Testimony 

Before the Subcommittee on Oversight 

and Investigations, Committee on Energy 

and Commerce, House of Representatives 

United States General Accounting Office 

GAO

For Release on Delivery 

Expected at 2:00 p.m. 

Wednesday, May 7, 2003 SARS OUTBREAK 

Improvements to Public 

Health Capacity Are Needed 

for Responding to 

Bioterrorism and Emerging 

Infectious Diseases 

Statement of Janet Heinrich 

Director, Health Care—Public Health Issues 

GAO-03-769T 
The efforts of public health agencies and health care organizations to 

increase their preparedness for major public health threats such as 

bioterrorism and the worldwide influenza outbreaks known as pandemics 

have improved the nation’s capacity to respond to SARS and other emerging 

infectious disease outbreaks, but gaps in preparedness remain. Specifically, 

GAO found that there are gaps in disease surveillance systems and 

laboratory facilities and that there are workforce shortages. The level of 

preparedness varied across seven cities GAO visited, with jurisdictions that 

have had multiple prior experiences with public health emergencies being 

generally more prepared than others. GAO found that planning for regional 

coordination was lacking between states. GAO also found that states were 

developing plans for receiving and distributing medical supplies for 

emergencies and for mass vaccinations in the event of a public health 

emergency. 

GAO found that most hospitals lack the capacity to respond to large-scale 

infectious disease outbreaks. Most emergency departments have 

experienced some degree of crowding and therefore in some cases may not 

be able to handle a large influx of patients during a potential SARS or other 

infectious disease outbreak. Most hospitals across the country reported 

participating in basic planning activities for such outbreaks. However, few 

hospitals have adequate medical equipment, such as the ventilators that are 

often needed for respiratory infections such as SARS, to handle the large 

increases in the number of patients that may result. 

The public health response to outbreaks of emerging infectious diseases 

such as SARS could be improved by the completion of federal and state 

influenza pandemic response plans that address problems related to the 

purchase, distribution, and administration of supplies of vaccines and 

antiviral drugs during an outbreak. The Centers for Disease Control and 

Prevention has provided interim draft guidance to facilitate state plans but 

has not made the final decisions on plan provisions necessary to mitigate the 

effects of potential shortages of vaccines and antiviral drugs in the event of 

an influenza pandemic. 

SARS has infected relatively few 

people nationwide, but it has raised 

concerns about preparedness for 

large-scale infectious disease 

outbreaks. The initial response to 

an outbreak occurs in local 

agencies and hospitals, with 

support from state and federal 

agencies, and can involve disease 

surveillance, epidemiologic 

investigation, health care delivery, 

and quarantine management. 

Officials have learned lessons 

applicable to preparedness for such 

outbreaks from experiences with 

other major public health threats. 

GAO was asked to examine the 

preparedness of state and local 

public health agencies and 

hospitals for responding to a largescale infectious disease outbreak 

and the relationship of federal and 

state planning for an influenza 

pandemic to preparedness for 

emerging infectious diseases. 

This testimony is based on 

Bioterrorism: Preparedness 

Varied across State and Local 

Jurisdictions, GAO-03-373 (Apr. 7, 

2003); findings from a GAO survey 

on hospital emergency room 

capacity (in Hospital Emergency 

Departments: Crowded Conditions 

Vary among Hospitals and 

Communities, GAO-03-460 (Mar. 

14, 2003)) and on hospital 

emergency preparedness; and 

information updating Influenza 

Pandemic: Plan Needed for 

Federal and State Response, GAO01-4 (Oct. 27, 2000). 

www.gao.gov/cgi-bin/getrpt?GAO-03-769T.

To view the full testimony, including the scope 

and methodology, click on the link above. 

For more information, contact Janet Heinrich 

at (202) 512-7119. 

Highlights of GAO-03-769T, testimony 

before the Subcommittee on Oversight 

and Investigations, Committee on Energy 

and Commerce, House of Representatives 

May 7, 2003 

SARS OUTBREAK 

Improvements to Public Health Capacity 

Are Needed for Responding to 

Bioterrorism and Emerging Infectious 

Diseases 
Page 1 GAO-03-769T 

Mr. Chairman and Members of the Subcommittee: 

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, such as the emerging infectious disease known as SARS.1

The initial response to an outbreak of infectious disease would occur at 

the local level, with support from state and federal agencies, and could 

involve disease surveillance,2 epidemiologic investigation,3 health care 

delivery, and quarantine management. The SARS outbreak has not infected 

large numbers of individuals in the United States, but it has raised 

concerns about the nation’s preparedness to manage these components of 

response should it, or other infections, reach large-scale proportions. 

