Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response
Published: 2003-08-06T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In the event of a large-scale infectious disease outbreak, as could be seen with a bioterrorist attack, hospitals and their emergency departments would be on the front line. Federal, state, and local officials are concerned, however, that hospitals may not have the capacity to accept and treat a sudden, large increase in the number of patients, as might be seen in a bioterrorist attack. In the Public Health Improvement Act that was passed in 2000, Congress directed GAO to examine preparedness for a bioterrorist attack. In this report GAO provides information on the extent of bioterrorism preparedness among hospitals in urban areas in the United States. To conduct this work, GAO surveyed over 2,000 urban hospitals and about 73 percent provided responses addressing emergency preparedness. The survey collected information on hospital preparedness for bioterrorism, such as data on planning activities, staff training, and capacity for response.
section_title: What GAO Found
paragraphs: While most urban hospitals across the country reported participating in basic planning and coordination activities for bioterrorism response, they did not have the medical equipment to handle the number of patients that would be likely to result from a bioterrorist incident. Four out of five hospitals reported having a written emergency response plan addressing bioterrorism, but many plans omitted some key contacts, such as other laboratories. Almost all hospitals reported participating in a local, state, or regional interagency disaster preparedness committee. In addition, most hospitals reported having provided at least some training to their personnel on identification and diagnosis of disease caused by biological agents considered likely to be used in a bioterrorist attack, such as anthrax or botulism. In contrast, fewer than half of hospitals have conducted drills or exercises simulating response to a bioterrorist incident. Hospitals also reported that they lacked the medical equipment necessary for a large influx of patients. For example, if a large number of patients with severe respiratory problems associated with anthrax or botulism were to arrive at a hospital, a comparable number of ventilators would be required to treat them. Yet half of hospitals reported having fewer than six ventilators per 100 staffed beds. In general, larger hospitals reported more planning and training activities than smaller hospitals. Representatives from the American Hospital Association provided oral comments on a draft of this report, which GAO incorporated as appropriate. They generally agreed with the findings.

section_title: Letter
paragraphs: In the event of a large-scale infectious disease outbreak, as could be seen  with a bioterrorist attack, hospitals and their emergency departments  would be on the front line. The release of a biological agent by a terrorist  might not be recognized for several days, during which time a  communicable disease could be spread to many people who were not  initially exposed. Because hospitals are open 24 hours a day, 7 days a  week, victims would be likely to seek treatment of their symptoms there,  putting hospital personnel in the role of first responders. Federal, state,  and local officials are concerned, however, that hospitals may not have the  capacity to accept and treat a sudden, large increase in the number of  patients, as might be seen in a bioterrorist attack. For example, these  officials are concerned that this surge in patients would be likely to  overwhelm emergency departments in urban areas, many of which are  already operating at or above capacity.
The Public Health Improvement Act directed that we examine state and  local levels of preparedness for a bioterrorist attack. We have previously  reported on activities by federal agencies and state and local public health  agencies and health care organizations, including hospitals, to prepare for  and respond to bioterrorism. In this report we are providing you with  additional information on the extent of bioterrorism preparedness among  urban hospitals in the United States, specifically with respect to planning  activities, staff training, and capacity for response.
To obtain information on the extent of hospital bioterrorism preparedness,  we conducted a survey between May and September 2002 of 2,041 urban  hospitals across the country that have emergency departments. (See app. I  for a description of the hospitals we surveyed.) The survey asked  questions relating to emergency room functioning and hospital  bioterrorism preparedness. We reported our survey findings on emergency  room functioning in March 2003. We obtained responses to the survey  addressing bioterrorism preparedness from 1,482 hospitals, for a response  rate of 73 percent and we are providing our survey findings in the current  report. The survey covered key components of hospital preparedness for  bioterrorism, including planning activities related to communication and  coordination with community and state organizations (e.g., participation in  an interagency disaster preparedness committee); staff training; and the  response capacity of the facility (e.g., number of isolation beds) and of the  equipment (e.g., number of ventilators). We weighted responses to adjust  for a lower response rate from investor-owned (for-profit) hospitals to  provide estimates representative of the entire universe of urban hospitals  we surveyed. Our report reflects hospital preparedness at the time of our  survey in 2002. Improvements in hospital preparedness may have occurred  since these data were collected. (For more detail on our scope and  methodology, see app. II.) We did our work from May 2002 through July  2003 in accordance with generally accepted government auditing  standards.
