Testimony 

Before the Permanent Subcommittee on 

Investigations, Committee on 

Governmental Affairs, U.S. Senate

United States General Accounting Office 

GAO

For Release on Delivery 

Expected at 9:00 a.m. 

Wednesday, July 30, 2003 SEVERE ACUTE 

RESPIRATORY 

SYNDROME 

Established Infectious 

Disease Control Measures 

Helped Contain Spread, But 

a Large-Scale Resurgence 

May Pose Challenges 

Statement of Marjorie E. Kanof 

Director, Health Care—Clinical 

 and Military Health Care Issues 

GAO-03-1058T 
Infectious disease experts emphasized that no new infectious disease 

control measures were introduced to contain SARS in the United States. 

Instead, strict compliance with and additional vigilance to enforce the use of 

current measures was sufficient. These measures—case identification and 

contact tracing, transmission control, and exposure management—are wellestablished infectious disease control measures that proved effective in both 

health care and community settings. The combinations of measures that 

were used depended on either the prevalence of the disease in the 

community or the number of SARS patients served in a health care facility. 

For SARS, case identification within health care settings included screening 

individuals for fever, cough, and recent travel to a country with active cases 

of SARS. Contact tracing, the identification and tracking of individuals who 

had close contact with someone who was infected or suspected of being 

infected, was important for the identification and tracking of individuals at 

risk for SARS. Transmission control measures for SARS included contact 

precautions, especially hand washing after contact with someone who was 

ill, and protection against respiratory spread, including spread by large 

droplets and by smaller airborne particles. The use of isolation rooms with 

controlled airflow and the use of respiratory masks by health care workers 

were key elements of this approach. Exposure management practices—

isolation and quarantine—occurred in both health care and home settings. 

Effective communication among health care professionals and the general 

public reinforced the need to adhere to infectious disease control measures. 

While no one knows whether there will be a resurgence of SARS, federal, 

state, and local health care officials agree that it is necessary to prepare for 

the possibility. As part of these preparations, CDC, along with national 

associations representing state and local health officials, and others, is 

involved in developing both SARS-specific guidelines for using infectious 

disease control measures and contingency response plans. In addition, these 

associations have collaborated with CDC to develop a checklist of 

preparedness activities for state and local health officials. Such preparation 

efforts also improve the health care system’s capacity to respond to other 

infectious disease outbreaks, including those precipitated by bioterrorism. 

However, implementing these plans during a large-scale outbreak may prove 

difficult due to limitations in both hospital and workforce capacity that 

could result in overcrowding, as well as potential shortages in health care 

workers and medical equipment—particularly respirators. 

SARS is a highly contagious 

respiratory disease that infected 

more than 8,000 individuals in 29 

countries principally throughout 

Asia, Europe, and North America 

and led to more than 800 deaths as 

of July 11, 2003. Due to the speed 

and volume of international travel 

and trade, emerging infectious 

diseases such as SARS are difficult 

to contain within geographic 

borders, placing numerous 

countries and regions at risk with a 

single outbreak. While SARS did 

not infect large numbers of 

individuals in the United States, the 

possibility that it may reemerge 

raises concerns about the ability of 

public health officials and health 

care workers to prevent the spread 

of the disease in the United States.

GAO was asked to assist the 

Subcommittee in identifying ways 

in which the United States can 

prepare for the possibility of 

another SARS outbreak. 

Specifically, GAO was asked to 

determine 1) infectious disease 

control measures practiced within 

health care and community settings 

that helped contain the spread of 

SARS and 2) the initiatives and 

challenges in preparing for a 

possible SARS resurgence. 

www.gao.gov/cgi-bin/getrpt?GAO-03-1058T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Marjorie E. 

Kanof at (202) 512-7101. 

Highlights of GAO-03-1058T, a report to 

the Permanent Subcommittee on 

Investigations, Committee on 

Governmental Affairs, U.S. Senate 

July 30, 2003 

SEVERE ACUTE RESPIRATORY 

SYNDROME 

Established Infectious Disease Control 

Measures Helped Contain Spread, But a 

Large-Scale Resurgence May Pose 

Challenges 
Page 1 GAO-03-1058T 

Mr. Chairman and Members of the Subcommittee: 

I am pleased to be here today as you consider effective infectious disease 

control measures to help contain the spread of Severe Acute Respiratory 

Syndrome (SARS) should future outbreaks occur. SARS is a highly 

contagious respiratory disease that infected more than 8,000 individuals in 

29 countries principally throughout Asia, Europe, and North America and 

led to more than 800 deaths as of July 11, 2003. Due to the speed and 

volume of international travel and trade, emerging infectious diseases such 

as SARS are difficult to contain within geographic borders, placing 

numerous countries and regions at risk with a single outbreak. SARS 

quickly became a worldwide health problem, prompting the World Health 

Organization (WHO) to issue a global alert for the first time in more than a 

decade—an alert that was cancelled on July 5, 2003. Although the 

outbreak is currently believed to be contained, the fact that SARS is a type 

of coronavirus—the source of some common colds—leads many to 

suggest that SARS could be seasonal and as such could recur in the fall 

and winter months. 

Although all the modes of SARS transmission may not have been 

identified, the disease is most likely spread through person-to-person 

contact. Experts agree that infected individuals are contagious when 

symptomatic—a time during which they are more likely to seek medical 

attention and come into contact with health care workers. One unique 

characteristic of the SARS outbreak was the high rate of infection among 

health care workers, who—before the institution of specific protective 

measures—may have become infected while treating patients with SARS. 

The SARS outbreak in Asia demonstrated that the disease can also spread 

rapidly in the community, outside of hospital settings. 

