most non-federal 

stakeholders we interviewed, awards provided through HHS’s three key 

preparedness and capacity-building programs with supplemental 

appropriations were important for allowing health care systems—which 

include state and local public health departments, laboratories, and 

hospitals—to make necessary surges in capacity or take other actions, 

such as creating plans and training staff, to respond to infectious disease 

threats.20 For example, one stakeholder told us that during the Zika 

threat, awards provided through ELC from supplemental appropriations 

allowed public health laboratories to hire additional staff and purchase 

laboratory testing equipment needed to conduct the high volume of Zika 

tests. We previously reported that awards from supplemental 

appropriations helped states and local jurisdictions respond to the H1N1 

pandemic influenza in 2009 and 2010.21 For example, we found that 

Vermont used its award to purchase lab equipment and hire 10 temporary 

employees to enter vaccination data into the state’s vaccine registry. We 

also found that Nebraska used its award to contract with nurses to 

administer the H1N1 influenza vaccine at mass vaccination clinics. As 

another example, the Association of State and Territorial Health Officials 

reported that the awards from supplemental appropriations provided 

states with resources necessary to respond to the H1N1 pandemic 

influenza by providing funds to support increased public health workforce 

capacity in surveillance and immunization.22

ASPR and CDC officials told us that awards provided through ELC, HPP, 

and PHEP are intended to establish and strengthen emergency 

preparedness and capacity building. Awards from annual appropriations 

may not fully support the need for surge capacity that states and other 

jurisdictions require in order to respond to an infectious disease threat, 

according to the officials. CDC officials said that the general decrease in 

PHEP awards from annual appropriations to state and local public health 

departments over time has limited state and local preparedness capacity. 

 20A health care system’s ability to “surge” is the ability to have the staff and resources in 

place to adequately care for increased numbers of affected individuals or individuals with 

unusual or highly specialized needs.

21See GAO-11-632.

22See Association of State and Territorial Health Officials, Assessing Policy Barriers to 

Effective Public Health Response in the H1N1Influenza Pandemic (Arlington, Va.: June 

2010), 25.

Stakeholders Reported 

That Available Funding

Assisted Surges in 

Capacity during Recent 

Infectious Disease 

Threats; Timing of Awards 

Can Limit Preparedness 

and Response Activities
Page 16 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

This, in turn, has increased the importance of awards from supplemental 

appropriations to respond to infectious disease threats. Agency officials 

cited a survey by the National Association of County and City Health 

Officials, which reported that there was a 12 percent rise in the number of 

local health departments that reported a decrease in their preparedness 

staff from 2015 levels to 2016 levels, with 34 percent reporting decreased 

levels in staff since 2015.23

Although the awards from supplemental appropriations have allowed 

state and local public health departments, laboratories, and hospitals to 

surge during a threat, most non-federal stakeholders, as well as ASPR 

and CDC officials, said that the timing of these awards can result in 

challenges to carrying out preparedness and response activities during 

infectious disease threats. For example, two stakeholders said that state 

and local public health departments’ routine activities or personnel hires 

can be delayed while resources are used to respond to an infectious 

disease threat. Two stakeholders also said that PHEP awardees were 

affected by CDC’s reprogramming of a portion of the PHEP awards from 

annual appropriations away from awardees to fund Zika response 

activities prior to the availability of supplemental appropriations.24

According to one of these stakeholders, the routine PHEP preparedness 

activities that awardees had planned were delayed or were not fully 

operational until the amounts of the reprogrammed awards were returned 

as new awards to the PHEP awardees. According to an April 2016 survey 

of PHEP awardees conducted by the National Association of County and 

City Health Officials and other organizations, about 72 percent of 

responding jurisdictions reported that ongoing preparedness program 

 23In June 2016, the National Association of County and City Health Officials conducted a 

survey of 871 local health departments across the country. Data for the assessment were 

self-reported, and had a response rate of 53 percent (458 local health departments). 

National Association of County and City Health Officials, The Public Health Emergency 

Preparedness Landscape: Findings from the 2016 Preparedness Profile Assessment

(Washington, D.C.: June 2017).

24The term reprogramming refers to shifting funds within an appropriation or fund account 

to use them for purposes other than those contemplated at the time of appropriation. In 

February 2016, prior to supplemental appropriations being enacted, CDC reprogrammed 

$44.25 million in annual appropriations away from PHEP awardees and used these funds 

for other activities to aid the Zika response. In September 2016, Zika supplemental 

funding was appropriated by the Zika Response and Preparedness Act. This funding 

allowed for the restoration of $44 million back to PHEP so that the program could reinstate 

the remaining awards. According to CDC officials, the agency restored the remaining 

$0.25 million from its operating budget so that the full amount of the funding—$44.25 

million—was eventually provided to the PHEP awardees. 
Page 17 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

areas (e.g., surveillance, epidemiological activities, and laboratory 

services) were likely to be affected by the reprogramming.25

ASPR and CDC officials also told us that it can take up to 4 months to 

disseminate awards through the existing programs, once supplemental 

appropriations are enacted. ASPR and CDC officials said that although 

the process for administering funds through ELC, HPP, and PHEP is 

familiar to states and other jurisdictions, these cooperative agreement 

programs do not allow for rapid dissemination of funds, because the 

agencies must follow their cooperative agreement administrative 

requirements and protocols. For example, before awarding funds from 

supplemental appropriations, the agencies have to create and provide 

notice of funding opportunities (NOFO) that jurisdictions have to apply to 

and be approved for before funds can be disseminated. For example, 

CDC officials stated that the process to get awards from supplemental 

appropriations to ELC awardees took about 4 months for the Ebola 

response and about 3 months for Zika.

