Testimony 

Before the Subcommittee on Emergency 

Preparedness and Response, Select 

Committee on Homeland Security, House 

of Representatives

United States General Accounting Office 

GAO

For Release on Delivery 

Expected at 2:30 p.m. 

Wednesday, September 24, 2003 INFECTIOUS DISEASES

Gaps Remain in 

Surveillance Capabilities of 

State and Local Agencies 

Statement of Janet Heinrich 

Director, Health Care—Public Health Issues 

GAO-03-1176T 
The efforts of public health agencies and health care organizations to 

increase their preparedness for infectious disease outbreaks and 

bioterrorism have improved the nation’s ability to recognize such events. 

However, gaps remain in state and local disease surveillance systems, which 

are essential to public health efforts to respond to disease outbreaks or 

bioterrorist attacks. Other essential elements of preparedness include 

laboratory facilities, workforce, and communication systems. State and local 

officials report that they are addressing gaps in communication systems. 

However, there are still significant workforce shortages in state and local 

health departments. GAO also found that while contingency plans are being 

developed at the state and local levels, planning for regional coordination for 

disease outbreaks or bioterrorist events was lacking between states. 

The disease surveillance capacities of many state and local pubic health 

systems depend, in part, on the surveillance capabilities of hospitals. 

Whether a disease outbreak occurs naturally or due to the intentional release 

of a harmful biological agent by a terrorist, much of the initial response 

would occur at the local level, particularly at hospitals and their emergency 

departments. Therefore, hospital personnel would be some of the first 

healthcare workers with the opportunity to identify an infectious disease 

outbreak or a bioterrorist event. Most hospitals reported training their staff 

on biological agents and planning coordination efforts with public health 

entities; however, preparedness limitations may impact hospitals’ ability to 

conduct disease surveillance. In addition, hospitals still lack the capacity to 

respond to large-scale infectious disease outbreaks. Also, most emergency 

departments across the country have experienced some degree of 

overcrowding, which could be exacerbated during a disease outbreak or 

bioterrorist event if persons with symptoms go to emergency departments 

for treatment. 

Recent challenges, such as the 

SARS outbreak and the anthrax 

incidents in the fall of 2001, have 

raised concerns about the nation’s 

preparedness for a large-scale 

infectious disease outbreak or 

bioterrorism event. In order to be 

adequately prepared for such a 

major public health threat, state 

and local public health agencies 

need to have several basic 

capabilities, including disease 

surveillance systems, laboratory 

facilities, communication systems 

and a sufficient workforce. 

GAO was asked to examine the 

capacity of state and local public 

health agencies and hospitals to 

detect and report illnesses or 

conditions that may result from a 

large-scale infectious disease 

outbreak or bioterrorism event. 

This testimony is based largely on 

recent work, including a report on 

state and local preparedness for a 

bioterrorist attack; preliminary 

findings from current work on 

updates of bioterrorism 

preparedness at the state and local 

levels; and findings from a survey 

GAO conducted on hospital 

emergency department capacity 

and emergency preparedness. 

www.gao.gov/cgi-bin/getrpt?GAO-03-1176T.

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-03-1176T, testimony 

before the Subcommittee on Emergency 

Preparedness and Response, Select 

Committee on Homeland Security, House 

of Representatives 

September 24, 2003

INFECTIOUS DISEASES

Gaps Remain in Surveillance Capabilities 

of State and Local Agencies 
Page 1 GAO-03-1176T 

Mr. Chairman and Members of the Subcommittee: 

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

done on state and local preparedness to manage outbreaks of infectious 

diseases, which may be naturally occurring or the product of bioterrorism. 

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

state and local public health agencies need to have several basic 

capabilities, including disease surveillance systems.1

 Surveillance is public 

health officials’ most important tool for detecting and monitoring both 

existing and emerging infections. Effective surveillance can facilitate 

timely action to control outbreaks and inform allocation of resources to 

meet changing disease conditions. Without adequate surveillance, local, 

state, and federal officials cannot know the true scope of existing health 

problems and may not recognize new diseases until many people have 

been affected. 