Public health officials and health care workers have learned lessons 

applicable to preparedness for large-scale infectious disease outbreaks 

from experiences with other major public health threats. Because of prior 

worldwide influenza outbreaks—known as pandemics4

—federal and state 

agencies have begun to focus special attention on planning for such 

events. Similarly, following the anthrax incidents of fall 2001, the Congress 

expressed concern that the nation may not be prepared to respond to a 

large-scale bioterrorist event. State and local response agencies and 

organizations have recognized the need to strengthen their infrastructure 

and capacity to respond to bioterrorism. The improvements they are 

making will also strengthen their ability to identify and respond to other 

major public health threats, including naturally occurring infectious 

disease outbreaks. Planning for a response to bioterrorism and influenza 

pandemics targets the public health resources essential for a response to 

emerging infectious diseases. 

To assist the Subcommittee in its consideration of our nation’s capacity to 

respond to a major public health threat such as SARS, my remarks today 

 1

SARS is the abbreviation for severe acute respiratory syndrome. 

2

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

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

3

An epidemiologic investigation seeks to determine how a disease is distributed in a 

population and the factors that influence or determine this distribution. 

4

Influenza pandemics are worldwide influenza epidemics that can have successive “waves” 

of disease and last for up to 3 years. Three pandemics occurred in the twentieth 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-03-769T 

will focus on (1) the preparedness of state and local public health agencies 

for responding to a large-scale infectious disease outbreak, (2) the 

preparedness of hospitals for responding to a large-scale infectious 

disease outbreak, and (3) the relationship of federal and state planning for 

an influenza pandemic to preparedness for emerging infectious diseases. 

My testimony today is based largely on our recently released report on 

state and local preparedness for a bioterrorist attack.5

 For that report, we 

conducted site visits to seven cities and their respective state 

governments. We also reviewed each state’s spring 2002 applications for 

bioterrorism preparedness funding distributed by the Department of 

Health and Human Services’ (HHS) Centers for Disease Control and 

Prevention (CDC) and Health Resources and Services Administration 

(HRSA), and each state’s fall 2002 progress report on the use of that 

funding. In addition, I will present some findings from a survey we 

conducted on hospital emergency department capacity and emergency 

preparedness,6

 as well as some information updating our 2000 report on 

federal and state planning for an influenza pandemic.7

In summary, while the efforts of public health agencies and health care 

organizations to increase their preparedness for major public health 

threats such as influenza pandemics and bioterrorism have improved the 

nation’s capacity to respond to SARS and other emerging infectious 

disease outbreaks, gaps in preparedness remain. Specifically, we found 

that there are gaps in disease surveillance systems and laboratory facilities 

and that there are workforce shortages. The level of preparedness varied 

across cities we visited, with jurisdictions that have had multiple prior 

experiences with public health emergencies being generally more 

prepared than others. We found that planning for regional coordination 

was lacking between states. We also found that states were developing 

 5

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

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

6

These findings include those related to emergency department capacity, which we 

reported in U.S. General Accounting Office, Hospital Emergency Departments: Crowded 

Conditions Vary among Hospitals and Communities, GAO-03-460 (Washington, D.C.: 

Mar. 14, 2003) and hospital emergency preparedness for mass casualty incidents from 

ongoing work. We did our work on the survey from May 2002 through May 2003 in 

accordance with generally accepted government auditing standards. 

7

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-03-769T 

plans for receiving and distributing medical supplies for emergencies and 

for mass vaccinations in the event of a public health emergency. 

We found that most hospitals across the country lack the capacity to 

respond to large-scale infectious disease outbreaks. Most emergency 

departments have experienced some degree of crowding and therefore in 

some cases may not be able to handle a large influx of patients during a 

potential SARS or other infectious disease outbreak. Although most 

hospitals report participating in basic planning activities for such 

outbreaks, few have adequate medical equipment, such as ventilators that 

are often needed for respiratory infections such as SARS, to handle the 

large increases in the number of patients that may result. 

The public health response to outbreaks of emerging infectious diseases 

such as SARS could be improved by the completion of federal and state 

influenza pandemic response plans that address problems related to the 

purchase, distribution, and administration of supplies of vaccines and 

antiviral drugs during an outbreak. CDC has provided interim draft 

guidance to facilitate state plans but has not made the final decisions on 

plan provisions necessary to mitigate the effects of potential shortages of 

vaccines and antiviral drugs in the event of an influenza pandemic. 

SARS is a respiratory illness that has recently been reported principally in 

Asia, Europe, and North America. The World Health Organization reported 

on May 5, 2003, that there were an estimated 6,583 probable cases 

reported in 27 countries, including 61 cases in the United States. There 

have been 461 deaths worldwide, none of which have been in the United 

States. Of the 56 probable cases in the United States reported through 

April 30, 2003, 37 (66 percent) were hospitalized, and 2 (4 percent) 

required mechanical ventilation. Symptoms of the disease, which may be 

caused by a previously unrecognized coronavirus,8

 can include a fever, 

chills, headache, other body aches, or a dry cough. 