While SARS did not infect large numbers of individuals in the United 

States, the possibility that it may reemerge raises concerns about the 

ability of public health officials and health care workers to prevent the 

spread of the disease in the United States. To assist the Subcommittee in 

identifying ways in which the United States can prepare for the possibility 

of another SARS outbreak, my remarks today will focus on 1) infectious 

disease control measures practiced within health care and community 

settings that helped contain the spread of SARS and 2) the initiatives and 

challenges in preparing for a possible SARS resurgence. 

My testimony today is based on the review of documentation about 

infection control practices and guidelines, as well as descriptions about 

the origin of SARS and its spread. In addition, we spoke with leading 
Page 2 GAO-03-1058T 

national and international disease experts—most of whom were involved 

in either the investigation of SARS or in the treatment of patients with 

SARS. Specifically, we spoke with experts in infectious diseases, 

epidemiology, clinical medicine, and occupational safety from the Centers 

for Disease Control and Prevention (CDC) and WHO. We also spoke with 

public health officials of Health Canada and Toronto Public Health 

because Canada had the highest prevalence of SARS cases in North 

America. We interviewed state and local public health officials in 

California and New York—both of which had the greatest number of SARS 

cases reported in the United States. These officials represented the 

California Department of Health Services, the New York State Department 

of Health, and the New York City Department of Health and Mental 

Hygiene. We also spoke with hospital infectious disease experts in each of 

these states. In addition, we spoke with national infectious disease 

experts, hospital epidemiologists, and representatives from the National 

Association of County and City Health Officials (NACCHO) and the 

Association of State and Territorial Health Officials (ASTHO). We also 

used our previous work on the capacity of the public health system to 

respond to both bioterrorism and emerging infectious diseases.1

 We 

conducted our work in July 2003 in accordance with generally accepted 

government auditing standards. 

In summary, infectious disease experts emphasized that no new infectious 

disease control measures were introduced to contain SARS in the United 

States. Instead, strict compliance with and additional vigilance to enforce 

the use of current measures was sufficient. These measures—case 

identification and contact tracing, transmission control, and exposure 

management—are well-established infectious disease control measures 

that proved effective in both health care and community settings. The 

combinations of measures that were used depended on either the 

prevalence of the disease in the community or the number of SARS 

patients served in a health care facility. For SARS, case identification 

within health care settings included screening individuals for fever, cough, 

and recent travel to a country with active cases of SARS. Contact tracing, 

the identification and tracking of individuals who had close contact with 

someone who was infected or suspected of being infected, was important 

for the identification and tracking of individuals at risk for SARS. 

 1

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). 
Page 3 GAO-03-1058T 

Transmission control measures for SARS included contact precautions, 

especially hand washing after contact with someone who was ill, and 

protection against respiratory spread, including spread by large droplets 

and by smaller airborne particles. The use of isolation rooms with 

controlled airflow and the use of respiratory masks by health care workers 

were key elements of this approach. Exposure management practices—

isolation and quarantine—occurred in both health care and home settings. 

Effective communication among health care professionals and the general 

public reinforced the need to adhere to infectious disease control 

measures. 

While no one knows whether there will be a resurgence of SARS, federal, 

state, and local health care officials we interviewed agree that it is 

necessary to prepare for the possibility. As part of these preparations, 

CDC, along with national associations that represent state and local health 

officials, and others, is involved in developing both SARS-specific 

guidelines for using infectious disease control measures and contingency 

response plans. In addition, these associations have collaborated with 

CDC to develop a checklist of preparedness activities for state and local 

health officials. Such preparation efforts also improve the health care 

system’s capacity to respond to other infectious disease outbreaks, 

including those precipitated by bioterrorism. However, implementing 

these plans may prove difficult due to limitations in both hospital and 

workforce capacity. A large-scale SARS outbreak could create 

overcrowding, as well as shortages in health care workers and in medical 

equipment—particularly respirators. 

SARS is an emerging respiratory disease that has been reported principally 

in Asia, Europe, and North America. SARS is believed to have originated in 

Guangdong Province, China in mid-November 2002. However, early cases 

of the disease went unreported, which then delayed identification and 

treatment of the disease allowing it to spread. On February 11, 2003, WHO 

received its first official report of an atypical pneumonia outbreak in 

China. This report stated that 305 individuals were affected by atypical 

pneumonia and that 5 deaths had been attributed to the disease. SARS was 

transmitted out of the Guangdong Province on February 21, 2003, by a 

physician who became infected after treating patients in the province. 

Subsequently, the physician traveled to a hotel in Hong Kong and began 

suffering from flu-like symptoms. Days later, other guests and visitors at 

the hotel contracted SARS. As infected hotel patrons traveled to other 

countries, such as Vietnam and Singapore, and sought medical attention 

for their symptoms, they spread the disease throughout each country’s 

Background 
Page 4 GAO-03-1058T 

hospitals as well as in some communities. Simultaneously, the disease 

began spreading around the world along international air travel routes as 

guests from the hotel flew homeward to Toronto and elsewhere. 

Scientific evidence indicates that SARS is caused by a previously 

unrecognized coronavirus.2

 Transmission of SARS appears to result 

primarily from close person-to-person contact3

 and contact with large 

respiratory droplets emitted by an infected person who coughs or sneezes. 

After contact, the incubation period for SARS—the time it takes for 

symptoms to appear after an individual is infected—is generally within a 

10-day period. Clinical evidence to date also suggests that people are most 

likely to be contagious at the height of their symptoms. However, it is not 

known how long after symptoms begin that patients with SARS are 

capable of transmitting the virus to others. There is no evidence that SARS 

can be transmitted from asymptomatic individuals. 