Recent challenges, such as the SARS2

 outbreak and the anthrax incidents 

in the fall of 2001, have raised concerns about the nation’s preparedness to 

manage a disease outbreak or a bioterrorist event should it reach largescale proportions. Existing surveillance systems have weaknesses, such as 

chronic underreporting and outdated laboratory facilities, which raise 

concerns about the ability of state and local agencies to detect emerging 

diseases or a bioterrorist event. As a result, state and local response 

agencies and organizations have recognized the need to strengthen their 

public health infrastructure and capacity. The improvements they are 

making are intended to strengthen their ability to identify and respond to 

major public health threats, including naturally occurring infectious 

disease outbreaks and acts of bioterrorism. 

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

detect and monitor an outbreak of an infectious disease, my remarks today 

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

for responding to an infectious disease outbreak, and (2) the contributions 

of hospitals to preparedness for an infectious disease outbreak. 

 1

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

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

2

SARS is the abbreviation for severe acute respiratory syndrome. 
Page 2 GAO-03-1176T 

My testimony today is based largely on our recent work, including a report 

on state and local preparedness for a bioterrorist attack.3

 For that report, 

we conducted site visits in December 2001 through March 2002 to seven 

cities and their respective state governments. We also reviewed each 

state’s spring 2002 applications for bioterrorism preparedness funding to 

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 discuss some preliminary findings 

from our current work that provides updated information on the 

preparedness of state and local public health agencies. For that work, we 

are reviewing the summer 2003 applications and progress reports and 

interviewing public health officials from 10 states and two major 

municipalities. I also will present some findings from a survey we 

conducted in 2002 on hospital emergency department capacity and 

emergency preparedness.4

 We conducted our work in accordance with 

generally accepted government auditing standards. 

In summary, state and local officials in the cities we visited reported 

varying levels of public health preparedness to respond to outbreaks of 

emerging infectious diseases such as SARS. They recognized gaps in 

preparedness elements that have been difficult to address, including the 

disease surveillance and laboratory systems and the response capacity of 

the workforce. They also were beginning to address gaps in preparedness 

elements such as communication. We found that planning for regional 

coordination was lacking between states. 

Because those with symptoms of an infectious disease might go to 

emergency departments for treatment, hospital personnel would likely be 

some of the first healthcare workers with the opportunity to identify an 

infectious disease outbreak. Therefore, the disease surveillance capacities 

of many state and local public health systems may depend, in part, on the 

 3

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

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

4

Findings from the survey 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 to hospital emergency preparedness for mass casualty incidents, 

which we reported in U.S. General Accounting Office, Hospital Preparedness: Most Urban 

Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism 

Response, GAO-03-924 (Washington, D.C.: Aug. 6, 2003). 
Page 3 GAO-03-1176T 

surveillance capabilities of hospitals. Most hospitals reported training their 

staff and planning coordination efforts with other public health entities. 

However, even with these preparations in place, hospitals lacked the 

capacity to respond to large-scale infectious disease outbreaks. 

Infectious diseases include naturally occurring outbreaks, such as SARS, 

as well as diseases from biological agents that are intentionally released by 

a terrorist, such as smallpox.5

 An infectious disease outbreak, either 

naturally occurring or from an intentional release, may not be recognized 

for a week or more because symptoms may not appear for several days 

after the initial exposure, during which time a communicable disease 

could be spread to those who were not initially exposed. 

The initial response to an infectious disease of any type, including a 

bioterrorist attack, is generally a local responsibility that could involve 

multiple jurisdictions in a region, with states providing additional support 

when needed. Figure 1 presents the probable series of responses to a 

covert release of a biological agent. Just as in a naturally occurring 

outbreak, exposed individuals would seek out local health care providers, 

such as private physicians or medical staff in hospital emergency 

departments or public clinics. Health care providers would report any 

illness patterns or diagnostic clues that might indicate an unusual 

infectious disease outbreak associated with the intentional release of a 

biologic agent to their state or local health departments. 