A Canadian official recently reported that more than 60 percent of 

probable SARS cases in Canada, where the bulk of North American cases 

have occurred, resulted from transmission to health care workers and 

 8

The coronavirus is one of a group of viruses that are responsible for some but not all 

common colds. They are so named because their microscopic appearance is that of a virus 

particle surrounded by a crown. 

Background 
Page 4 GAO-03-769T 

patients. Canada’s experience with managing the SARS outbreak has 

shown that measures used to prevent and control emerging infectious 

diseases appear to have been useful in controlling this outbreak. One of 

the measures that it has undertaken to control the outbreak is isolating 

probable cases in hospitals, including closing two hospitals to new 

admissions.9

 Other measures include isolating people, either in their 

homes or in a hospital, who have had close contact with a SARS patient 

and providing educational materials regarding SARS to people who have 

traveled to locations of concern. 

In order to be adequately prepared for a major public health threat such as 

SARS in the United States, state and local public health agencies need to 

have several basic capabilities, whether they possess them directly or have 

access to them through regional agreements. Public health departments 

need to have disease surveillance systems and epidemiologists to detect 

clusters of suspicious symptoms or diseases in order to facilitate early 

detection of disease and treatment of victims. Laboratories need to have 

adequate capacity and necessary staff to test clinical and environmental 

samples in order to identify an agent promptly so that proper treatment 

can be started and infectious diseases prevented from spreading. All 

organizations involved in the response must be able to communicate easily 

with one another as events unfold and critical information is acquired, 

especially in a large-scale infectious disease outbreak. In addition, plans 

that describe how state and local officials would manage and coordinate 

an emergency response need to be in place and to have been tested in an 

exercise, both at the state and local levels and at the regional level. 

Local health care organizations, including hospitals, are generally 

responsible for the initial response to a public health emergency. In the 

event of a large-scale infectious disease outbreak, hospitals and their 

emergency departments would be on the front line, and their personnel 

would take on the role of first responders. Because hospital emergency 

departments are open 24 hours a day, 7 days a week, exposed individuals 

would be likely to seek treatment from the medical staff on duty. Staff 

would need to be able to recognize and report any illness patterns or 

diagnostic clues that might indicate an unusual infectious disease 

outbreak to their state or local health department. Hospitals would need to 

have the capacity and staff necessary to treat severely ill patients and limit 

the spread of infectious disease. In addition, hospitals would need 

 9

The two hospitals have since been reopened. 
Page 5 GAO-03-769T 

adequate stores of equipment and supplies, including medications, 

personal protective equipment, quarantine and isolation facilities, and air 

handling and filtration equipment. 

The federal government also has a role in preparedness for and response 

to major public health threats. It becomes involved in investigating the 

cause of the disease, as it is doing with SARS. In addition, the federal 

government provides funding and resources to state and local entities to 

support preparedness and response efforts. CDC’s Public Health 

Preparedness and Response for Bioterrorism program provided funding 

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

states and municipalities to improve bioterrorism preparedness and 

response, as well as other public health emergency preparedness 

activities. HRSA’s Bioterrorism Hospital Preparedness Program provided 

funding through cooperative agreements in fiscal year 2002 of 

approximately $125 million to states and municipalities to enhance the 

capacity of hospitals and associated health care entities to respond to 

bioterrorist attacks. In March 2003, HHS announced that the CDC and 

HRSA programs would provide funding of approximately $870 million and 

$498 million, respectively, for fiscal year 2003. Among the other public 

health emergency response resources that the federal government 

provides is the Strategic National Stockpile, which contains 

pharmaceuticals, antidotes, and medical supplies that can be delivered 

anywhere in the United States within 12 hours of the decision to deploy. 

Just as was true with the identification of the coronavirus as the likely 

causative agent in SARS, deciding which influenza viral strains are 

dominant depends on data collected from domestic and international 

surveillance systems that identify prevalent strains and characterize their 

effect on human health.10 Antiviral drugs and vaccines against influenza are 

expected to be in short supply if a pandemic occurs. Antiviral drugs, which 

can be used against all forms of viral diseases, have been as effective as 

vaccines in preventing illness from influenza and have the advantage of 

being available now. HHS assumes shortages of antiviral drugs and 

vaccines will occur in a pandemic because demand is expected to exceed 

current rates of production. For example, increasing production capacity 

of antiviral drugs can take at least 6 to 9 months, according to 

manufacturers. 

 10CDC participates in international disease and laboratory surveillance sponsored by the 

World Health Organization, which operates in 83 countries. 
Page 6 GAO-03-769T 

In the cities we visited, state and local officials reported varying levels of 

public health preparedness to respond to outbreaks of diseases such as 

SARS. They recognized gaps in preparedness elements such as 

communication and were beginning to address them. Gaps also remained 

in other preparedness elements that have been more difficult to address, 

including the disease surveillance and laboratory systems and the 

response capacity of the workforce. In addition, we found that the level of 

preparedness varied across the cities. Jurisdictions that had multiple prior 

experiences with public health emergencies were generally more prepared 

than those with little or no such experience prior to our site visits. We 

found that planning for regional coordination was lacking between states. 