subsections: section_title: Background
paragraphs: The resources that hospitals and their emergency departments would  require for responding to a large-scale bioterrorist attack are far greater  than those needed for everyday performance. The specific equipment,  supplies, and facilities needed could vary depending upon what type of  attack occurred, but many scenarios anticipate that the demand for health  care could quickly outstrip the ability of hospitals to respond. For  example, the TOPOFF 2000 exercise testing terrorism preparedness  included a bioterrorism scenario of an attack using pneumonic plague  released at a public event in a single location in one city. In this exercise,  officials found that by the third day following the covert release, 500  persons with symptoms had been reported and antibiotic and ventilator  shortages were beginning to occur. By the end of this day, nearly 800 cases  were identified and over 100 persons had died. In each of the succeeding 2  days, the situation worsened and medical care in the city was described as  beginning to shut down, with insufficient hospital staff, beds, ventilators,  and drugs. At the conclusion of the exercise, 1 week after the attack, an  estimated 3,700 cases of plague had been reported, with 950 to 2,000  deaths, including cases in other cities and abroad. In the early stages of the  epidemic, hospitals were seeing 2 to 3 times their normal volume of  patients and later in the exercise up to 10 times normal volumes were  arriving at hospitals. Hospitals were not able to effectively isolate patients  to prevent the spread of the disease to hospital staff.
In order to be adequately prepared for bioterrorism, hospitals would need  to have several basic capabilities, whether they possess them directly or  have access to them through regional agreements. Plans that describe how  hospitals would work with state and local officials to manage and  coordinate an emergency response would need to be in place and to have  been tested in an exercise, both at the state and local levels and at the  regional level. Regional plans can help address capacity deficiencies by  providing for the sharing, among hospitals and other community and state  agencies and organizations, of resources that, while adequate for everyday  needs, may be in short supply on a local level in an emergency. In addition,  hospitals would need to be able to communicate easily with all  organizations involved in the response as events unfold and critical  information is acquired. Staff would need to be able to recognize and  report to their state or local health department any illness patterns or  diagnostic clues that might indicate an outbreak of a disease caused by a  biological agent likely to be used by a terrorist. Finally, hospitals would  need to have the capacity and staff necessary to treat large numbers of  severely ill patients and limit the spread of infectious disease. They would  need adequate stores of equipment and supplies, including medications,  personal protective equipment, quarantine and isolation facilities, and air  handling and filtration equipment.
Many of the capabilities required for responding to a large-scale  bioterrorist attack are also required for response to naturally occurring  disease outbreaks. Such a “dual-use” response infrastructure improves the  capacity of local public health agencies to respond to all hazards. For  example, a large-scale outbreak of Severe Acute Respiratory Syndrome  (SARS) would require many of the same capabilities that would be needed  to respond to an intentionally caused epidemic.
Prior to our survey, efforts had been made by organizations to assist  hospitals in preparing for bioterrorism. For example, the American  Hospital Association distributed a checklist to help hospitals describe and  assess their state of preparedness for chemical and biological incidents.  This checklist covered, for example, emergency response plans for  hospital operations during a biological or chemical disaster; emergency  preparedness training of the workers; and the hospital’s ability to increase  its capacity—for example, in terms of such items as ventilators and  decontamination equipment—in the event of a large number of patients  seeking care. Another organization, the Association for Professionals in  Infection Control and Epidemiology, developed a mass casualty disaster  plan checklist for health care facilities, including hospitals. This checklist  included disease surveillance activities, communication systems, plans  for receiving and treating casualties, and plans for the organized discharge  of nonemergency patients on short notice.
Nevertheless, in our April 2003 report, we noted the general lack of  guidance on what capacities hospitals should have to be prepared for  bioterrorism. We also noted that efforts to improve hospitals’ bioterrorism  response capacities must be mindful that hospitals face multiple  challenges, including having to prepare for other types of disasters and  continuing to meet the everyday needs of cities for emergency care. In that  report, among other things, we recommended that the Department of  Health and Human Services (HHS) develop specific benchmarks that  define adequate preparedness for a bioterrorist attack and can be used to  guide preparedness efforts.
Since our survey, there have been continuing efforts to assist hospitals in  bioterrorism preparedness. For example, the Joint Commission on  Accreditation of Healthcare Organizations released a report in 2003 on  strategies for creating and sustaining communitywide preparedness  systems for health care organizations, including hospitals. The report  outlined critical issues to be addressed in developing communitywide  preparedness and discussed federal and state responsibilities for  eliminating barriers to preparedness and for facilitating and sustaining  hospital and community-based emergency preparedness. It called for  hospitals to address the full range of potential disasters, including  terrorism, in their planning and to be aware of the specific hazards  applicable to their communities.