In October 2017, CDC issued a new NOFO that is intended to shorten the 

amount of time it takes the agency to disseminate funding to respond to 

public health threats. This NOFO establishes a list of awardees, with 

existing emergency preparedness and response capacity, that are preapproved for funding by CDC when a public health threat occurs, 

including infectious disease threats. According to CDC officials, any CDC 

program, including ELC and PHEP, could use this funding mechanism. 

The NOFO requires that awardees have administrative structures and 

plans in place to receive funding, as well as plans to respond to a public 

health threat. According to CDC officials, awards could potentially be 

provided within 2 weeks to pre-approved awardees after supplemental 

appropriations are enacted, as opposed to months under the current 

cooperative agreement programs. According to officials, all of the 64 ELC 

and PHEP awardees have applied to the NOFO and have been deemed 

 25The majority of jurisdictions also reported that vector control, contractual services, 

supplies, and staffing levels were likely to be affected. The survey was fielded between 

April 8, 2016, and April 15, 2016, to all 62 PHEP awardees. The survey was completed by 

representatives from 61 jurisdictions for a total response rate of 98.4 percent. National 

Association of County and City Health Officials, the Association of State and Territorial 

Health Officials, Council of State and Territorial Epidemiologists, and the Association of 

Public Health Laboratories, Impact of the Redirection of Public Health Emergency 

Preparedness (PHEP) Funding from State and Local Health Departments to Support 

National Zika Response (Washington, D.C.: May 2016).
Page 18 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

eligible.26 As of February 2018, the agency had begun notifying these 

awardees that they are on CDC’s pre-approved list for funding in the case 

of a future public health threat. The NOFO does not apply to ASPR 

programs, including HPP, and ASPR officials told us that the agency does 

not have plans to develop a similar opportunity for ASPR programs.27

ASPR and CDC officials, as well as all non-federal stakeholders, also 

noted that a funding mechanism to fund rapid response activities when 

additional support is needed would be beneficial and could help address 

timing challenges. Such a mechanism could include the use of the 

existing Public Health Emergency Fund (PHEF) or a new emergency 

response fund specific to infectious disease.28 The availability of any such 

fund for immediate use would be subject to available appropriations. 

According to CDC officials and most non-federal stakeholders we 

interviewed, such a mechanism could allow HHS to provide additional 

funds to state and other jurisdictions for a rapid response to infectious 

disease threats while the department waits for any supplemental 

appropriations to be enacted by Congress. While one non-federal 

stakeholder stated that PHEF, with available funding, could be a viable 

funding mechanism for funding infectious disease threats, the stakeholder 

 26The NOFO was open to all 64 ELC and PHEP awardees, as well as five tribes, which 

CDC defines as federally or state recognized American Indian or Alaska Native tribal 

governments serving a population of at least 50,000 members. According to CDC officials, 

no tribes had applied to the NOFO. Agency officials told us that they were contacting the 

tribes to ensure they were aware of the opportunity. They also said that the application 

process for the NOFO will be reopened at a later date, and eligible tribes will have the 

opportunity to apply.

27According to CDC and ASPR officials, the agencies are in the process of shifting the 

responsibility for HPP grants management—which includes administration of the HPP 

cooperative agreements—from CDC to ASPR. While ASPR has had programmatic 

management responsibility for HPP, CDC has had grants management responsibility for 

HPP (in addition to its programmatic management and grants management 

responsibilities for ELC and PHEP). Officials told us that this change will begin in July 

2019, and that moving the HPP grants management to ASPR will allow more staff to 

oversee the HPP administrative process, which could aid the timeliness of awards 

provided from supplemental appropriations. 

28PHEF, established in 1983, is available to the Secretary of Health and Human Services 

to respond to a public health emergency, including infectious disease threats. See Pub. L. 

No.98-49, 97 Stat. 245 (1983) (codified as amended at 42 U.S.C. § 247d). A 

Congressional Research Service report issued in 2009 indicated that the fund had not 

received an appropriation since Congress reauthorized it in 2000. Congressional 

Research Service, Public Health and Medical Response to Disasters: Federal Authority 

and Funding, RL33579 (Washington, D.C.: Apr. 29, 2009). According to HHS’s 2016 

budget justification estimates, PHEF has no balance. 
Page 19 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

cautioned against the use of such a fund without having clear definitions 

as to when it should be used. The stakeholder stated that there should be 

ongoing investments at all levels of government for preparedness and 

capacity-building activities, and that PHEF or another type of emergency 

fund should not be used to make-up for a lack in those investments. A 

few other stakeholders also commented that they would not want an 

emergency fund to be a substitute to providing ongoing funding to 

preparedness and capacity-building programs, such as ELC, HPP, and 

PHEP. (See app. I for six factors that the non-federal stakeholders said 

may be considered for an emergency response fund, whether using an 

existing fund like PHEF or creating a new fund.)