In addition, states were working on plans for receiving and distributing the 

Strategic National Stockpile and for administering mass vaccinations. 

States and local areas were addressing gaps in public health preparedness 

elements, such as communication, but weaknesses remained in other 

preparedness elements, including the disease surveillance and laboratory 

systems and the response capacity of the workforce. Gaps in capacity 

often are not amenable to solution in the short term because either they 

require additional resources or the solution takes time to implement. 

We found that officials were beginning to address communication 

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

how communication would take place in a public health emergency. Many 

cities had purchased communication systems that allow officials from 

different organizations to communicate with one another in real time. In 

addition, state and local health agencies were working with CDC to build 

the Health Alert Network (HAN), an information and communication 

system. The nationwide HAN program has provided funding to establish 

infrastructure at the local level to improve the collection and transmission 

of information related to public health preparedness. Goals of the HAN 

program include providing high-speed Internet connectivity, broadcast 

capacity for emergency communication, and distance-learning 

infrastructure for training. 

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

attempting to address inadequacies in their surveillance systems and 

laboratory facilities. Local officials were concerned that their surveillance 

systems were inadequate to detect a bioterrorist event, and all of the states 

State and Local 

Officials Reported 

Varying Levels of 

Public Health 

Preparedness for 

Infectious Disease 

Outbreaks 

Progress Has Been Made 

in Elements of Public 

Health Preparedness, But 

Gaps Remain 

Communication 

Surveillance Systems and 

Laboratory Facilities 
Page 7 GAO-03-769T 

we visited were making efforts to improve their disease surveillance 

systems. Six of the cities we visited used a passive surveillance system11 to 

detect infectious disease outbreaks.12 However, passive systems may be 

inadequate to identify a rapidly spreading outbreak in its earliest and most 

manageable stage because, as officials in three states noted, there is 

chronic underreporting and a time lag between diagnosis of a condition 

and the health department’s receipt of the report. To improve disease 

surveillance, six of the states and two of the cities we visited were 

developing surveillance systems using electronic databases. Several cities 

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

pharmacy sales, to conduct surveillance.13 Three of the cities we visited 

were attempting to improve their surveillance capabilities by 

incorporating active surveillance components into their systems. 

However, work to improve surveillance systems has proved challenging. 

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

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

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

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

other cities reported that they lacked the resources to sustain active 

surveillance. 

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

public health laboratory systems and said that they needed to be 

upgraded. All states were planning to purchase the equipment necessary 

 11Passive surveillance systems rely on laboratory and hospital staff, physicians, and other 

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

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

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

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

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

than a system that is wholly dependent on voluntary reporting. 

12Officials in one city told us that although it had no local disease surveillance, its state 

maintained a passive disease surveillance system. 

13This type of active surveillance system in which the public health department obtains 

information from such sources as hospitals and pharmacies and conducts ongoing analysis 

of the data to search for certain combinations of signs and symptoms, is sometimes 

referred to as a syndromic surveillance system. One federal official has stated that research 

examining the usefulness of syndromic surveillance needs to continue. See S. Lillibridge, 

Disease Surveillance, Bioterrorism, and Homeland Security, Conference Summary and 

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

Md.: U.S. Medicine Institute for Health Studies, Dec. 4, 2001). 
Page 8 GAO-03-769T 

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

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

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

sudden and significant increases in workload during the anthrax incidents 

in the fall of 2001. During these incidents, the demand for laboratory 

testing was significant even in states where no anthrax was found and 

affected the ability of the laboratories to perform their routine public 

health functions. Following the incidents, over 70,000 suspected anthrax 

samples were tested in laboratories across the country. 

Officials in the states we visited were working on other solutions to their 

laboratory problems. States were examining various ways to manage peak 

loads, including entering into agreements with other states to provide 

surge capacity, incorporating clinical laboratories into cooperative 

laboratory systems, and purchasing new equipment. One state was 

working to alleviate its laboratory problems by upgrading two local public 

health laboratories to enable them to process samples of more dangerous 

pathogens and by establishing agreements with other states to provide 

backup capacity. Another state reported that it was using the funding from 

CDC to increase the number of pathogens the state laboratory could 

diagnose. The state also reported that it has worked to identify 

laboratories in adjacent states that are capable of being reached within 3 

hours over surface roads. In addition, all of the states reported that their 

laboratory response plans had been revised to cover reporting and sharing 

laboratory results with local public health and law enforcement agencies. 