Currently, there is no definitive test to identify SARS during the early 

phase of the illness, which complicates diagnosing infected individuals. As 

a result, the early diagnosis of SARS relies more on interpreting 

individuals’ symptoms and identification of travel to locations with SARS 

transmission. SARS symptoms include fever, chills, headaches, body 

aches, and respiratory symptoms such as shortness of breath and dry 

cough—making SARS difficult to distinguish from other respiratory 

illnesses, such as the flu and pneumonia. The initial symptoms can be quite 

mild, and gradually increase in severity, often peaking in the second week 

of illness. In some individuals, the disease might progress to the point 

where insufficient oxygen is getting to the blood. 

CDC has established for health care providers criteria used for the 

identification of individuals with SARS, called case definitions.4

 In the 

absence of a definitive diagnostic test for the disease in its early phase, 

 2

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. 

3

Close contact is usually defined as having cared for, lived with, or having direct contact 

with bodily secretions of an infected individual. 

4

See Centers for Disease Control and Prevention, Department of Health and Human 

Services, Updated Interim U.S. Case Definition for Severe Acute Respiratory Syndrome 

(SARS) (Atlanta, Ga.: July 16, 2003). 

Description of Severe 

Acute Respiratory 

Syndrome 
Page 5 GAO-03-1058T 

reported cases of SARS are classified into two categories based on clinical 

and epidemiologic criteria—“suspect” and “probable.” These case 

definitions continue to be refined as more is learned about this disease. A 

“suspect” case of SARS includes the following criteria: 

• high fever, 

• respiratory illness, and 

• recent travel to an area with current or previously documented suspected 

transmission of SARS,5

 and/or 

• close contact within 10 days of the onset of symptoms with a person 

known or suspected to have SARS. 

A “probable” case of SARS includes the following criteria: 

• all the criteria for “suspect” cases and 

• evidence in the form of chest x-ray findings of pneumonia, acute 

respiratory distress syndrome (ARDS), or an unexplained respiratory 

illness resulting in death with autopsy findings of ARDS. 

The final determination of whether cases meeting the definitions for 

“suspect” and “probable” SARS are due to infection with the SARS virus is 

based on results of testing a blood specimen obtained 28 days after the 

onset of illness. 

Furthermore, there is no specific treatment for SARS. In the absence of a 

rapid diagnostic test, it can be very difficult to distinguish clinically 

between individuals with SARS and individuals with atypical pneumonia. 

Therefore, CDC currently recommends that individuals suspected of 

having SARS be managed using the same diagnostic and therapeutic 

strategies that would be used for any patient with serious atypical 

pneumonia. In mild cases of SARS, management at home may be 

appropriate, while more severe cases may require treatment, such as 

intravenous medication and oxygen supplementation, that necessitates 

hospitalization. In 10 to 20 percent of SARS cases, patients require 

mechanical ventilation.6

 As of July 11, 2003, the mortality rate for SARS 

 5

The last date for illness onset is 10 days (i.e., one incubation period) after removal of a 

CDC travel alert. To be considered a suspect case, an individual’s travel would have 

occurred on or before the last date the travel alert was in place. 

6

Mechanical ventilation involves artificial ventilation of the lung using means external to 

the body. A mechanical ventilator is a machine that generates a controlled flow of gas (a 

mixture of oxygen and air) into a patient’s airways. 
Page 6 GAO-03-1058T 

was approximately 10 percent, but the mortality rates in individuals over 

60 years of age approached 50 percent. 

As of July 11, 2003, WHO reported that there were an estimated 8,427 

“probable” cases from 29 countries, with 813 deaths from SARS. China, 

Hong Kong, Singapore, Taiwan, and Canada reported the highest number 

of cases. As of July 15, 2003, the United States identified 211 SARS cases in 

39 states (including Puerto Rico), with no related deaths. Of these cases, 

175 are classified as “suspect” cases, while 36 are classified as “probable.”7

In the United States, 34 of the 36 “probable” cases contracted SARS 

through international travel. However, in the other affected countries, 

SARS spread extensively among health care workers. For example, of the 

138 diagnosed cases in Hong Kong as of March 25, 2003, that were not due 

to travel, 85 (62 percent) occurred among health care workers; among the 

144 cases in Canada as of April 10, 2003, 73 (51 percent) were health care 

workers. 

In the United States, the Healthcare Infection Control Practices Advisory 

Committee (HICPAC), a federal advisory committee made up of 14 

infection control experts, develops recommendations and guidelines 

regarding general infectious disease control measures for CDC. Important 

components of these infectious disease control measures are the 

following: case identification and contact tracing, transmission control, 

and exposure management. 

Case Identification and Contact Tracing. Case identification and 

contact tracing are considered by health care providers to be important 

first steps in the containment of infectious diseases in both the community 

and health care settings. Case identification is the process of determining 

whether or not a person meets the specific definitions for a given disease. 

Generally, health care providers interview patients in order to obtain the 

history, signs, and symptoms of the patient’s complaint and perform a 

physical examination. Tests, such as blood tests or x-rays, can be 

performed to provide additional information to help determine the 

diagnosis. Public awareness of the symptoms of a disease can help case 

identification to the extent that individuals who believe they exhibit the 

 7

Additionally, on July 16, 2003, CDC revised the case definition to exclude individuals with 

negative test results for SARS coronavirus. This resulted in 207 previously identified SARS 

cases (169 suspect cases and 38 probable cases) being removed from the count of SARS 

cases in the United States. 

General Infectious Disease 

Control Measures 
Page 7 GAO-03-1058T 

symptoms seek medical attention. Contact tracing involves the 

identification and tracking of individuals who may have been exposed to a 

person with a specific disease. 

Transmission Control. Transmission control measures decrease the risk 

for transmission of microorganisms through proper hand hygiene and the 

use of personal protective equipment, such as masks, gowns, and gloves. 

These measures also include the decontamination of objects and rooms. 