The 20 performance measures we reviewed for HHS’s three key 

preparedness and capacity-building programs (ELC, HPP, and PHEP) fell 

into four preparedness capacity areas: electronic lab reporting, 

epidemiology capacity, laboratory capacity, and responder protection.29

The majority of awardees (states and other jurisdictions) that reported on 

performance measures in the responder protection area met all 

performance targets in this area. However, awardee performance in the 

other three preparedness capacity areas was mixed.

ELC had measures in each of the four preparedness capacity areas, 

while PHEP had measures in two areas, and HPP’s performance 

measures fell into one of the four preparedness capacity areas. (See 

table 1.) The programs’ performance measures are meant to demonstrate 

accountability and identify awardees’ strengths, weaknesses, and areas 

for improvement on discrete activities related to preparedness capacity. 

According to CDC officials, the measures can include targets that are 

intended to challenge awardees to continuously meet high standards.

 29The 20 performance measures included in our review directly relate to infectious 

disease preparedness capacity. While the agencies have not categorized the performance 

measures, ASPR and CDC officials agreed with our categorization of the performance 

measures in the four areas.

Majority of Awardees 

Met Targets for All 

Responder Protection 

Measures, but 

Performance Was 

Mixed Across Other 

Areas
Page 20 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Table 1: Performance Measures Used by HHS’s Three Key Preparedness and Capacity-Building Programs, by Preparedness 

Capacity Area

Preparedness capacity areaa

Program Performance measure

Electronic lab 

reporting

Epidemiology 

capacity

Laboratory 

capacity

Responder 

protection

ELC Percentage of laboratory reports received 

electronically.

√ - - -

Number of new electronic lab reporting feeds 

established.

√ - - -

Investigated reported outbreaks. - √ - -

Laboratory test turnaround time completed within 

established time frame.

- - √ -

Laboratories have designated a biosafety officer. - - - √

Laboratories have conducted risk assessments and 

mitigated risks.b - - - √

Laboratories have a biosafety plan in place that has 

been reviewed and communicated.

- - - √

Standard operating procedure in place to perform 

risk assessments for laboratories.

- - - √

HPP Ebola treatment centers can access personal 

protective equipment.c - - - √

Assessment hospitals can access personal 

protective equipment.d - - - √

Frontline facilities can receive information on 

personal protective equipment from their health 

care coalition.e

- - - √

Emergency medical services agencies that are 

required to participate in awardee’s concept of 

operations are engaged in the process of

developing an operational plan for the state.f

- - - √

Health care coalitions that participate in an advisory 

group that makes recommendations on the 

prevention of health care-associated infections.

- - - √

PHEP Percentage of required disease reports received on 

time.

- √ - -

Percentage of required disease reports for which 

initial control measures were initiated on time.g - √ - -

Completed emergency contact drill one on time.h - - √ -

Completed emergency contact drill two on time.h - - √ -

Proportion of laboratory response networkbiological proficiency tests passed.i - - √ -
Page 21 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Preparedness capacity areaa

Program Performance measure

Electronic lab 

reporting

Epidemiology 

capacity

Laboratory 

capacity

Responder 

protection

Submitted subtyping results from E. coli samples to 

a national database.j - - √ -

Submitted subtyping results from Listeria 

monocytogenes samples to a national database.j - - √ -

Total number of measures in each area 2 3 6 9

Legend: √= Performance measure included in preparedness capacity area. - = Performance measure not included in preparedness capacity area.

Source: GAO analysis of Office of the Assistance Secretary for Preparedness and Response (ASPR) and the Centers for Disease Control and Prevention (CDC) performance measurement information. | 

GAO-18-362

Note: The Department of Health and Human Services (HHS) provides funding to states, localities, 

territories, and freely associated states to aid capacity building and preparedness for public health 

threats, including infectious disease threats, natural disasters, or terrorist events, through three key 

programs: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), the Hospital 

Preparedness Program (HPP), and Public Health Emergency Preparedness (PHEP). This table 

shows the performance measures used in these key programs that are directly related to infectious 

disease preparedness capacity, as we determined through consultation with ASPR and CDC officials.

a

We categorized the 20 performance measures in this table into four preparedness capacity areas. 