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

local public health departments and laboratories and were difficult to 

remedy. Officials from state and local health departments told us that 

staffing shortages were a major concern. Two of the states and cities that 

we visited were particularly concerned that they did not have enough 

epidemiologists to do the appropriate investigations in an emergency. One 

state department of public health we visited had lost approximately onethird of its staff because of budget cuts over the past decade. This 

department had been attempting to hire more epidemiologists. Barriers to 

finding and hiring epidemiologists included noncompetitive salaries and a 

general shortage of people with the necessary skills. 

Shortages in laboratory personnel were also cited. Officials in one city 

noted that they had difficulty filling and maintaining laboratory positions. 

People that accepted the positions often left the health department for 

better-paying positions. Increased funding for hiring staff cannot 

necessarily solve these shortages in the near term because for many types 

Workforce 
Page 9 GAO-03-769T 

of laboratory positions there are not enough trained individuals in the 

workforce. According to the Association of Public Health Laboratories, 

training laboratory personnel to provide them with the necessary skills 

will take time and require a strategy for building the needed workforce.14

We found that the overall level of public health preparedness varied by 

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

recurring experience with public health emergencies, including those 

resulting from natural disasters, or with preparation for National Security 

Special Events, such as political conventions,15 were generally more 

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

with multiple public health emergencies in the past might have been 

further along because they had learned which organizations and officials 

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

include all pertinent parties in the efforts. Experience with natural 

disasters raised the awareness of local officials regarding the level of 

public health emergency preparedness in their cities and the kinds of 

preparedness problems they needed to address. 

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

For example, one city reported that communications had been effective 

during public health emergencies and that the city had an active disease 

surveillance system. However, officials reported gaps in laboratory 

capacity. Another one of the better-prepared cities was connected to HAN 

and the Epidemic Information Exchange (Epi-X),16 and all county 

emergency management agencies in the state were linked. However, the 

state did not have written agreements with its neighboring states for 

responding to a public health emergency. 

 14Association of Public Health Laboratories, “State Public Health Laboratory Bioterrorism 

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

D.C.: October 2002). 

15Presidential Decision Directive 62 created a category of special events called National 

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

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

party conventions, such events include presidential inaugurations. 

16Epi-X is a secure, Web-based exchange for public health officials to rapidly exchange 

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

events as they are identified and investigated. 

Level of Preparedness 

Varied across Cities We 

Visited 
Page 10 GAO-03-769T 

Response organization officials were concerned about a lack of planning 

for regional coordination between states of the public health response to 

an infectious disease outbreak. As called for by the guidance for the CDC 

and HRSA funding, all of the states we visited organized their planning on 

the basis of regions within their states, assigning local areas to particular 

regions for planning purposes. A concern for response organization 

officials was the lack of planning for regional coordination between states. 

A hospital official in one city we visited said that state lines presented a 

“real wall” for planning purposes. Hospital officials in one state reported 

that they had no agreements with other states to share physicians. 

However, one local official reported that he had been discussing these 

issues and had drafted mutual aid agreements for hospitals and emergency 

medical services. Public health officials from several states reported 

developing working relationships with officials from other states to 

provide backup laboratory capacity. 

States have begun planning for use of the Strategic National Stockpile.17 To 

determine eligibility for the CDC funding, applicants were required to 

develop interim plans to receive and manage items from the stockpile, 

including mass distribution of antibiotics, vaccines, and medical materiel. 

However, having plans for the acceptance of the deliveries from the 

stockpile is not enough. Plans have to include details about dividing the 

materials that are delivered in large pallets and distributing the 

medications and vaccines. 

Of the seven states we visited, five states had completed plans for the 

receipt and distribution of items from the stockpile. One state that was 

working on its plan stated that it would be completed in January 2003. 

Only one state had conducted exercises of its stockpile distribution plan, 

while the other states were planning to conduct exercises or drills of their 

plans sometime in 2003. 

In addition, five states reported on their plans for mass vaccinations and 

seven states reported on their plans for large-scale administration of 

smallpox vaccine in response to an outbreak. Some states we visited had 

completed plans for mass vaccinations, whereas other states were still 

 17HHS is planning to purchase approximately 2,700 ventilators by September 2003 to 

supplement those now available in the Strategic National Stockpile to enhance 

preparedness for a potential outbreak of SARS in the United States. 

Planning for Regional 

Coordination Was Lacking 

between States 

States Have Begun 

Planning for Receiving and 

Distributing Items from the 

Strategic National 

Stockpile and for 

Administering Mass 

Vaccinations 
Page 11 GAO-03-769T 

developing their plans. The mass vaccination plans were generally closely 

tied to the plans for receiving and administering the stockpile. In addition, 

two states had completed smallpox response plans, which include plans 

for administering mass smallpox vaccinations to the general population, 

whereas four of the other states were drafting plans. The remaining state 

was discussing such a plan. However, only one of the states we visited has 

tested in an exercise its plan for conducting mass smallpox vaccinations. 