 5

CDC developed a critical agent list that focuses on the biological agents that would have 

the greatest impact on public health. This list includes a category of agents identified by 

CDC as most likely to be used in a bioterrorist attack and includes communicable diseases 

such as smallpox and pneumonic plague. 

Background 
Page 4 GAO-03-1176T 

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

Release of a Biological Agent 
Page 5 GAO-03-1176T 

a

Health care providers can also contact state entities directly. 

b

Federal departments and agencies can also respond directly to local and state entities. 

c

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

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

other) attack. 

In order to be adequately prepared for emerging infectious diseases 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 
Page 6 GAO-03-1176T 

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 the event of an 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. 

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 a disease, as it did 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. The funding 

supported development and improvements in a number of areas CDC 

considers critical to preparedness and response, including surveillance 

capacity to rapidly detect outbreaks of illness that may be the result of 

bioterrorism or other public health threats. 

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. Earlier this month, HHS announced that approximately 

$870 million and $498 million have been provided for fiscal year 2003 

through the CDC and HRSA programs, respectively, to states and 

municipalities to continue these efforts. 
Page 7 GAO-03-1176T 

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

public health preparedness to respond to outbreaks of emerging infectious 

diseases such as SARS. They recognized gaps in preparedness elements 

that have been difficult to address, including the disease surveillance and 

laboratory systems and the response capacity of the workforce. They also 

were beginning to address gaps in preparedness elements such as 

communication. We found that planning for regional coordination was 

lacking between states. 

States and local areas had weaknesses in some public health 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. States and 

local areas were addressing gaps in communication. 

State and local officials for the cities we visited in early 2002 recognized 

and were attempting to address inadequacies in their surveillance systems. 

Local officials were concerned that their surveillance systems were 

inadequate to detect a bioterrorist event, and all of the states we visited 

were making efforts to improve their disease surveillance systems. Six of 

the cities we visited used a passive surveillance system6

 to detect 

infectious disease outbreaks.7

 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 

 6

Passive 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. 

7

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

maintained a passive disease surveillance system. 

Despite 

Improvements, Gaps 

Remain in Disease 

Surveillance 

Capabilities of State 

and Local Public 

Health Agencies 

Progress Has Been Made 

in Elements of Public 

Health Preparedness, but 

Gaps Remain 

Surveillance Systems 
Page 8 GAO-03-1176T 

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

pharmacy sales, to conduct surveillance.8

 Three of the cities we visited 

were attempting to improve their surveillance capabilities by 

incorporating active surveillance components into their systems. For our 

ongoing work, state and local officials told us that their surveillance 

systems had improved somewhat. The officials reported that CDC funds 

have enabled them make some of these improvements in their surveillance 

systems, including the development of Web-based disease reporting and 

active surveillance systems. 

Officials from all of the states we visited in early 2002 reported problems 

with their public health laboratory systems and said that they needed to be 

upgraded. All states were planning to purchase the equipment necessary 

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

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

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

sudden and significant increases in workload during the anthrax incidents 

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. According to 

preliminary data from our interviews and review of 2003 progress reports, 

officials reported that CDC funds enabled them to make improvements to 

their laboratory infrastructure, including upgrading their laboratory 

facilities, purchasing reagents and equipment, and improving their 

capability to test for select biologic agents. 

Officials in the states we visited in 2002 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 

 8

This 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. A senior HHS official 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). 

Laboratory Facilities 
Page 9 GAO-03-1176T 

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 early 2002 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. Officials at one state department of public health we visited 

said that the department had lost approximately one-third of its staff 

because of budget cuts over the past decade. This department had been 

attempting to hire more epidemiologists. Barriers to finding and hiring 

epidemiologists included noncompetitive salaries and a general shortage 

of people with the necessary skills. 

Workforce capacity issues may also hinder implementation of infectious 

disease control measures. For example, the shortage of epidemiologists 

could grow worse if, in the event of a severe outbreak, existing health care 

workers became infected as a result of their more frequent exposure to a 

contaminated environment or became exhausted working longer hours. 

