Testimony 

Before the Committee on Government 

Reform, House of Representatives

United States General Accounting Office 

GAO

For Release on Delivery 

Expected at 10:00 a.m. EST 

Thursday, February 12, 2004 PUBLIC HEALTH 

PREPAREDNESS 

Response Capacity 

Improving, but Much 

Remains to Be 

Accomplished 

Statement of Janet Heinrich 

Director, Health Care—Public Health Issues 

GAO-04-458T 
www.gao.gov/cgi-bin/getrpt?GAO-04-458T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Janet Heinrich 

at (202) 512-7119. 

Highlights of GAO-04-458T, a testimony 

before the Committee on Government 

Reform, House of Representatives 

February 12, 2004

PUBLIC HEALTH PREPAREDNESS

Response Capacity Improving, but Much 

Remains to Be Accomplished 

Although states have further developed many important aspects of public 

health preparedness, since April 2003, no state is fully prepared to respond 

to a major public health threat. States have improved their disease 

surveillance systems, laboratory capacity, communication capacity, and 

workforce needed to respond to public health threats, but gaps in each 

remain. Moreover, regional planning between states is lacking, and many 

states lack surge capacity—the capacity to evaluate, diagnose, and treat the 

large numbers of patients that would present during a public health 

emergency. Although states are developing plans for receiving and 

distributing medical supplies and material for mass vaccinations from the 

Strategic National Stockpile in the event of a public health emergency, most 

of these plans are not yet finalized. 

HHS has not published the federal influenza pandemic plan, and most of the 

state plans have not been finalized. In 2000, GAO recommended that HHS 

complete the national plan for responding to an influenza pandemic, but 

according to HHS, the plan is still under review. Absent a federal plan, key 

questions about the federal role in the purchase, distribution, and 

administration of vaccines and antiviral drugs during a pandemic remain 

unanswered. HHS reports that most states continue to develop their state 

plans despite the lack of a federal plan. 

The anthrax incidents in the fall of 

2001 and the severe acute 

respiratory syndrome (SARS) 

outbreak in 2002-2003 have raised 

concerns about the nation’s ability 

to respond to a major public health 

threat, whether naturally occurring 

or the result of bioterrorism. The 

anthrax incidents strained the 

public health system, including 

laboratory and workforce 

capacities, at the state and local 

levels. The SARS outbreak 

highlighted the challenges of 

responding to new and emerging 

infectious disease. The current 

influenza season has heightened 

concerns about the nation’s ability 

to handle a pandemic. 

GAO was asked to examine 

improvements in state and local 

preparedness for responding to 

major public health threats and 

federal and state efforts to prepare 

for an influenza pandemic. 

This testimony is based on GAO’s 

recent report, HHS Bioterrorism 

Preparedness Programs: States 

Reported Progress but Fell Short of 

Program Goals for 2002, GAO-04-

360R (Feb. 10, 2004). This 

testimony also updates information 

contained in GAO’s report on 

federal and state planning for an 

influenza pandemic, Influenza 

Pandemic: Plan Needed for 

Federal and State Response, GAO01-4 (Oct. 27, 2000). 
Page 1 GAO-04-458T 

Mr. Chairman and Members of the Committee: 

I appreciate the opportunity to be here today to discuss the work we have 

done pertaining to the nation’s preparedness to manage major public 

health threats. The anthrax incidents in the fall of 2001, the SARS1

outbreak in 2002-2003, and the recent incidents involving ricin have raised 

concerns about the nation’s ability to respond to a major public health 

threat, whether naturally occurring or the result of bioterrorism. The 

anthrax incidents strained the public health system, including surveillance2

and laboratory capacities as well as the workforce, at the state and local 

levels.3

 The SARS outbreak highlighted the challenges in responding to 

new and emerging infectious disease—especially when the ability to 

identify the disease and a vaccine for preventing it are lacking.4

 The 

current influenza season has heightened concerns about our nation’s 

ability to handle a pandemic.5

 The Congress has recognized the need to 

strengthen the nation’s ability to respond to such threats and has 

increased appropriations for federal, state, and local public health 

preparedness efforts. The Department of Health and Human Services 

(HHS) has been developing a national plan for responding to an influenza 

pandemic. 