We found that most hospitals lack the capacity to respond to large-scale 

infectious disease outbreaks. Persons with symptoms of infectious disease 

would potentially go to emergency departments for treatment. Most 

emergency departments across the country have experienced some degree 

of crowding and therefore in some cases may not be able to handle a large 

influx of patients during a potential SARS outbreak. In addition, although 

most hospitals across the country reported participating in basic planning 

activities for large-scale infectious disease outbreaks, few have acquired 

the medical equipment resources, such as ventilators, to handle large 

increases in the number of patients that may result from outbreaks of 

diseases such as SARS. 

Our survey found that most emergency departments have experienced 

some degree of overcrowding.18 Persons with symptoms of infectious 

disease would potentially go to emergency departments for treatment, 

further stressing these facilities. The problem of overcrowding is much 

more pronounced in some hospitals and areas than in others. In general, 

hospitals that reported the most problems with crowding were in the 

largest metropolitan statistical areas (MSA) and in the MSAs with high 

population growth. For example, in fiscal year 2001, hospitals in MSAs 

with populations of 2.5 million or more had about 162 hours of diversion 

(an indicator of crowding),19 compared with about 9 hours for hospitals in 

MSAs with populations of less than 1 million. Also the median number of 

hours of diversion in fiscal year 2001 for hospitals in MSAs with a high 

percentage population growth was about five times that for hospitals in 

MSAs with lower percentage population growth. 

 18GAO-03-460. 

19Diversions occur when hospitals request that en route ambulances bypass their 

emergency departments and transport patients that would have been otherwise taken to 

those emergency departments to other medical facilities. 

Most Hospitals Lack 

Response Capacity 

for Large-Scale 

Infectious Disease 

Outbreaks 

Most Emergency 

Departments Have 

Experienced Some Degree 

of Crowding 
Page 12 GAO-03-769T 

Diversion varies greatly by MSA. Figure 1 shows each MSA and the share 

of hospitals within the MSA that reported being on diversion more than 10 

percent of the time—or about 2.4 hours or more per day—in fiscal year 

2001. Areas with the greatest diversion included Southern California and 

parts of the Northeast. Of the 248 MSAs for which data were available,20

171 (69 percent) had no hospitals reporting being on diversion more than 

10 percent of the time. By contrast, 53 MSAs (21 percent) had at least onequarter of responding hospitals on diversion for more than 10 percent of 

the time. 

 20The 248 MSAs include those MSAs for which (1) more than half of hospitals in the MSA 

returned surveys and (2) more than half of those hospitals that returned surveys provided 

data on diversion hours. 
Page 13 GAO-03-769T 

Figure 1: Percentage of Hospitals on Diversion More Than 10 Percent of the Time, by MSA, Fiscal Year 2001 

Note: Percentage of hospitals reflects those hospitals that responded to the survey; responses were 

not weighted to represent all hospitals in the MSA. 

a

MSAs with a response rate of 50 percent or less or MSAs with 50 percent or more of data missing for 

responding hospitals. In 12 MSAs, no hospitals responded; these MSAs were excluded from the map. 
Page 14 GAO-03-769T 

Hospitals in the largest MSAs and in MSAs with high population growth 

that have reported crowding in emergency departments may have 

difficulty handling a large influx of patients during a potential SARS 

outbreak, especially if this outbreak occurred in the winter months when 

the incidence of influenza is quite high. Thus far, the largest SARS 

outbreaks worldwide have primarily occurred in areas with dense 

populations.21

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

coordinate with other local response organizations and collaborate with 

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

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

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

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

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

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

difficult to impress the importance of cooperation on hospitals because 

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

local government officials were asking them to create plans that integrated 

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

and off-site acute care. 

In our survey of over 2,000 hospitals,22 4 out of 5 hospitals reported having 

a written emergency response plan for large-scale infectious disease 

outbreaks. Of the hospitals with emergency response plans, most include a 

description of how to achieve surge capacity for obtaining additional 

pharmaceuticals, other supplies, and staff. In addition, almost all hospitals 

reported participating in community interagency disaster preparedness 

committees. 

 21These areas include mainland China and the Hong Kong Special Administrative Region 

within the People’s Republic of China; Singapore; Taiwan; and Toronto, Canada. 

22Between May and September 2002, we surveyed over 2,000 short-term, nonfederal general 

medical and surgical hospitals with emergency departments located in metropolitan 

statistical areas. (See U.S. General Accounting Office, Hospital Emergency Departments: 

Crowded Conditions Vary among Hospitals and Communities, GAO-03-460 (Washington, 

D.C.: Mar. 14, 2003) for information on the survey universe and development of the survey.) 

For the part of the survey that specifically addressed hospital preparedness for mass 

casualty incidents, we obtained responses from 1,482 hospitals for the third section of the 

survey addressing emergency preparedness, a response rate of about 73 percent. 