The types of transmission control measures used are based on how an 

illness is transmitted. For example, some categories of transmission are as 

follows: 

• Direct contact: person-to-person contact (e.g., two people shaking hands) 

and physical transfer of the microorganism between an infected person 

and an uninfected person. 

• Indirect contact: contact with a contaminated object, such as secretions 

from an infected person on a doorknob or telephone receiver. 

• Droplet: eye, nose, or mouth of an uninfected person coming into contact 

with droplets (larger than 5 micrometers) containing the microorganism 

from an infected person, for example an infected person sneezing without 

covering his/her mouth with a tissue. 

• Airborne: contact with small droplets (5 micrometers or smaller) or dust 

particles containing the microorganism, which are suspended in the air. 

Exposure Management. Exposure management is the separation of 

infected individuals from noninfected individuals through isolation or 

quarantine. Isolation refers to the separation of individuals who have a 

specific infectious illness from healthy individuals and the restriction of 

their movement to contain the spread of that illness. Quarantine refers to 

the separation and restriction of movement of individuals who are not yet 

ill, but who have been exposed to an infectious agent and are potentially 

infectious. 

The success of these infectious disease control measures—case 

identification and contact tracing, transmission control, and exposure 

management—depends, in part, on the frequent and timely exchange of 

information. Public health officials and health care providers need to be 

informed about any modifications of existing infectious disease control 

measures, the geographic progression of an outbreak, and reports of 

disease occurrence. Likewise, elevating public knowledge about an 

infectious disease and its symptoms will enable infected individuals to 

seek medical attention as soon as possible to contain the spread. 
Page 8 GAO-03-1058T 

Infectious disease experts emphasized that existing infectious disease 

control measures played a pivotal role in containing the spread of SARS in 

both health care and community settings. The combinations of measures 

that were used depended on either the prevalence of the disease in the 

community or the number of SARS patients served in a health care facility. 

No new measures were introduced to contain the SARS outbreak in the 

United States; instead, experts said strict compliance with and additional 

vigilance to enforce the use of current measures was sufficient. The 

successful implementation of all of the infectious disease control 

measures depended, in part, on effective communication among health 

care professionals and the general public. 

To prevent the spread of SARS, public health authorities worked to 

identify every individual who might have been infected with the disease. 

Rapid identification of these individuals was critical, but the lack of an 

effective and timely diagnostic test that could be used during the early 

stages of the disease to identify those who actually had SARS was an 

obstacle in halting its spread. Experts acknowledged that identification of 

individuals who might have been infected with the SARS virus was likely 

to include many people who did not have SARS because the case 

definition of an individual with SARS is not highly specific and the disease 

resembles other respiratory illnesses, such as pneumonia and the flu. The 

long incubation period for SARS provided health care workers the 

opportunity to identify cases and close contacts of infected individuals 

before those who actually had the SARS virus could spread the disease to 

others. 

An important part of case identification is screening individuals for 

symptoms of a disease. CDC recommended that when individuals called 

for appointments and as soon as possible after the individual arrived in a 

health care setting, all individuals should be screened with targeted 

questions concerning SARS-related symptoms, close contact with a SARS 

suspect case patient, and recent travel. For SARS, public health and 

hospital officials in California and New York said 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 included these 

criteria and asked individuals to identify themselves to hospital staff if 

they met them. According to these officials, an individual identified as a 

potential SARS case generally was given a surgical mask and moved into a 

separate area for further medical evaluation. CDC officials said that these 

Experts Recommend 

Case Identification 

and Contact Tracing, 

Transmission Control, 

and Exposure 

Management 

Measures To Prevent 

the Spread of SARS 

Timely Case Identification 

and Contact Tracing of 

SARS Cases Was Critical 

But Difficult 
Page 9 GAO-03-1058T 

measures were also important for physicians in private practice. The New 

York City and California health departments used e-mail health alert 

notices to inform private physicians, such as family practitioners and 

pediatricians, about these case identification procedures. These notices 

directed physicians to information posted on the health departments’ Web 

sites. In addition, officials from these health departments provided 

information about SARS case identification, among other topics, during 

local meetings for members of the medical community, including 

physicians in private practice. 

Toronto, which experienced a much greater prevalence of SARS than the 

United States, used somewhat different case identification practices. At 

the height of the outbreak in Toronto, everyone entering a hospital was 

required to answer screening questions and to have their temperature 

checked before they were allowed to enter. Toronto public health 

department officials said this heightened screening was useful for case 

identification and had an added benefit of educating staff and visitors 

about SARS symptoms. As a further measure, Toronto health officials 

established SARS assessment clinics, also known as fever clinics; persons 

suspecting they might have SARS were asked to go to the clinics rather 

than directly to hospital emergency rooms to avoid infecting other 

individuals. However, officials acknowledged several limitations to using 

these assessment clinics. Because there was no follow-up to an initial 

assessment, some SARS cases that were in the early stages were not 

identified, but later these individuals went to hospital emergency rooms. 

Other difficulties included finding physicians to staff the clinics and 

implementing hospital-level infectious disease control measures at these 

separate clinics. For example, some clinics were set up in non-hospital 

locations—one assessment clinic was set up in a tent near a hospital 

emergency room entrance, while another was situated in a hospital 

ambulance bay where emergency personnel transfer patients into the 

hospital. 

Contact tracing—the identification and tracking of individuals who had 

close contact with a “suspect” or “probable” case—is an important 

component of case identification. Contact tracing to identify individuals at 

significant risk for SARS required significant local health department 

resources. In New York City, four teams from the communicable disease 

bureau, comprised of either a physician or nurse and several field workers, 

interviewed each suspect or probable case in order to identify contacts. 

They then called each contact to advise them of their exposure and 

provided information on monitoring for symptoms of SARS and receiving 

treatment if necessary. The calls were also to ensure that the contacts 
Page 10 GAO-03-1058T 

were following infection control measures in the home. Each contact 

received routine calls during a 10-day period—an average of four calls 

each from a team member. A New York City health department official 

characterized the process of contact tracing as labor and time intensive. 