While the agencies have not categorized the performance measures, ASPR and CDC officials agreed 

with our categorization of the performance measures into these areas.

b

Risk assessments involve identifying potential hazards, assessing risks associated with those 

hazards, and establishing precautions and standard procedures to minimize exposure to those risks.

c

Ebola treatment centers are hospitals that are prepared to provide comprehensive care to people 

diagnosed with Ebola virus disease for the duration of a patient’s illness, as designated by states and 

localities with CDC input after conducting site visits.

d

Ebola assessment hospitals are those that are prepared to receive and isolate a patient with 

potential Ebola virus disease, as designated by the state.

e

Most U.S. acute care facilities that are equipped for emergency care (such as hospital-based 

emergency departments, urgent care clinics, and critical access hospitals) are frontline facilities.

f

A concept of operations is an overview of the processes and steps for an effective system or 

operation, such as a response to an infectious disease outbreak.

g

Initial control measures vary by disease. Some examples of control measures include identification 

of potentially exposed individuals, investigation into the causes of an infectious disease threat after it 

is identified, and immunization.

h

Drill one is time to complete notification between CDC, on-call laboratorian, on-call epidemiologist, 

and then back to CDC; drill two is the reverse direction: time to complete notification between CDC, 

on-call epidemiologist, on-call laboratorian, and then back to CDC.

i

The laboratory response network-biological is a group of state, local, and other public health 

laboratories that provides routine and specialized laboratory testing to quickly respond to public 

health threats.

j

Subtyping procedures can identify certain attributes of bacteria to distinguish between bacteria of the 

same species. Subtyping can be used to predict the severity and transmissibility of a certain strain of 

bacteria, such as E. coli or Listeria monocytogenes.
Page 22 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Of the 20 measures, we found that the majority of reporting awardees met 

the performance targets for 9 of the 9 measures in the responder 

protection area, 5 of the 6 measures in the laboratory capacity area, 1 of 

the 2 measures in the electronic lab reporting area, and 1 of the 3 

measures in the epidemiology capacity area. These areas, and related 

awardee performance, are discussed in detail in the sections that follow.

The responder protection performance measures apply to ELC’s and 

HPP’s Ebola awards from supplemental appropriations, and measure 

activities related to safety and coordination for laboratorians, hospital and 

emergency personnel, and other responders, including the coordination of 

these responders. The measures assess the extent to which awardees 

can safely respond in the event of a highly contagious infectious disease 

threat. Though these performance measures were designed specifically 

for Ebola, ASPR and CDC officials told us that these measures may also 

have some application to preparedness for other highly infectious 

diseases. For each of the four ELC measures in this area, the majority of 

ELC awardees met each target—the percentage of reporting awardees 

that met the target ranged from 77 to 97 percent. For each of the five 

HPP measures in this area, the majority of HPP awardees met each 

target—the percentage of reporting awardees that met the target ranged 

from 61 to 97 percent. (See table 2.)

Table 2: Awardee Performance on Responder Protection Performance Measures, by Program

Program Performance measure Target Percent of 

reporting 

awardees that 

met targeta

ELC Laboratories have designated a biosafety officer. Awardee reported “yes.” 97 percent

(n = 61)

Laboratories have conducted risk assessments and mitigated 

risks.

Awardee reported “yes.” 87 percent

(n = 60)

Laboratories have a biosafety plan in place that has been 

reviewed and communicated.

Awardee reported “yes.” 90 percent

(n = 60)

Standard operating procedure in place to perform risk 

assessments for laboratories.

Awardee reported “yes.” 77 percent

(n= 60)

HPP Ebola treatment centers can access personal protective 

equipment.

All Ebola treatment centers 

accessed within 10 minutes.

97 percent

(n = 29)

Assessment hospitals can access personal protective 

equipment.

All assessment hospitals 

accessed within 10 minutes.

94 percent

(n = 49)

Responder Protection
Page 23 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Program Performance measure Target Percent of 

reporting 

awardees that 

met targeta

Frontline facilities can receive information on personal 

protective equipment from their health care coalition.

All frontline facilities received 

within 8 hours.

68 percent

(n = 56)

Emergency medical services agencies that are required to 

participate in awardee’s concept of operations are engaged 

in the process of developing an operational plan for the state.

All required emergency medical 

services agencies engaged.

85 percent

(n = 55)

Health care coalitions that participate in an advisory group 

that makes recommendations on the prevention of health 

care-associated infections.

80 percent of health care 

coalitions participated.

61 percent

(n = 57)

Source: GAO analysis of awardee performance measurement data provided by the Office of the Assistance Secretary for Preparedness and Response (ASPR) and the Centers for Disease Control and 

Prevention (CDC). | GAO-18-362

Note: Data are from October 1, 2016, through March 31, 2017, for Epidemiology and Laboratory 

Capacity for Infectious Diseases (ELC) and from May 18, 2015, through May 17, 2016, for the 

Hospital Preparedness Program (HPP), according to ASPR and CDC officials. These are the most 

recent years for which validated data were available.

a

The percentages in this column are based on the subsets of awardees that provided data and to 

which the measure applied, or (n). While almost all awardees reported data on eight of the nine 

measures, the exact number of awardees that provided data varied across measures. Some 

awardees did not report data for certain measures, because, for example, they did not conduct the 

exercise necessary to determine performance on a measure, or were not required to report on a 

measure, according to ASPR and CDC officials. For example, HPP’s Ebola treatment center measure 

was not required of many awardees, because they did not have Ebola treatment centers within their 

jurisdictions.