Most Hospitals Reported 

Planning and Training 

Efforts, but Fewer Than 

Half Have Participated in 

Drills or Exercises 
Page 15 GAO-03-769T 

Our survey showed that hospitals have provided training to staff on 

biological agents, but fewer than half have participated in exercises 

related to bioterrorism. Most hospitals we surveyed reported providing 

training about identifying and diagnosing symptoms for the six biological 

agents identified by the CDC as most likely to be used in a bioterrorist 

attack. At least 90 percent of hospitals reported providing training for two 

of these agents—smallpox and anthrax—and approximately three-fourths 

of hospitals reported providing training about the other four—plague, 

botulism, tularemia, and hemorrhagic fever viruses. 

Most hospitals lack adequate equipment, isolation facilities, and staff to 

treat a large increase in the number of patients for an infectious disease 

such as SARS. To prevent transmission of SARS in health care settings, 

CDC recommends that health care workers use personal protective 

equipment, including gowns, gloves, respirators, and protective eyewear.23

SARS patients in the United States are being isolated until they are no 

longer infectious. CDC estimates that patients require mechanical 

ventilation in 10 to 20 percent of SARS cases.24

In the seven cities we visited, hospital, state, and local officials reported 

that hospitals needed additional equipment and capital improvements—

including medical stockpiles, personal protective equipment, quarantine 

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

enhance preparedness. Five of the states we visited reported shortages of 

hospital medical staff, including nurses and physicians, necessary to 

increase response capacity in an emergency. One of the states we visited 

reported that only 11 percent of its hospitals could readily increase their 

capacity for treating patients with infectious diseases requiring isolation, 

such as smallpox and SARS. Another state reported that most of its 

hospitals have little or no capacity for isolating patients diagnosed with or 

being tested for infectious diseases. 

According to our hospital survey, availability of medical equipment varied 

greatly between hospitals, and few hospitals seemed to have adequate 

 23CDC, Interim Domestic Guidance for Management of Exposures to Severe Acute 

Respiratory Syndrome (SARS) for Healthcare and Other Institutional Settings (Apr. 12, 

2003), http://www.cdc.gov/ncidod/sars/exposureguidance.htm (downloaded May 5, 2003). 

24CDC, Frequently Asked Questions: Severe Acute Respiratory Syndrome (SARS), 

http://www.cdc.gov/ncidod/sars/faq.htm (downloaded May 5, 2003). 

Most Hospitals Lack 

Adequate Equipment, 

Facilities, and Staff 

Required to Respond to a 

Large-Scale Infectious 

Disease Outbreak 
Page 16 GAO-03-769T 

equipment and supplies to handle a large-scale infectious disease 

outbreak. While most hospitals had, for every 100 staffed beds, at least 1 

ventilator, 1 personal protective equipment suit, or 1 isolation bed, half of 

the hospitals had, for every 100 staffed beds, fewer than 6 ventilators, 3 or 

fewer personal protective equipment suits, and fewer than 4 isolation 

beds. 

The completion of final federal influenza pandemic response plans that 

address the problems related to the purchase, distribution, and 

administration of supplies of vaccines and antiviral drugs during a 

pandemic could facilitate the public health response to emerging 

infectious disease outbreaks. CDC has provided interim draft guidance to 

facilitate state plans but has not made the final decisions on plan 

provisions necessary to mitigate the effects of potential shortages of 

vaccines and antiviral drugs. Until such decisions are made, the timeliness 

and adequacy of response efforts may be compromised. 

In the most recent version of its pandemic influenza planning guidance for 

states, CDC lists several key federal decisions related to vaccines and 

antiviral drugs that have not been made. These decisions include 

determining the amount of vaccines and antiviral drugs that will be 

purchased at the federal level; the division of responsibility between the 

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

administration of vaccines and drugs; and how population groups will be 

prioritized and targeted to receive limited supplies of vaccines and drugs. 

In each of these areas, until federal decisions are made, states will not be 

able to develop strategies consistent with federal action. 

The interim draft guidance for state pandemic plans says that resources 

can be expected to be available through federal contracts to purchase 

influenza vaccine and some antiviral agents, but some state funding may 

be required. The amounts of antiviral drugs to be purchased and 

stockpiled are yet to be determined, even though these drugs are available 

and can potentially be used for both treatment and prevention during a 

pandemic. 

CDC has indicated in its interim draft guidance that the policies for 

purchasing, distributing, and administering vaccines and drugs by the 

private and public sectors will change during a pandemic, but some 

decisions necessary to prepare for these expected changes have not been 

made. During a typical annual influenza response, influenza vaccine and 

antiviral drug distribution is primarily handled directly by manufacturers 

Key Federal Decisions 

for Influenza 

Pandemic Planning 

Could Facilitate 

Response to 

Emerging Infectious 

Diseases 
Page 17 GAO-03-769T 

through private vendors and pharmacies to health care providers. During a 

pandemic, however, CDC interim draft guidance indicates that many of 

these private-sector responsibilities may be transferred to the public 

sector at the federal, state, or local levels and that priority groups within 

the population would need to be established for receiving limited supplies 

of vaccines and drugs. 