Standardized forms and electronic contact and case databases helped the 

teams manage contact tracing. Additionally, routine weekly meetings with 

other health department divisions ensured that if assistance was needed 

from these departments, they would be up-to-date. Furthermore, New 

York City developed procedure manuals that would allow staff from other 

departments to be trained quickly if needed to assist members of the 

communicable disease bureau. The health department official emphasized 

that the electronic database created to log information about SARS 

contacts was an important tool to facilitate contact tracing. Toronto 

officials agreed that daily contact tracing required a large amount of 

resources. Adding to Toronto’s difficulties, its health department did not 

have an electronic case or contact database, but had to rely on separate 

paper files for each individual. 

Experts recommended a combination of transmission control measures 

because not all modes of SARS transmission are known. The primary 

mode of transmission is direct person-to-person contact, although contact 

with body fluids and contaminated objects, and possibly airborne spread, 

may play a role. Therefore, multiple infection control practices that are 

used for each type of transmission are included in SARS infection control 

guidelines. Some combination of practices was recommended for both 

health care settings and in the community, with more intensive infection 

control procedures recommended for health care settings. According to 

several experts, the simple “things your mother taught you,” such as 

washing your hands and covering your mouth and nose with a tissue when 

sneezing or coughing were effective in reducing the spread of SARS. 

CDC prepared SARS guidelines for transmission control measures for both 

inpatient (such as hospitals) and outpatient (such as physician offices) 

health care settings.8

 These recommendations combined what the CDC 

calls “standard” hospital transmission control measures with transmission 

 8

See Centers for Disease Control and Prevention, Department and Health and Human 

Services, Updated Interim Domestic Infection Control Guidance in the Health-Care and 

Community Setting for Patients with Suspected SARS (Atlanta, Ga.: May 1, 2003). 

Multiple Transmission 

Control Measures Used to 

Contain Spread 
Page 11 GAO-03-1058T 

control measures specific to contact and airborne transmission. For the 

inpatient setting, the guidelines included: 

• Routine standard precautions, including hand washing. In addition to 

standard precautions, CDC recommended eye protection—such as goggles 

or a face shield. 

• Contact precautions, such as the use of a gown and gloves for encounters 

with the patient or his/her environment. 

• Airborne precautions, such as an isolation room with negative pressure 

relative to the surrounding area,9

 and the use of an N-95 filtering 

disposable respirator for persons entering the room. The CDC guidelines 

suggested that if an isolation room was not available, patients should be 

placed in a private room, and all persons entering the room should wear N95 respirators (or respirators offering comparable protection) to protect 

the wearer from particles expelled by a sick person, such as in coughing or 

sneezing. CDC recommended that, where possible, a test to ensure that the 

N-95 respirators fit properly should be conducted. If N-95 respirators were 

not available for health care personnel, then surgical masks should be 

worn. Generally, the material of N-95 respirators is designed to filter 

smaller particles than a surgical mask, and they also are designed to seal 

more tightly to the face. 

The health department and hospital officials we spoke with said they 

generally adopted these CDC guidelines for transmission control in 

inpatient settings. Officials said one of the most effective practices to 

contain SARS was frequent hand washing with soap and water. CDC 

guidelines also allow the use of waterless alcohol-based hand rubs after 

coming in contact with “suspect” or “probable” SARS patients or their 

environments. Additionally, a hospital and a health department official 

said careful cleaning of SARS patient rooms was an important hygiene 

measure. 

Inpatient facilities in the United States generally saw few SARS patients. In 

New York and California, the hospital officials stated that because of the 

small number of cases that were seen in each hospital, usually only one or 

two at a time, the hospitals were able to manage SARS patients in available 

isolation rooms. Because of the greater prevalence of SARS in Toronto, all 

22 acute care hospitals were directed to have a SARS unit with negative 

pressure to the rest of the hospital, individual rooms, and specific staff 

 9

Negative pressure rooms generally are private rooms in which air flow is from the hallway 

into the room, and then outdoors. 
Page 12 GAO-03-1058T 

who only cared for SARS patients. Toronto health department officials 

later were able to designate four hospitals as SARS hospitals and direct all 

SARS patients to these four facilities. 

The use of face masks or N-95 respirators was highly recommended by 

experts as an effective means of transmission control for SARS in 

inpatient settings. In one study of health care workers who had extensive 

contact with SARS patients in five Hong Kong hospitals, researchers found 

that no health care worker who consistently used either type of face 

covering became infected.10 Experts also noted that the use of N-95 

respirators and isolation rooms was especially important for high-risk 

medical procedures, such as intubation, where a patient’s secretions are 

likely to be transformed into a fine spray and spread for a longer distance 

than large droplets.11 Officials cautioned, however, that there can be 

difficulties in the use of N-95 respirators. One public health official said 

that compliance may be limited in hospitals in several ways—either staff 

has never been properly fitted for the respirators, or some staff who were 

fitted many years ago should have a more recent fitting. In Canada, 

Ontario’s health ministry directed health care workers in the province 

(which includes Toronto) to employ an additional level of protective 

equipment when conducting high-risk medical procedures that was not 

recommended in the United States. For example, health care workers used 

a protective system that included a hood, a full-face respirator, and a 

complete body covering such as long-sleeved floor-length gowns and 

gloves. 