Workforce shortages could be further exacerbated because of the need to 

conduct contact tracing.9

 According to World Health Organization officials, 

an individual infected with SARS came in contact with, on average, 30 to 

40 people in Asian countries—all of whom had to be contacted and 

informed of their possible exposure. 

During our site visits in early 2002, shortages in laboratory personnel were 

also cited. Officials in one city noted that they had difficulty filling and 

maintaining laboratory positions and that people that accepted the 

 9

Contact tracing is the identification and tracking of individuals who may have been 

exposed to a person with a specific disease. 

Workforce 
Page 10 GAO-03-1176T 

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 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.10 For our current work updating these 

findings, many of the state and local officials we interviewed cited 

shortages in trained epidemiologists or laboratory personnel as persistent. 

In 2002, state and local officials told us that sustained funding would be 

necessary to address one important need—hiring and retaining needed 

staff. They told us they would be reluctant to hire additional staff unless 

they were confident that the funding would be sustained and staff could be 

retained. These statements are consistent with the findings of the Advisory 

Panel to Assess Domestic Response Capabilities for Terrorism Involving 

Weapons of Mass Destruction, which recommended that federal support 

for state and local public health preparedness and infrastructure building 

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

material impact on state and local governments’ preparedness for a 

bioterrorist event.11 We have noted previously that federal, state, and local 

governments have a shared responsibility in preparing for terrorist attacks 

and other disasters.12 However, prior to the infusion of federal funds, few 

states were investing in their public health infrastructure. 

 10Association of Public Health Laboratories, “State Public Health Laboratory Bioterrorism 

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

D.C.: October 2002). 

11Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving 

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

the Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving 

Weapons of Mass Destruction (Arlington, Va.: RAND, Dec. 15, 2002). The Advisory Panel 

was established to assess federal agency efforts to enhance domestic preparedness, the 

progress of federal training programs for local emergency responses, and deficiencies in 

federal programs for response to incidents involving weapons of mass destruction; to 

recommend strategies for ensuring effective coordination of federal agency response 

efforts and for ensuring fully effective local response capabilities for weapons of mass 

destruction incidents; and to assess appropriate state and local roles in funding effective 

local response capabilities. The Advisory Panel issues annual reports to the President and 

to the Congress and has submitted four annuals reports to date. 

12See U.S. General Accounting Office, Homeland Security: Effective Intergovernmental 

Coordination Is Key to Success, GAO-02-1013T (Washington, D.C.: Aug. 23, 2002). 
Page 11 GAO-03-1176T 

We found that officials were beginning to address communication 

problems. For example, six of the seven cities we visited in early 2002 

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. For our current work, our 

preliminary review of the 2003 progress reports from 12 jurisdictions 

shows that 11 reported that over 90 percent of their population was 

covered by HAN. 

As part of the effort to prepare for a possible outbreak of an infectious 

disease, there is contingency planning at the state and local levels. Health 

departments, for instance, are in the process of developing contingency 

response plans for SARS. The SARS preparations have been modeled after 

a checklist designed for pandemic influenza. To facilitate these 

preparations, the Association of State and Territorial Health Officials and 

the National Association of County and City Health Officials, in 

collaboration with CDC, published a checklist for state and local health 

officials to use in the event of a SARS resurgence. The checklist 

encompasses a broad spectrum of preparedness activities, such as legal 

issues related to isolation and quarantine, strategies for communicating 

information to health care providers, and suggestions for ensuring other 

community partners such as law enforcement and school officials are 

prepared. 

During our 2002 site visits, however, we found that response organization 

officials were concerned about a lack of planning for regional 

coordination between states during an infectious disease outbreak. As 

called for by the guidance for the CDC and HRSA funding, all of the states 

we visited in 2002 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 

Communication 

Some State and Local 

Contingency Planning 

Underway, but Regional 

Coordination Is Lacking 
Page 12 GAO-03-1176T 

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. 