State officials are particularly concerned that a national plan has not been 

issued with final recommendations for how population groups should be 

prioritized to receive vaccines and antiviral drugs. In its interim draft 

guidance, CDC lists eight population groups that should be considered in 

establishing priorities among groups for receiving vaccines and drugs 

during a pandemic. The list includes such groups as health care workers 

and public health personnel involved in the pandemic response, persons 

traditionally considered to be at increased risk of severe influenza illness 

and mortality, and preschool and school-aged children. 

Although state officials acknowledge the need for flexibility in planning 

because many aspects of a pandemic cannot be known in advance, the 

absence of more detail leaves them uncertain about how to plan for the 

use of limited supplies of vaccine and drugs. In our 2000 report on the 

influenza pandemic, we recommended that HHS determine the capability 

of the private and public sectors to produce, distribute, and administer 

vaccines and drugs and complete the national response plan.25 To date, 

only limited progress has been made in addressing these 

recommendations. 

Many actions taken at the state and local level to prepare for a bioterrorist 

event have enhanced the ability of state and local response agencies and 

organizations to manage an outbreak of an infectious disease such as 

SARS. However, there are significant gaps in public health surveillance 

systems and laboratory capacity, and the number of personnel trained for 

disease detection is insufficient. Most emergency departments across the 

country have experienced some degree of overcrowding. Hospitals have 

begun planning and training efforts to respond to large-scale infectious 

disease outbreaks, but many hospitals lack adequate equipment, medical 

stockpiles, personal protective equipment, and quarantine and isolation 

facilities. Federal and state plans for the purchase, distribution, and 

 25GAO-01-4. 

Concluding 

Observations 
Page 18 GAO-03-769T 

administration of supplies of vaccines and drugs in response to an 

influenza pandemic have still not been finalized. The lack of these final 

plans has serious implications for efforts to mobilize the distribution of 

vaccines and drugs for other infectious disease outbreaks. 

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

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

have at this time. 

For further information about this testimony, please contact me at (202) 

512-7119. Robert Copeland, Marcia Crosse, Martin T. Gahart, Deborah 

Miller, Roseanne Price, and Ann Tynan also made key contributions to this 

statement. 

Contact and Staff 

Acknowledgments 
Page 19 GAO-03-769T 

Smallpox Vaccination: Implementation of National Program Faces 

Challenges. GAO-03-578. Washington, D.C.: April 30, 2003. 

Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have 

Improved Public Health Response Capacity, but Gaps Remain. GAO-03-

654T. Washington, D.C.: April 9, 2003. 

Bioterrorism: Preparedness Varied across State and Local Jurisdictions. 

GAO-03-373. Washington, D.C.: April 7, 2003. 

Hospital Emergency Departments: Crowded Conditions Vary among 

Hospitals and Communities. GAO-03-460. Washington, D.C.: March 14, 

2003. 

Homeland Security: New Department Could Improve Coordination but 

Transferring Control of Certain Public Health Programs Raises 

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

Homeland Security: New Department Could Improve Biomedical R&D 

Coordination but May Disrupt Dual-Purpose Efforts. GAO-02-924T. 

Washington, D.C.: July 9, 2002. 

Homeland Security: New Department Could Improve Coordination but 

May Complicate Priority Setting. GAO-02-893T. Washington, D.C.: June 

28, 2002. 

Homeland Security: New Department Could Improve Coordination but 

May Complicate Public Health Priority Setting. GAO-02-883T. 

Washington, D.C.: June 25, 2002. 

Bioterrorism: The Centers for Disease Control and Prevention’s Role in 

Public Health Protection. GAO-02-235T. Washington, D.C.: November 15, 

2001. 

Bioterrorism: Review of Public Health Preparedness Programs. GAO-02-

149T. Washington, D.C.: October 10, 2001. 

Bioterrorism: Public Health and Medical Preparedness. GAO-02-141T. 

Washington, D.C.: October 9, 2001. 

Bioterrorism: Coordination and Preparedness. GAO-02-129T. 

Washington, D.C.: October 5, 2001. 

Related GAO Products 
Page 20 GAO-03-769T 

Bioterrorism: Federal Research and Preparedness Activities. GAO-01-

915. Washington, D.C.: September 28, 2001. 

West Nile Virus Outbreak: Lessons for Public Health Preparedness. 

GAO/HEHS-00-180. Washington, D.C.: September 11, 2000. 

Combating Terrorism: Need for Comprehensive Threat and Risk 

Assessments of Chemical and Biological Attacks. GAO/NSIAD-99-163. 

Washington, D.C.: September 14, 1999. 

Combating Terrorism: Observations on Biological Terrorism and Public 

Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16, 

1999. 

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