The CDC guidelines for outpatient settings included the same standard 

and contact precautions outlined for inpatient settings. Reflecting the 

different types of facilities likely available in a physician office compared 

to a hospital, for example, outpatient guidelines did not advocate the use 

of specialized isolation rooms. Instead, for outpatient settings, the 

guidelines advised health care personnel to separate the potential SARS 

patient from others in a reception area as soon as possible, preferably in a 

private room with negative pressure relative to the surrounding area. At 

the same time, the guidelines said that a surgical mask should be placed 

 10See W.H. Seto, et.al., Effectiveness of precautions against droplets and contact in 

prevention of nosocomial transmission of severe acute respiratory syndrome (SARS), 

The Lancet (Vol. 361, May 3, 2003), pp. 1519-20. 

11Generally, intubation is the introduction of a tube into an individual’s airway to facilitate 

breathing. 
Page 13 GAO-03-1058T 

over the patient’s nose and mouth—if this was not feasible, the patient 

should be asked to cover his or her mouth with a disposable tissue when 

coughing, talking, or sneezing. 

Transmission control guidelines for community settings incorporated 

many of the same types of measures for containing the spread of SARS as 

recommended for health care settings.12 CDC published SARS transmission 

control guidelines for two community settings—the workplace and 

households. The workplace guidelines recommended frequent hand 

washing with soap and water or waterless alcohol-based hand rubs. Along 

with handwashing, guidelines for household transmission control included 

the following: 

• Infection control precautions should be continued for SARS patients for 10 

days after respiratory symptoms and fever are gone. SARS patients should 

limit interactions outside the home and should not go to work, school, outof-home day care, or other public areas during the 10-day period. 

• During this 10-day period, each patient with SARS should cover his or her 

mouth and nose with a tissue before sneezing or coughing. If possible, a 

person recovering from SARS should wear a surgical mask during close 

contact with uninfected persons. If the patient is unable to wear a surgical 

mask, other people in the home should wear one when in close contact 

with the patient. 

• Disposable gloves should be considered for any contact with body fluids 

from a SARS patient. Immediately after activities involving contact with 

body fluids, gloves should be removed and discarded, and hands should be 

washed. Gloves should not be washed or reused, and were not intended to 

replace proper hand hygiene. 

• SARS patients should avoid sharing eating utensils, towels, and bedding 

with other members of the household, although these items could be used 

by others after routine cleaning, such as washing or laundering with soap 

and hot water. 

• Frequent use should be made of common household cleaners for 

disinfecting toilets, sinks, and other surfaces touched by patients with 

SARS. 

 12See Centers for Disease Control and Prevention, Department of Health and Human 

Services, Interim Guidance on Infection Control Precautions for Patients with Suspected 

Severe Acute Respiratory Syndrome (SARS) and Close Contacts in Households (Atlanta, 

Ga.: Apr. 29, 2003). 
Page 14 GAO-03-1058T 

Exposure management methods such as isolation and quarantine are 

important infectious disease control measures. These measures were 

particularly effective for SARS because of its long incubation period 

during which infected individuals could be isolated before they become 

contagious. In fact, experts stated that isolation of infected individuals and 

quarantine measures used for exposed individuals were critical for the 

containment of SARS. 

Isolation of SARS infected individuals occurred in both health care and 

home settings. In Toronto, patients were typically isolated in the 

hospital—even in cases where individuals were not ill enough to need 

hospitalization. During the height of Toronto’s outbreak, all 22 acute care 

hospitals were directed to have separate SARS units. On the other hand, in 

the United States, individuals were hospitalized only if they needed 

intensive medical treatment. According to an infectious disease expert 

who consulted with the CDC, this practice was prompted by concerns that 

grouping SARS cases together, such as in a hospital ward, could increase 

the likelihood of spread to both health care workers and other hospital 

patients. 

For home isolation in New York City, each patient and contact was given 

detailed information that included instructions on what to do if ill, 

reminders of the importance of calling ahead before going to a physician’s 

office or other health care settings, and information on how to travel to a 

health care setting without coming in contact with others. These 

instructions also included guidelines for transmission control measures to 

be used in the home. For all probable cases, the New York City health 

department conducted a home assessment to ensure that a SARS patient 

could be adequately isolated at home, which included the need for such 

things as adequate ventilation and bathrooms that would not be shared by 

noninfected individuals. 

Quarantine of exposed individuals was based on different parameters, 

depending on the number of “suspect” or “probable” SARS cases in the 

community. CDC officials said the agency’s guidance reflected the fact 

that there was little or no transmission of SARS in the United States, and 

therefore quarantine was less warranted because there were so few cases 

in a community. CDC’s guidance advised individuals who were exposed 

but not symptomatic to monitor themselves for symptoms—such as fever, 

a cough, and difficulty breathing, and further advised home isolation and 

medical evaluation if symptoms began. CDC officials also advised transfer 

to a hospital only if the illness became severe. 

Exposure Management 

Used to Prevent SARS 

Spread 
Page 15 GAO-03-1058T 

In contrast, Toronto, which experienced a high level of person-to-person 

transmission, used a more conservative quarantine standard. Individuals 

who did not have symptoms but had been in contact with SARS infected 

individuals were ordered to stay in their homes and avoid public 

gatherings for 10 days. Thousands people were asked to undergo 

quarantine in their homes in the Toronto area. During the outbreak, 

exposed Toronto health care workers were restricted to “work 

quarantine”—they were only allowed to travel to and from work alone in 

their vehicles, but they were not allowed to have visitors or visit public 

places. Quarantine efforts in Toronto again required a high level of 

resources. Daily phone calls required 60 staff per 1,000 people who were 

quarantined in the Toronto area; these staff worked 7 days a week to 

follow up with twice-daily calls to each individual. 

According to health officials, rapid and frequent communications of 

crucial information about SARS—such as the level of outbreak worldwide 

and recommended infectious disease control measures—were vital 

components of the efforts to contain the spread of SARS. Since March 

2003, health organizations have shared extensive SARS-related 

information and guidelines with health care workers. For example, WHO 

scheduled numerous press briefings that updated the health community 

about the status of international SARS containment and prevention efforts. 