According to CDC officials, the benefits of the ELC measures in this area 

include promoting a culture of safety within the awardee’s jurisdiction, 

learning new technologies and procedures that could be used during a 

highly contagious infectious disease outbreak, and establishing written 

plans and procedures to train staff on how to respond to certain risks. 

These measures all asked for a “yes” or “no” response, and CDC’s target 

was for awardees to submit a “yes” to each measure.

ASPR officials stated that the HPP measures in this area related to 

medical facilities’ ability to quickly access personal protective equipment 

in the case of a potentially highly contagious infectious disease. The 

measures also assess coordination among various health care entities to 

help ensure that groups, such as emergency medical services and health 

care advisory groups, are involved in the planning for an infectious 

disease threat. The majority of awardees have already met targets for 

each of the five performance measures in this area, even though the 

targets set by ASPR are 5-year targets that do not need to be achieved 

until 2020. While ASPR has not yet established targets for awardees to 

aim for every year, officials stated they are planning to establish interim 
Page 24 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

targets for these performance measures in 2018, using data collected in 

2016 and 2017 as a benchmark.

Laboratory capacity refers to both laboratory testing of certain pathogens 

and communication between laboratories and other public entities. ELC 

had one measure and PHEP had five measures in this area. Half of the 

reporting awardees (50 percent) met the target for ELC’s only measure in 

this area, while a large majority of PHEP awardees met the targets for 

each of the five PHEP measures in this area—the percentage of reporting 

awardees that met the target ranged from 75 to 100 percent. (See table 

3.)

Table 3: Awardee Performance on Laboratory Capacity Performance Measures, by Program

Program Performance measure Target Percent of reporting 

awardees that met 

targeta

ELC Laboratory test turnaround time completed within established 

time frame.

Varied between 2 and 65 

days.

50 percent

(n = 48)

PHEP Completed emergency contact drill one on time. Completed within 45 

minutes.

96 percent

(n = 51)

Completed emergency contact drill two on time. Completed within 45 

minutes.

96 percent

(n = 52)

Proportion of laboratory response network-biological 

proficiency tests passed.

Failed no more than one 

proficiency test.

100 percent

(n = 53)

Submitted subtyping results from E. coli samples to a 

national database.

90 percent of samples 

within 4 working days.

90 percent

(n = 52)

Submitted subtyping results from Listeria monocytogenes 

samples to a national database.

90 percent of samples 

within 4 working days.

75 percent

(n = 40)

Source: GAO analysis of awardee performance measurement data provided by the Centers for Disease Control and Prevention (CDC). | GAO-18-362

Note: Data are from calendar year 2015 for Epidemiology and Laboratory Capacity for Infectious 

Diseases (ELC); from July 1, 2016, through June 30, 2017, for Public Health Emergency 

Preparedness’s (PHEP) two emergency contact drill measures; and from July 1, 2014, through June 

30, 2015, for PHEP’s other three measures, according to CDC officials. These were the most recent 

years for which validated data were available.

a

The percentages in this column are based on the subset of awardees that provided data and to 

which the measure applied, or (n). While most awardees reported data for these measures, the exact 

number of awardees that provided data varied across measures. According to CDC officials, some 

awardees did not report data for certain measures, because, for example, they did not perform the 

necessary testing to determine performance on a measure, or were not required to report on a 

measure, as was the case for some localities and U.S. territories.

Laboratory Capacity
Page 25 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

CDC officials stated that the ELC measure in this area—turnaround time 

for laboratory tests—allows awardees to choose diseases for which they 

would like to focus on to improve the timeliness of their laboratory testing. 

Targets for this measure were set by the awardee and varied from 2 to 62 

days. Certain circumstances may make it more difficult for an awardee to 

meet the target, such as implementing complex laboratory procedures, 

according to CDC officials. Performance varied widely among awardees 

that missed the target; for example, several awardees missed their 

selected target by one or two days, while others missed the target by a 

week or more.

PHEP’s two emergency contact drill measures in this area assess 

whether there is effective contact between on-call epidemiologists and 

laboratorians, which relates to how quickly they can respond during a 

public health threat, such as an infectious disease outbreak. The other 

three PHEP measures are important, because they ensure that 

laboratories have the capability to detect and report potentially deadly 

diseases. CDC established the targets for all five of these measures.

Electronic lab reporting involves sending clinical and laboratory reports to 

public health agencies via electronic means (as opposed to traditional 

paper reports). ELC had two measures in this area. The majority of 

reporting ELC awardees (58 percent) met the performance target for one 

of the two ELC performance measures in this area (establishing two or 

more electronic lab reporting feeds), while 16 percent met the target for 

the other measure (increasing the percentage of laboratory reports 

received electronically by at least 10 percentage points).30 (See table 4.)

 30Electronic lab reporting feeds are direct data lines that electronically load laboratory 

results from a laboratory’s data system to another data system, such as a public health 

department’s data system.

Electronic Lab Reporting
Page 26 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Table 4: Awardee Performance on Electronic Lab Reporting Performance Measures

Program Performance measure Target Percent of 

reporting 

awardees that met 

targeta

ELC Percentage of laboratory reports received electronically. Increased at least 10 

percentage points.