As you requested, to assist the Committee in its consideration of our 

nation’s ability to respond to a major public health threat, whether 

naturally occurring or the result of bioterrorism, my remarks today will 

focus on (1) state and local preparedness for responding to major public 

health threats and (2) federal and state efforts to prepare for an influenza 

pandemic. 

 1

SARS is the abbreviation for severe acute respiratory syndrome. 

2

Public health surveillance uses systems that provide for the ongoing collection, analysis, 

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

3

See U.S. General Accounting Office, Bioterrorism: Public Health Response to Anthrax 

Incidents of 2001, GAO-04-152 (Washington, D.C.: Oct. 15, 2003). 

4

See U.S. General Accounting Office, SARS Outbreak: Improvements to Public Health 

Capacity Are Needed for Responding to Bioterrorism and Emerging Infectious Diseases, 

GAO-03-769T (Washington, D.C.: May 7, 2003). 

5

Pandemics are worldwide epidemics. Influenza pandemics can have successive “waves” of 

disease and last for up to 3 years. Three pandemics occurred in the 20th century: the 

“Spanish flu” of 1918, which killed at least 20 million people worldwide; the “Asian flu” of 

1957; and the “Hong Kong flu” of 1968. 
Page 2 GAO-04-458T 

My testimony today updates testimony that we provided to you in April 

20036

 and is based largely on work we conducted for our recently released 

report on HHS’s programs that support state and local preparedness for 

bioterrorism and other public health threats.7

 For that report, we reviewed 

each state’s progress report8

 on the use of bioterrorism preparedness 

funding distributed in 2002 by HHS’s Centers for Disease Control and 

Prevention (CDC) and Health Resources and Services Administration 

(HRSA). The progress reports covered the period through August 30, 2003, 

for CDC’s program and through July 1, 2003, for HRSA’s program. For that 

report we also interviewed officials from 10 states, 1 local health 

department within each of these states, and 2 major metropolitan areas 

directly funded by CDC and HRSA. My testimony today also updates 

information provided in our October 2000 report on federal and state 

planning for an influenza pandemic.9

 To update that information, in 

February 2004, we spoke with officials from CDC and HHS’s National 

Vaccine Program Office. We conducted our work in accordance with 

generally accepted government auditing standards. 

In summary, although states have further developed many important 

aspects of public health preparedness, since I testified before you in April 

2003, no state is fully prepared to respond to a major public health threat. 

States have improved their disease surveillance systems, laboratory 

capacity, communication capacity, and workforce needed to respond to 

public health threats, but gaps in each remain. Moreover, regional planning 

between states is lacking, and many states lack surge capacity—the 

capacity to evaluate, diagnose, and treat the large numbers of patients that 

would present during a public health emergency. Although states are 

developing plans for receiving and distributing medical supplies and 

material for mass vaccinations from the Strategic National Stockpile in the 

event of a public, most of these plans are not yet finalized. 

 6

U.S. General Accounting Office, Infectious Disease Outbreaks: Bioterrorism 

Preparedness Efforts Have Improved Public Health Response Capacity, but Gaps 

Remain, GAO-03-654T (Washington, D.C.: Apr. 9, 2003). 

7

U.S. General Accounting Office, HHS Bioterrorism Preparedness Programs: States 

Reported Progress but Fell Short of Program Goals for 2002, GAO-04-360R (Washington, 

D.C.: Feb. 10, 2004). 

8

The progress reports were for the 50 states, the District of Columbia, and the nation’s 

three largest municipalities (New York City, Chicago, and Los Angeles County). 