The federal government has also provided assistance for improving the  bioterrorism preparedness of hospitals. In January 2002 HHS announced  the availability of funding for that purpose. The Bioterrorism Hospital  Preparedness Program, administered by HHS’s Health Resources and  Services Administration (HRSA), provided funding in fiscal year 2002 of  approximately $125 million through cooperative agreements to states and  eligible municipalities to enhance the capacity of hospitals and associated  health care entities to respond to bioterrorism.
These noncompetitive cooperative agreements covered two phases. In the  first phase, states and municipalities applying for this funding were  required to develop a needs assessment for a comprehensive bioterrorism  preparedness program for hospitals and other health care entities, such as  community health centers, and an implementation plan, as well as to begin  initial implementation of the plan. Applications for the first phase were  due to HHS by February 25, 2002, and funding for this phase,  approximately $25 million, was awarded shortly after receipt of  applications. For the second phase, jurisdictions were required to submit  more detailed implementation plans, in which they addressed three  “critical benchmarks,” including a regional hospital plan for dealing with a  potential epidemic involving at least 500 patients. In addition, applicants  were to address four top-priority planning areas: medications and  vaccines; personal protection, quarantine, and decontamination;  communications; and biological disaster drills. Applications for the second  phase were due April 15, 2002, and the additional funding, approximately  $100 million, was awarded after HHS’s review and approval of the plans. In  March 2003, HHS announced that HRSA’s National Bioterrorism Hospital  Preparedness Program would provide funding in fiscal year 2003 of  approximately $498 million through cooperative agreements to states and  eligible municipalities. In response to our recommendations concerning  additional guidance, HHS noted that it is developing some additional  guidelines and templates to assist in preparedness efforts.
In addition, the federal government has established a stockpile of  pharmaceuticals, antidotes, and medical supplies that can be delivered to  the site of a bioterrorist (or other) attack. This Strategic National Stockpile  has recently been expanded and HHS disclosed that it is planning to  purchase 2,700 ventilators by September 2003 to supplement those now  available in the stockpile. These supplies could be deployed to the site of  an attack within 12 to 36 hours following a declaration of an emergency.
section_title: Hospitals Reported Planning for Bioterrorism Response but Do Not Have Certain Medical Capacities to Handle a Large Increase in Patient Load
paragraphs: Most hospitals in urban areas across the country reported participating in  basic planning and coordination activities for bioterrorism response.  Although most hospitals reported providing at least some training to their  personnel on identification and diagnosis of disease caused by biological  agents considered likely to be used in a bioterrorist attack, only about half  report they have conducted drills or exercises simulating response to a  bioterrorist incident. Further, few reported having acquired the medical  equipment to handle the large increase in the number of patients that  would be likely to result from a bioterrorist incident.
subsections: section_title: Most Hospitals Have Emergency Response Plans Addressing Bioterrorism and Are Participating in Local, State, or Regional Planning and Coordination Activities
paragraphs: Our survey showed that hospitals have engaged in a variety of planning  and coordination activities, with most having prepared an emergency  response plan addressing bioterrorism; participated in a local, state, or  regional interagency disaster preparedness committee; and made  agreements with at least one other organization to share personnel or  equipment in the event of a bioterrorist or other mass casualty incident.
Four out of five hospitals reported having a written emergency response  plan that specifically addresses bioterrorism (see fig. 1). Hospitals that had  a plan were on average around 15 percent larger than those that did not in  terms of number of staffed beds. Of those hospitals that reported not  having such a plan, almost all were currently developing one.
We asked hospitals whether certain elements were specified in their  emergency response plan: contacting other response agencies and  organizations in the event of a bioterrorist incident and managing various  critical functions such as decontamination of victims. As shown in figure  2, of the hospitals that reported having an emergency response plan for  bioterrorism, approximately 90 percent reported specifying in their plan to  contact state and local government agencies, public health agencies, other  hospitals, hazardous materials (HAZMAT) teams, emergency medical  services (EMS), fire departments, or law enforcement. These entities  would be critical to mounting a larger communitywide response,  communicating with the public, investigating and controlling sources of  the outbreak, transporting patients, maintaining order, and investigating  those responsible for the bioterrorism. Hospitals that planned to contact  HAZMAT teams or public health agencies were on average around 15 and  20 percent larger, respectively, than those that did not. There were no  significant differences in average sizes of hospitals with respect to  contacting any of the other entities. Approximately 75 percent of hospitals  reported planning to contact public or private utilities, whose assistance  could be needed to increase or maintain power supplies to critical  equipment or to control water- or sewer-borne pathogens. Although  establishing contact with other laboratories that could potentially provide  additional capacity for overstretched hospital laboratories would be  critical, the percentage of hospitals planning to make that link was lowest,  at approximately 60 percent. Approximately 40 percent of hospitals  reported specifying contacting all nine types of entities listed in figure 2.