WHO, with CDC support, sponsored a videoconference broadcast globally 

to discuss the latest findings of the outbreak and prevention of 

transmission in health care settings (which was also available for 

computer download). CDC activated its Emergency Operations Center and 

devoted over 800 medical experts and support personnel worldwide to 

provide round-the-clock coordination and response to the SARS outbreak. 

CDC also had regular conference calls and information-sharing sessions 

with various medical professional associations and state and local health 

departments and laboratories. 

At the state level, the California health department utilized the California 

Health Alert Network to send e-mails with SARS information (often based 

on CDC information) to all local health departments and many hospitals 

and physicians. The New York City health department hosted a 

symposium specifically for health care workers, to share the latest 

available SARS information. Hospital officials we spoke with also offered 

training seminars for their health care personnel on the signs and 

symptoms of SARS, recommended screening questions, and appropriate 

infectious disease control measures. Furthermore, hospitals kept their 

Success in Implementing 

Infectious Disease Control 

Measures Depended on 

Rapid and Frequent 

Communication 
Page 16 GAO-03-1058T 

patients informed about SARS via posters and flyers throughout their 

facilities, especially in emergency room waiting areas. 

Health organizations maintained open and frequent communications in the 

community setting to facilitate the containment of SARS. For example, in a 

2-week period early in the SARS outbreak, CDC conducted nine telephone 

press conferences with the media to keep the public informed about the 

latest SARS information, including numbers of “suspect” and “probable” 

SARS cases, laboratory and surveillance findings, travel advisories, and 

CDC’s efforts nationally and worldwide. CDC also distributed more than 

two million health alert notices to travelers entering the United States 

from China, Hong Kong, Singapore, Taiwan, Vietnam, or Toronto. These 

cards, printed in eight languages, asked individuals to monitor their health 

for at least 10 days and to contact their health care provider if they 

exhibited SARS symptoms. A state and a local health official also stressed 

the importance of informing and educating the general public in 

workplaces and schools on the signs and symptoms of SARS, an effort 

which was intended to foster self-identification, minimize panic, and 

assuage fears of being infected. 

Public health officials also concurred that collaboration between federal, 

state, and local health agencies as well as the medical community was 

crucial in containing the spread of SARS. Through the collaboration of all 

the appropriate players, coordination of prevention activities could be 

maintained, roles could be identified and assigned, available resources 

could be shared, and subsequent evaluations could be conducted. For 

instance, the Toronto health department maintained active 

communications with its local, provincial, and national governments in 

regard to isolation and quarantine practices, travel jurisdictions, and other 

SARS-related matters. The health department published directives for all 

Toronto area health care providers, outlining their SARS-related roles and 

responsibilities. The health department also maintained ongoing contact 

with identified liaisons at Toronto hospitals where SARS patients were 

hospitalized. Furthermore, the city of Toronto activated its local 

emergency operations center, which brought together emergency medical 

services, police, and community neighborhood planners to work together 

to contain SARS. Throughout Toronto’s efforts, numerous briefings and 

teleconferences were organized to keep all players abreast about the latest 

SARS information in the community. 
Page 17 GAO-03-1058T 

While no one knows whether there will be a resurgence of SARS, federal, 

state, and local health care officials we interviewed agree that it is 

necessary to prepare for the possibility. As part of these preparations, 

CDC, along with national associations that represent state and local health 

officials, and others, is involved in developing SARS-specific guidelines for 

using infectious disease control measures and contingency response plans. 

In addition, these associations have collaborated with CDC to develop a 

checklist of preparedness activities for state and local health officials. 

Such preparation efforts also improve the health care system’s capacity to 

respond to other infectious disease outbreaks, including those precipitated 

by bioterrorism. However, implementing these plans may prove difficult 

due to limitations in both hospital and workforce capacity. A large-scale 

SARS outbreak could create overcrowding, as well as shortages in medical 

equipment (including N-95 respirators) and in health care personnel, who 

are at higher risk for infection due to their more frequent exposure to a 

contaminated environment. 

At the federal level, CDC has begun contingency planning for a SARS 

outbreak, having convened a task force of infection control experts who 

are responsible for developing SARS-specific guidelines and 

recommendations, which address various infection control measures. The 

task force plans to publish its guidelines and recommendations by 

September 2003. CDC is collaborating with several professional 

associations, such as the Council of State and Territorial Epidemiologists, 

ASTHO, and NACCHO, to develop these response plans that vary 

according to the prevalence of the disease and the type of setting (i.e., 

health care or community) in which control measures need to be 

implemented. 

At the state and local levels, health departments are also in the process of 

developing contingency response plans for SARS. To facilitate this, 

ASTHO and NACCHO, in collaboration with CDC, published a checklist 

for state and local health officials to use in the event of a SARS 

resurgence. The SARS preparations have been modeled after a checklist 

designed for pandemic influenza. 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 (see 

app. I for a copy of the checklist). 

Federal, State, and 

Local Health Officials 

Are Preparing for a 

Possible SARS 

Resurgence, But 

Implementing Plans 

May Pose Challenges 

if the Resurgence Is 

Large-Scale 

Federal, State, and Local 

Health Officials Are 

Preparing for the 

Possibility of Future 

Outbreaks 
Page 18 GAO-03-1058T 

In specific local preparedness efforts, California and New York, which had 

the highest number of SARS cases in the United States, are also preparing 

for a large-scale SARS outbreak. For example, California health 

department officials said they were developing a plan for surge capacity by 

considering staff rotations or details of health department specialists to 

maintain a high level of response during a potential SARS outbreak.13

Similarly, officials with the New York City health department said they had 

created a formal procedure manual, which outlines the roles of reallocated 

staff from various teams in the department, to help contain a large-scale 

SARS outbreak. 