9

U.S. General Accounting Office, Influenza Pandemic: Plan Needed for Federal and State 

Response, GAO-01-4 (Washington, D.C.: Oct. 27, 2000). 
Page 3 GAO-04-458T 

HHS has not published the federal influenza pandemic plan, and most of 

the state plans for influenza have not been finalized. In 2000, we 

recommended that HHS complete the national plan for responding to an 

influenza pandemic, but according to HHS, the plan is still under review. 

Absent a federal plan, key questions about the federal role in the purchase, 

distribution, and administration of vaccines and antiviral drugs during a 

pandemic remain unanswered. HHS reports that most states continue to 

develop their state plans despite the lack of a federal plan. 

The initial response to a public health emergency—for instance an 

outbreak of an infectious disease—generally occurs at the local and state 

levels and could involve disease surveillance, laboratory testing, 

epidemiologic investigation,10 communication, and health care treatment. 

As a public health emergency develops, each plays a critical role in an 

effective response. Local and state health departments collect and monitor 

data, such as reports from clinicians, for disease trends and evidence of an 

outbreak. Laboratory personnel test clinical and environmental samples 

for possible exposures and identification of illnesses. Epidemiologists in 

the health departments use disease surveillance systems to detect clusters 

of suspicious symptoms or diseases in order to facilitate early detection of 

disease and treatment of victims. Public health officials provide needed 

information to the clinical community, other responders, and the public 

and implement control measures to prevent additional cases from 

occurring. Health care providers treat patients and limit the spread of 

infectious disease. All these response activities require a workforce that is 

sufficiently skilled and adequate in number. 

The federal government provides funding and resources to state and local 

entities to support preparedness and response efforts. For example, in 

fiscal year 2002 CDC’s Public Health Preparedness and Response for 

Bioterrorism cooperative agreement11 program provided approximately 

$918 million to states to improve bioterrorism preparedness and response 

as well as other public health emergency preparedness capacities. 

Similarly, HRSA’s Bioterrorism Hospital Preparedness cooperative 

 10Epidemiology is the study of how disease is distributed in populations and the factors that 

influence or determine this distribution. 

11A cooperative agreement is used as a mechanism to provide financial support for a 

particular activity when substantial interaction is expected between the executive agency 

and a state, local government, or other recipient carrying out the funded activity. 

Background 
Page 4 GAO-04-458T 

agreement program provided approximately $125 million to states in fiscal 

year 2002 to enhance the capacity of hospitals and associated health care 

entities to respond to bioterrorist attacks. HHS renewed these cooperative 

agreements for the period of August 31, 2003 through August 30, 2004. For 

these renewed agreements, CDC’s program and HRSA’s program 

distributed about $870 million and about $498 million, respectively. Among 

the other resources that the federal government provides is the Strategic 

National Stockpile, which contains pharmaceuticals and medical supplies 

that can be delivered to the site of a public health emergency anywhere in 

the United States within 12 hours of the decision to deploy them. 

The federal government also supports preparedness efforts for an 

influenza pandemic. HHS’s National Vaccine Program Office is responsible 

for the development of federal plans for vaccine and immunization 

activities and coordinating these efforts among federal agencies. To foster 

state and local planning, HHS issued interim planning guidance for the 

states in 1997 that outlined general federal and state responsibilities during 

an influenza pandemic. HHS expects that if a pandemic occurs, both the 

vaccines that are used to prevent influenza and the antiviral drugs that are 

used to treat influenza will be in short supply.12 The guidance discussed 

certain key issues related to limited supplies of the influenza vaccine and 

antiviral drugs—for instance the amount of vaccine and antiviral drugs 

that will be purchased at the federal level; the division of responsibility 

between the public and private sectors for the purchase, distribution, and 

administration of these supplies during a pandemic; and priorities for 

vaccinating population groups, such as health workers and public health 

personnel involved in the pandemic response, and persons traditionally 

considered to be at increased risk of severe influenza illness and mortality. 