16 percent

(n = 19)

Number of new electronic lab reporting feeds established. Two or more. 58 percent

(n = 19)

Source: GAO analysis of awardee performance measurement data provided by the Centers for Disease Control and Prevention (CDC). | GAO-18-362

Note: Data are from calendar year 2016 for the two Epidemiology and Laboratory Capacity for 

Infectious Diseases’ (ELC) measures in this area, according to CDC officials. These are the most 

recent years for which validated data were available.

a

The percentages in this column are based on the subsets of awardees that provided data and to 

which the measure applied, or (n). The two measures in this table did not apply to the majority of 

awardees, because these measures were only required of awardees that did not receive at least 75 

percent of their laboratory reports electronically.

According to CDC officials, using electronic lab reporting instead of paper 

reports results in timelier, more complete, and more accurate reports. 

ELC applies these measures to awardees that have not already reached 

the program threshold of reporting at least 75 percent of their laboratory 

reports electronically. CDC officials stated that the process of submitting 

reports via electronic lab reporting requires significant technical expertise 

and repeated communication between the laboratories, hospitals, and the 

state’s public health department. CDC-established targets measure 

whether or not awardees are increasing their volume of reports received 

via electronic lab reporting each year. Awardees who have not met ELC’s 

reporting threshold may struggle with electronic lab reporting for several 

reasons, such as difficultly hiring or maintaining skilled personnel to 

advance electronic lab reporting or implementing electronic reporting in 

low volume laboratories, according to CDC officials. The performance of 

the ELC awardees that did not meet the electronic lab reporting target 

varied widely. For example, over 20 percent of awardees submitted a 

smaller proportion of laboratory reports electronically in 2016 than they 

did in 2015, while other awardees came close to meeting the target (a 10 

percent increase in electronic reports).
Page 27 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Epidemiology capacity refers to identifying and responding to infectious 

disease outbreaks.31 ELC had one measure in this area, and PHEP had 

two. The majority of reporting ELC awardees (84 percent) met the 

established target for ELC’s measure; however, few PHEP awardees met 

the targets of the two PHEP measures in this area—the percentage of 

reporting awardees that met the target ranged from 10 to 12 percent. 

(See table 5.)

Table 5: Awardee Performance on Epidemiology Capacity Performance Measures, by Program

Program Performance measure Target Percent of reporting awardees that met targeta

ELC Investigated reported outbreaks. All reported 

outbreaks 

investigated.

84 percent

(n = 61)

PHEP Percentage of required disease reports 

received on time.

Disease reports 

received on time 

across all 

diseases.b

Across all six diseases combined: 10 percent (n = 52)c

• Botulism: 63 percent

• Tularemia: 50 percent

• E. coli: 15 percent

• Hepatitis A: 28 percent

• Measles: 77 percent

• Meningococcal: 30 percent

Percentage of disease reports for 

which required initial control measures 

were initiated on time.

Initial control 

measures 

implemented on 

time across all 

diseases.b

Across all six diseases combined: 12 percent

(n = 52)d

• Botulism: 69 percent

• Tularemia: 54 percent

• E. coli: 17 percent

• Hepatitis A: 36 percent

• Measles: 77 percent

• Meningococcal: 62 percent

Source: GAO analysis of awardee performance measurement data provided by the Centers for Disease Control and Prevention (CDC). | GAO-18-362

Note: Data are from calendar year 2015 for Epidemiology and Laboratory Capacity for Infectious 

Diseases (ELC) and from July 1, 2015, through June 30, 2016, for Public Health Emergency 

Preparedness (PHEP), according to CDC officials. This is the most recent year for which validated 

data were available.

a

The percentages in this column are based on the subsets of awardees that provided data and to 

which the measure applied, or (n). While almost all awardees reported data for these measures, the 

exact number of awardees that provided data varied across measures. Some awardees did not report 

 31CDC defines disease outbreak as the occurrence of cases of disease in excess of what 

would normally be expected in a defined community, geographical area, or season. In 

some situations, a single case of disease may qualify as an outbreak. Awardees are also 

permitted to use their own definitions of what constitutes an outbreak when reporting 

performance measure data, according to CDC officials.

Epidemiology Capacity
Page 28 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

data for a measure, because, for example, the awardee was not required to report on a measure, as 

was the case for some localities and U.S. territories.

b

This target is not indicated in CDC’s performance measurement guidance to PHEP awardees. 

Rather, it is an expectation that CDC has for the awardees, according to CDC officials.

c

CDC officials stated that awardees determine their own reporting time frames for each of the six 

diseases that are required to be reported, and CDC expects each awardee to report all required 

diseases within those time frames. We have provided the percent of reporting awardees that met this 

expectation as it applies to all six diseases combined, as well as by each of the six diseases

individually. Reporting time frames for what is considered “on time” vary by awardee but are from 

immediately to within 1 week, depending on the disease, according to CDC officials.

d

CDC officials stated that CDC determines the initial control measure time frames for each of the six

diseases that are required to be reported, and CDC expects each awardee to implement all required 

initial control measures within those time frames. We have provided the percent of reporting 

awardees that met this expectation as it applies to all six diseases combined, as well as by each of 

the six diseases individually. The time frames for what is considered “on time” vary by disease and 

are from within 24 hours to 1 week, according to CDC officials.