While hospital officials we spoke with stated that they are taking steps to 

ensure that they have the necessary preparations to address a large-scale 

SARS outbreak, hospitals may still be limited in their capacity to respond. 

Because of the inability to precisely determine if someone has SARS, many 

people may be treated who do not have the virus. In the event of a largescale outbreak, this imprecision may result in severe overcrowding in 

health care settings—especially if a SARS resurgence occurs during a peak 

season for another respiratory disease like influenza. This could strain the 

available capacity of hospitals. For example, public health officials with 

whom we spoke said that in the event of a large-scale SARS outbreak, 

entire hospital wards (along with their staff) may need to be used as 

separate SARS isolation facilities. Moreover, certain hospitals within a 

community might need to be designated as SARS hospitals. 

We recently reported that most hospitals lack the capacity to respond to 

large-scale infectious disease outbreaks.14 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 

outbreak of SARS or another infectious disease. Few hospitals have 

adequate staff, medical resources, and equipment, such as N-95 

respirators, needed to care for the potentially large numbers of patients 

 13Surge capacity is the ability of the health care system to handle a large number of 

patients. 

14U.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). 

Limitations in Hospital and 

Workforce Capacity Make 

Implementing Infectious 

Disease Control Measures 

Difficult in the Event of a 

Large-Scale SARS 

Outbreak 
Page 19 GAO-03-1058T 

that may seek treatment.15 We reported that in the seven cities we visited, 

hospital, state, and local officials indicated 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. According to our survey of over 2,000 hospitals,16 the 

availability of medical equipment varied greatly among hospitals, and few 

hospitals reported having the equipment and supplies needed to handle a 

large-scale infectious disease outbreak. Half the hospitals we surveyed 

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

personal protective equipment suits, and fewer than 4 isolation beds. 

Workforce capacity issues may also hinder implementation of infectious 

disease control measures. Health officials noted that there is a lack of 

qualified and trained personnel, including epidemiologists, who would be 

needed in the event of a SARS resurgence. This shortage 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. According to WHO officials, an individual infected with 

SARS came into contact with, on average, 30 to 40 people in Asian 

countries—all of whom had to be contacted and informed of their possible 

exposure. In contrast, New York City health department officials said that 

infected individuals came into contact with 4 people on average. 

In addition, the monitoring of individuals placed under isolation and 

quarantine may strain resources if widespread isolations and quarantines 

are needed. For example, follow-up with isolated or quarantined 

individuals requires significant resources. Officials of the New York City 

 15Shortages in N-95 respirators occurred during the SARS outbreak because of the high 

demand. CDC officials said that shortages in the United States may have been due to high 

demand in other countries, particularly when WHO recommended that health care workers 

in all affected countries use N-95 respirators. 

16Between 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. 
Page 20 GAO-03-1058T 

Department of Health and Mental Hygiene said that they made home visits 

to SARS cases when officials became concerned that these individuals 

were not following infection control measures or were not remaining in 

their homes. Similarly, Canadian public health officials said that they, and 

in some cases Canadian police, made home visits to check compliance 

with quarantine orders. These officials also described the difficulty in 

providing necessary resources (food, medicines, masks, and 

thermometers) to individuals under isolation or quarantine. In Canada, 

police and the Red Cross had to help deliver food to those under isolation 

or quarantine. 

The global spread of SARS was contained through an unprecedented level 

of international scientific collaboration and the use of well-established 

infection control measures that have been used effectively in the past to 

control diseases. Although questions remain about SARS, especially about 

the ways it can be transmitted, many lessons were learned that could be 

helpful to the United States in the event of a resurgence. Lessons to carry 

forward are the importance of early identification of infected individuals 

and their contacts, the effectiveness of safety precautions to control 

transmission and ensure the protection of health care workers, and the 

need to use, in some cases, isolation and quarantine. Swift and unfettered 

communication among heath care workers, public health officials, 

government agencies, as well as the public provided the essential 

backbone to support ongoing efforts to contain the disease. 

Although SARS is currently believed to be contained, now is the time to 

prepare for the possibility of a future outbreak. Some preparations are 

already underway and encompass, in large part, approaches similar to 

those for pandemic influenza and are also part of general bioterrorism 

preparedness. Worldwide disease surveillance would facilitate prompt 

identification of a resurgence of SARS, allowing rapid implementation of 

infectious disease control measures that would reduce both the spread of 

SARS and the risk of a large outbreak. Should a large-scale outbreak occur 

in the near term, limitations in the capacity of our nation’s health system 

to undertake effective and rapid implementation of infectious disease 

control measures could prove problematic. A major SARS outbreak would 

necessitate rapid escalation of infectious disease control resources 

including health care workers, emergency room and hospital capacity, and 

the requisite control and support equipment. 

Concluding 

Observations 
Page 21 GAO-03-1058T 

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 more information regarding this testimony, please contact Marjorie 

Kanof at (202) 512-7101. Bonnie Anderson, Karen Doran, John Oh, Danielle 

Organek, and Krister Friday also made key contributions to this statement. 

Contact and Staff 

Acknowledgments 
Page 22 GAO-03-1058T 

Source: National Association of County and City Health Officials.

Appendix I: SARS Preparedness Checklist 
Page 23 GAO-03-1058T 

Source: National Association of County and City Health Officials.
Page 24 GAO-03-1058T 

Source: National Association of County and City Health Officials.
Page 25 GAO-03-1058T 

Source: National Association of County and City Health Officials.
Page 26 GAO-03-1058T 

Source: National Association of County and City Health Officials.
Page 27 GAO-03-1058T 

Source: National Association of County and City Health Officials.
Page 28 GAO-03-1058T 

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. 

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. 

Related GAO Products 
Page 29 GAO-03-1058T 

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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