 12These shortages are expected because demand would exceed current rates of production 

and because manufacturers report that increasing the production capacity of antiviral 

drugs can take at least 6 to 9 months. 
Page 5 GAO-04-458T 

States reported that as of the summer of 2003 they have made 

improvements in their preparedness to respond to major public health 

threats, but no aspect of preparedness has been fully addressed by all of 

the states.13 Specifically, although states have strengthened their disease 

surveillance systems, laboratory capacity, communications, workforce, 

surge capacity, regional coordination across state borders, and readiness 

to utilize the Strategic National Stockpile, all of these important aspects of 

preparedness require additional work. 

Although some states have made improvements to their disease 

surveillance systems, the nation’s ability to detect and report a disease 

outbreak is not uniformly strong across all states. For example, about half 

of the states reported that their health departments are capable of 

receiving and evaluating urgent disease reports on a 24-hour-per-day, 

7-day-per-week basis; however, few states reported having the ability to 

rapidly detect an outbreak of an influenza-like illness in the state. 

Similarly, few states reported efforts to strengthen links between their 

public health and animal surveillance systems14 and the veterinary 

community in order to monitor diseases in animals that may be spread to 

humans, such as the West Nile virus.15

States have increased their capacity to test and identify specimens and 

improve laboratory security, although laboratory capacity is not uniformly 

robust in all states. All states participate in CDC’s Laboratory Response 

Network, a network of local, state, federal, and international laboratories 

that are equipped to respond to biological and chemical terrorism, 

emerging infectious diseases and other public health threats. However, 

only about half of the states reported that they have at least one public 

health laboratory within the state that has the appropriate instrumentation 

and appropriately trained staff to conduct certain tests for rapidly 

 13In this section, “state” refers to the 50 states, the District of Columbia, New York City, 

Chicago and Los Angeles County. 

14Animal health surveillance involves the collection, evaluation, and interpretation of data 

to provide timely and accurate detection, diagnosis, prevention, and control of diseases in 

animals. 

15For more information, see U.S. General Accounting Office, West Nile Virus Outbreak: 

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

2000). 

States Have Further 

Developed Important 

Aspects of Public 

Health Preparedness, 

but Additional Work 

Is Needed 

Disease Surveillance 

Systems 

Laboratory Capacity 
Page 6 GAO-04-458T 

detecting and correctly identifying biological agents. About half of the 

states reported that they had a facility with a biosafety level sufficient to 

handle such agents as anthrax.16 About half the states also reported that 

laboratory security within the state is consistent with HHS guidelines, 

which include recommendations for protecting laboratory personnel and 

preventing the unauthorized removal of dangerous biologic agents from 

the laboratory. 

Although improving, communication, both among those involved in 

responding to a major public health threat—such as public health officials, 

health care providers, and emergency management agencies—and with 

the public, remains a challenge. CDC’s Health Alert Network has been 

expanded—most of the states reported that the local health departments 

that cover at least 90 percent of their populations are involved in this 

network.17 However, many states reported that they were still in the 

process of assessing their communication needs. Although about half the 

states have a plan for educating the public about the risks posed by 

bioterrorism and other public health threats, few states have mechanisms 

in place for communicating with the general public during an incident 

about such issues as when it is necessary to go to the hospital. 

States have increased the number of personnel essential to public health 

preparedness, but concerns about workforce shortages remain. Most of 

the states reported that the bioterrorism preparedness funding from CDC 

allowed each to appoint an executive director of its bioterrorism 

preparedness and response program, to designate a response coordinator, 

and to hire at least one epidemiologist for each metropolitan area with a 

population greater than 500,000. However, most states continue to have 

staffing concerns. As we have reported previously,18 some state and local 

health officials have had difficulty finding and hiring epidemiologists and 

 16Biosafety measures the degree of protection a laboratory offers to personnel, the 

environment, and the community. 

17The Health Alert Network is a nationwide program designed to ensure communication 

capacity at all state and local health departments. This network enables local health 

departments to receive health alerts and other information from CDC and state health 

departments. 

18U.S. General Accounting Office, Bioterrorism: Preparedness Varied across State and 

Local Jurisdictions, GAO-03-373 (Washington, D.C.: Apr. 7, 2003); GAO-04-360R; 

GAO-03-654T. 