ELC’s measure in this area—the percent of total outbreaks investigated—

is meant to assess the extent to which state public health agencies can 

effectively respond, prevent, and control infectious disease outbreaks. 

The measure indicates the proportion of outbreaks that were investigated 

by each awardee for reportable diseases compared to the total number of 

outbreaks, with the CDC-established target of investigating 100 percent of 

outbreaks, according to CDC officials.

The two PHEP measures in this area are key to being able to initiate 

timely investigations and limit the spread of disease. CDC officials stated 

that the nature of a disease may make it difficult for an awardee to meet 

the performance targets. For example, the source of foodborne diseases 

can be particularly difficult to track in order to implement control 

measures, especially when contamination may have originated outside of 

the United States. While few PHEP awardees met the targets for 

submitting all disease reports and implementing all initial control 

measures on time, awardee performance varied by disease. For example, 

among the awardees that had cases of disease, only 15 percent of 

disease reports were received on time and 17 percent of initial control 

measures were implemented on time for E. coli, but both targets were 

met 77 percent of the time for measles.
Page 29 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

We provided a draft of this report to the Secretary of Health and Human 

Services for comment. HHS provided technical comments, which we 

incorporated as appropriate.

We are sending copies of this report to the appropriate congressional 

committees, the Secretary of Health and Human Services, and other 

interested parties. In addition, the report is available at no charge on the 

GAO website at http://www.gao.gov.

If you or your staff members have any questions about this report, please 

contact me at (202) 512-7114 or crossem@gao.gov. Contact points for 

our Offices of Congressional Relations and Public Affairs may be found 

on the last page of this report. GAO staff who made key contributions to 

this report are listed in appendix II.

Marcia Crosse

Director, Health Care

Agency Comments
Appendix I: Non-Federal Stakeholders’ Views 

on Factors to Consider for an Emergency 

Response Fund

Page 30 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Ten non-federal stakeholders told us that a mechanism to fund rapid 

response to an infectious disease threat could be beneficial during 

infectious disease threats. Such a mechanism could include the use of 

the existing Public Health Emergency Fund or a new emergency 

response fund specific to infectious disease. The availability of any such 

fund for immediate use would be subject to available appropriations. 

Stakeholders reported six factors that may be considered for a new 

emergency response fund. The table below summarizes the information 

from stakeholders regarding the factors.

Table 6: Six Factors That May Be Considered for an Emergency Response Fund, According to Non-Federal Stakeholders

Factor Stakeholder discussion

Who determines when to 

use an emergency fund 

Most of the non-federal stakeholders stated that it would be beneficial if the Secretary of Health and 

Human Services were authorized to determine when to use an emergency fund. Two stakeholders 

explained that it would be beneficial for the Secretary to make the determination, because the Department 

of Health and Human Services (HHS) is in charge of the public health response in the case of 

emergencies. Further, one of these stakeholders said that the Secretary can consult with, and benefit 

from, the technical and scientific knowledge of the Centers for Disease Control and Prevention (CDC) 

when making the decision. One stakeholder said that it would be beneficial for the use of such a fund to be 

determined by the CDC Director, because the agency has the expertise to dealing with public health 

threats. One stakeholder commented that a benefit of the existing Public Health Emergency Fund (PHEF) 

is that its use is determined by the Secretary of Health and Human Services.a

One non-federal stakeholder stated that it could be beneficial for use of the fund to be determined at the 

White House level because a cross-agency response is often required.

What factors would 

trigger the use of an 

emergency fund

A few non-federal stakeholders said that no one specific factor, or set of factors, could be used to 

determine when to trigger the use of an emergency fund. For example, one stakeholder provided the 

example that the factors for Zika and Ebola were very disparate, and both outbreaks started abroad with 

little mortality in the United States; however, according to the stakeholder, it would have been appropriate 

to use an emergency fund for both. Further, two other stakeholders commented that while factors such as 

morbidity and mortality rates are important, these rates might not be fully known before it is appropriate to 

take emergency action to stop an infectious disease threat. As a result of the varying factors, a few 

stakeholders commented it would be important to consult with subject matter experts—including the 

Secretary of Health and Human Services and other public health professionals, such as those within 

CDC—to determine if and when to trigger the use of an emergency fund.

A few non-federal stakeholders also said that the capacity of the state and local response entities and 

whether their resources have been depleted are considerations for determining when to use an 

emergency fund. For example, two stakeholders told us that those with authority over a fund need to be in 

communication with the state and local public health departments, and use of an emergency fund could be 

considered when state and local capacities are overwhelmed.

Methods to determine the 

amount of available 

funding 

While a few non-federal stakeholders supported the idea of maintaining a set amount in an emergency 

fund, there was no consensus on how that amount should be calculated. Two stakeholders liked the idea 

of using a formula that included data on past infectious disease response spending as a basis for 

determining the amount to maintain in an emergency fund, though two other stakeholders agreed that past 

events (and their costs) do not determine future events. 