Because those with symptoms of an infectious disease might go to 

emergency departments for treatment, hospital personnel would likely be 

some of the first healthcare workers with the opportunity to identify an 

emerging infectious disease outbreak. Therefore, the disease surveillance 

capacities of many state and local public health systems may depend, in 

part, on the surveillance capabilities of hospitals. Most hospitals reported 

training their staff and planning coordination efforts with other public 

health entities. However, even with these preparations in place, hospitals 

lacked the capacity to respond to large-scale infectious disease outbreaks. 

The disease surveillance capacities of many state and local public health 

systems may depend, in part, on the surveillance capabilities of hospitals. 

During the recent SARS outbreak in North America, for instance, hospital 

emergency rooms played an important role in identifying those who had 

the disease. According to hospital officials in California and New York, 

hospital emergency room or other waiting room staff routinely used 

questionnaires to screen incoming patients for fever, cough, and travel to a 

country with active cases of SARS. They said that hospitals’ signs in 

various locations generally used by incoming patients and visitors also 

asked individuals to identify themselves to hospital staff if they met these 

criteria. In Toronto, which experienced a much greater prevalence of 

SARS than the United States, everyone entering a hospital was required to 

answer screening questions and to have their temperature checked before 

they were allowed to enter. 

Hospital 

Preparedness 

Improved, but 

Limitations in 

Response Capacity 

Remain 

Hospitals Provide Vital 

Disease Surveillance 

Capacity 
Page 13 GAO-03-1176T 

In our survey of over 2,000 metropolitan hospitals,13 most reported that 

they have provided training to staff on biological agents, but fewer than 

half have participated in drills or 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. 

Our hospital survey found that 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. 

At the time of our site visits between December 2001 and March 2002, 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 offsite acute care. 

 13Between 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, 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 14 GAO-03-1176T 

Our survey of metropolitan hospitals found that most emergency 

departments have experienced some degree of overcrowding.14 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),15 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. 

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 infectious 

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

when the incidence of influenza is quite high. For example, public health 

officials with whom we spoke said that in the event of a large-scale SARS 

outbreak, entire hospital wards may need to be used as separate SARS 

isolation facilities. Moreover, certain hospitals within a community may 

need to be designated as SARS hospitals. 

Efforts at the state and local level have improved the ability to identify and 

respond to infectious disease outbreaks and bioterrorism. These 

improvements have included upgrades to laboratory facilities and 

communication systems. Hospitals have also begun planning and training 

efforts to respond to large-scale infectious disease outbreaks. Despite 

these improvements, gaps in preparedness remain. We found that some 

disease surveillance systems may be inadequate, that there are shortages 

of key personnel in some localities, and that most hospital emergency 

departments across the country have experienced some degree of 

overcrowding, which could be exacerbated during a disease outbreak. 

 14GAO-03-460. 

15Diversions occur when hospitals request that en route ambulances bypass their 

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

those emergency departments to other medical facilities. 

Most Emergency 

Departments Have 

Experienced Some Degree 

of Crowding 

Concluding 

Observations 
Page 15 GAO-03-1176T 

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 Janet 

Heinrich at (202) 512-7119. Angela Choy, Krister Friday, Martin T. Gahart, 

Gay Hee Lee, and Deborah Miller also made key contributions to this 

statement. 

Contact and Staff 

Acknowledgments 
Page 16 GAO-03-1176T 

Hospital Preparedness: Most Urban Hospitals Have Emergency Plans 

but Lack Certain Capacities for Bioterrorism Response. GAO-03-924. 

Washington, D.C.: August 6, 2003. 

Severe Acute Respiratory Syndrome: Established Infectious Disease 

Control Measures Helped Contain Spread, But a Large-Scale Resurgence 

May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003. 

Bioterrorism: Information Technology Strategy Could Strengthen 

Federal Agencies’ Abilities to Respond to Public Health Emergencies. 

GAO-03-139. Washington, D.C.: May 30, 2003. 

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. 

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. 

Related GAO Products 
Page 17 GAO-03-1176T 

Homeland Security: New Department Could Improve Coordination but 

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

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

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

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

2001. 

Bioterrorism: Review of Public Health Preparedness Programs. 

GAO-02-149T. Washington, D.C.: October 10, 2001. 

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

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

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

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

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

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

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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