Communication 

Workforce 
Page 7 GAO-04-458T 

laboratory personnel. The ability to hire and retain personnel in these 

areas is still a concern for state and local health officials, who identify 

workforce shortages as a long-term challenge to their preparedness 

efforts. 

Most states lack surge capacity—that is, the capacity to respond to the 

large influx of patients that could occur during a public health emergency. 

For example, few states reported that they had the capacity to evaluate, 

diagnose, and treat 500 or more patients involved in a single incident. 

Furthermore, no state reported having protocols in place for augmenting 

personnel in response to large influxes of patients, and few states reported 

having plans for sharing clinical personnel among hospitals. In addition, 

few states reported having the capacity to rapidly establish clinics to 

immunize or provide treatment to large numbers of patients. 

Few states have regional plans in place that would coordinate the 

response among states during a public health emergency, and state 

officials remain concerned about a lack of regional planning across state 

borders. Few states have completed regional response plans for incidents 

of bioterrorism and other public health threats and emergencies. Most of 

the states that do have such plans have not established training programs 

to support their plans or mechanisms to test their plans. 

Most state plans for using the Strategic National Stockpile in the event of a 

public health emergency have not been fully developed. All states have 

prepared preliminary plans for the receipt and management of stockpile 

materials, but only about a third of the states have plans that outline how 

they would distribute antibiotics, chemical/nerve agent antidotes, and 

other materials to areas within the state. 

Surge Capacity 

Regional Planning 

Strategic National 

Stockpile 
Page 8 GAO-04-458T 

Federal officials have not finalized plans for responding to an influenza 

pandemic, and state influenza pandemic response plans are in various 

stages of completion. 

As we have reported previously,19 federal officials have drafted but not 

finalized the federal influenza pandemic plan. In 2000, we recommended 

that HHS complete the national plan for responding to an influenza 

pandemic, but HHS reported recently that the plan was still under review 

within HHS. However, HHS is taking other steps to prepare for an 

influenza pandemic. For example, CDC has increased the supply of 

ventilators and added an antiviral drug to the Strategic National Stockpile. 

HHS is also coordinating with other federal partners, such as the 

Department of Agriculture, to improve the nation’s ability to respond to 

public health emergencies involving the veterinary and agricultural 

sectors. 

Despite the absence of a finalized, federal response plan for an influenza 

pandemic, states are developing their own response plans. According to 

HHS officials, as of February 2004, 15 states have final or draft plans, and 

34 states are actively working on plans. In these plans, states have had to 

make assumptions about what the federal role during an influenza 

pandemic will be. It is still unclear whether the private sector, the public 

sector, or both will have responsibility for purchasing and distributing 

vaccines and antiviral drugs. Some states have assumed that vaccine 

supply will be under the control of the federal government, while others 

have assumed that it will not. States have also made different assumptions 

about who will pay for vaccines, antiviral medications, and related 

supplies. 

States have taken many actions to improve their ability to respond to a 

major public health threat, but no state has reported being fully prepared. 

Federal plans for the purchase, distribution, and administration of 

vaccines and drugs in response to an influenza pandemic still have not 

been finalized, complicating the efforts of states to develop their state 

plans and heightening concern about our nation’s ability to respond 

effectively to an influenza pandemic. States are more prepared now, but 

much remains to be accomplished. 

 19GAO-01-4; GAO-03-654T. 

The Federal Influenza 

Plan Has Not Been 

Finalized, but State 

Planning and Other 

Efforts Continue 

Concluding 

Observations 
Page 9 GAO-04-458T 

Mr. Chairman, this completes my prepared statement. I would be happy to 

respond to any questions you or other Members of the Committee may 

have at this time. 

For further information about this testimony, please contact Janet 

Heinrich at (202) 512-7119. Angela Choy, Maria Hewitt, Krister Friday, 

Nkeruka Okonmah, and Michele Orza also made key contributions to this 

statement. 

Contact and 

Acknowledgments 

(290350) 
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