A few non-federal stakeholders commented that it was important that any appropriations to an emergency 

fund supplement, but not supplant, regular annual appropriations that support preparedness and capacitybuilding programs. This is the case for funds appropriated to PHEF. 42 U.S.C. § 247d(c).

Appendix I: Non-Federal Stakeholders’ 

Views on Factors to Consider for an 

Emergency Response Fund
Appendix I: Non-Federal Stakeholders’ Views 

on Factors to Consider for an Emergency 

Response Fund

Page 31 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Factor Stakeholder discussion

Activities to fund with an 

emergency fund

A few non-federal stakeholders stressed that an emergency fund could be reserved for activities that need 

immediate action. For an infectious disease threat, a few non-federal stakeholders mentioned a variety of 

activities that could be funded with an emergency fund—including state and local public health laboratory 

operations and surveillance, risk communications, mass dispensing of medical countermeasures, and 

other activities—to provide additional surge capacity, some of which may be unpredictable.b Because of 

the unpredictability of the next big infectious disease threat, a few stakeholders said that it would be 

beneficial for an emergency fund to be flexible in terms of the activities it is allowed to fund. 

A few non-federal stakeholders commented that it would be most beneficial for an emergency fund to be 

used for defined, short-term needs over long-term public health threats, such as the opioid epidemic. For 

example, one stakeholder stated that while PHEF could be used to support the initial response to any 

public health threat, it would not be beneficial for it to support any long-term or ongoing response efforts. 

Long-term public health threats, such as the opioid epidemic, could rapidly deplete the fund without 

making a difference in the threat itself, according to the stakeholder. 

Accountability for use of 

an emergency fund

Most non-federal stakeholders generally agreed that it would be beneficial to have reporting requirements 

attached to an emergency fund, which include financial accountability measures, and a few of these 

stakeholders commented that such requirements are already in place for existing preparedness and 

capacity-building programs, as this is a part of good governance.c

A few non-federal stakeholders also said that requiring an after action report following the emergency 

would be beneficial.

Whether an emergency 

fund would be specific to 

infectious disease threats

One non-federal stakeholder told us that it would be beneficial to have a fund specific to infectious disease 

threats, while half of the non-federal stakeholders we interviewed did not agree with having an emergency 

fund limited to infectious disease threats. One of these stakeholders commented that an emergency fund

is needed to surge quickly for any type of public health threat—including bioterrorism and radio-nuclear 

threats—and that often the same core resources are needed to respond to infectious disease threats, as 

well as these other types of threats. 

A few other stakeholders stated that there is not a consensus on how broad or narrow a fund should be. 

One of these stakeholders said that although there is not consensus, besides hurricanes, the last three big 

public health threats were infectious disease threats, so it would make sense to start with that type of 

event. A fund limited to infectious disease threats could be put it in place, used, evaluated, and then 

analyzed over time to determine if it should be expanded to other public health threats.

Source: GAO summary of information received from non-federal stakeholders interviewed. | GAO-18-362

a

PHEF, established in 1983, is available to the Secretary of Health and Human Services to respond to 

a public health emergency, including infectious disease threats. See Pub. L. No.98-49, 97 Stat. 245 

(1983) (codified as amended at 42 U.S.C. § 247d). A Congressional Research Service report issued 

in 2009 indicated that the fund had not received an appropriation since Congress reauthorized it in 

2000. Congressional Research Service, The Public Health and Medical Response to Disasters: 

Federal Authority and Funding, RL33579 (Washington, D.C.: Apr. 29, 2009). According to HHS’s 

2016 budget justification estimates, PHEF has no balance.

b

A health care system’s ability to “surge” is the ability to have the staff and resources in place to 

adequately care for increased numbers of affected individuals or individuals with unusual or highly 

specialized needs.

c

We previously reported on the application, financial, and reporting requirements that awardees must 

adhere to as part of the terms of the cooperative agreements of two programs that support 

preparedness capacity—the Hospital Preparedness Program and Public Health Emergency 

Preparedness. These include adhering to the HHS Office of Assistant Secretary for Preparedness 

and Response and CDC guidelines for the appropriate use of cooperative agreement funds, 

undergoing biennial financial audits of their cooperative agreement funds, and submitting midyear 

and end-of-year progress reports and periodic financial reports. For more detailed information, see 

GAO, National Preparedness: Improvements Needed for Measuring Awardee Performance in 

Meeting Medical and Public Health Preparedness Goals, GAO-13-278 (Washington, D.C.: Mar. 22, 

2013).
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 32 GAO-18-362 Infectious Disease Preparedness and Capacity-Building

Marcia Crosse, (202) 512-7114, crossem@gao.gov

In addition to the contact named above, Hernan Bozzolo (Assistant 

Director), Deirdre Gleeson Brown (Analyst-in-Charge), Alexander Cattran, 

and Jessica L. Preston made key contributions to this report. Also 

contributing were George Bogart, Muriel Brown, and Drew Long.

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(102113)
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