As shown in figure 3, most of the hospitals that reported having an  emergency response plan for bioterrorism indicated that they specified in  that plan how certain critical functions were to be managed. The functions  specified by more than 87 percent of hospitals included providing for  hospital security to control entry to and exit from all parts of the hospital;  obtaining additional staff, supplies, and pharmaceuticals to increase the  hospital’s capacity to handle a surge of patients; or planning for mass  evacuation of nonemergency patients on short notice. In general, larger  hospitals had emergency response plans that covered more of these  functions than the plans of smaller hospitals. Hospitals that reported  addressing how to obtain additional pharmaceuticals for surge capacity,  “worried well” management, and mass fatalities were on average around  15 percent larger than those that did not. There were no significant  differences in average sizes of hospitals with respect to any of the other  functions. Approximately 77 percent of the hospitals reported addressing  the question of how to manage a large influx of the worried well and  distinguish them from victims who may be in the early stages of illness.  Approximately 50 percent of hospitals addressed the management of all of  the critical functions listed in figure 3.
Whether they had an emergency response plan addressing bioterrorism or  not, more than 95 percent of hospitals reported participating in a local,  state, or regional interagency disaster preparedness committee, task force,  or working group. Most commonly, these committees also included  representatives from city and county emergency medical services  organizations, fire departments, city and county offices of emergency  management, other local hospitals or medical institutions, city and county  public health or health departments and agencies, and law enforcement  organizations (see table 1). As we have previously reported, it was not  until after September 11, 2001, that government and hospital officials came  to view hospitals as an integral component in local planning for  responding to a terrorist event.
Another planning and coordination activity that hospitals reported on in  our survey was their participation in agreements to share or provide  resources in the event of a bioterrorist or other mass casualty incident. We  asked about agreements at the hospital, city, county, state, and regional  levels. The survey results indicated that hospitals mostly coordinated with  other hospitals, about half coordinated with the local government, and  about one-third coordinated at the state or regional level to provide or  share resources. About 70 percent of hospitals reported that they had  agreements, such as memoranda of understanding or mutual aid  agreements, with other hospitals to provide or share personnel,  equipment, or other resources (see fig. 4). Fewer (between 37 and 54  percent) hospitals had agreements with regional, state, county, or city  organizations (fig. 4). In general, hospitals that had agreements with other  organizations were larger than those that did not. Hospitals that had  agreements with other hospitals or with city organizations were on  average around 10 percent larger than hospitals that did not. Fewer than  20 percent of hospitals had agreements with entities at all five levels.
section_title: Staff Training on Biological Agents Was Reported to Be Widespread, While Hospital Participation in Drills Was Less Common
paragraphs: Approximately 7 out of 10 hospitals reported that their staff had received  training (services, courses, or self-learning materials) for identifying and  diagnosing illness caused by all six biological agents that CDC has stated  would be most likely to be used in a bioterrorist incident (see fig. 5).  Hospitals that reported training activities for all of the biological agents  were on average around 15 percent larger than hospitals that did not. A  greater percentage of hospitals reported that staff had received training for  anthrax or smallpox (around 90 percent or more) than for plague or  botulism (approximately 80 percent) or tularemia or hemorrhagic fever  viruses (approximately 70 percent). However, the extensiveness of the  reported training cannot be determined from our survey.
About half of all hospitals reported participating in drills or tabletop  exercises simulating a biological attack during the past 2 years. Hospitals  that reported participating in biological drills were on average around 20  percent larger than hospitals that did not. Of all of the hospitals that  participated in biological drills or exercises, approximately 80 percent  carried out these activities with other organizations.
section_title: Hospitals Reported Insufficient Medical Equipment to Handle a Large Increase in Patients
paragraphs: The availability of medical equipment needed for bioterrorism response  varied greatly among hospitals, and hospitals reported that they did not  have the capacity to respond to the large increase in the number of  patients that would be likely to result from a bioterrorist incident with  mass casualties (see table 2). For example, if a large number of patients  were to arrive at a hospital with severe respiratory problems associated  with anthrax or botulism, a comparable number of ventilators would be  required to treat them. However, half of the hospitals had, per 100 staffed  beds, fewer than six ventilators, three or fewer personal protective  equipment (PPE) suits, fewer than four isolation beds, or the ability to  handle fewer than six patients per hour through a 5-minute  decontamination shower. More specifically, fewer than 31 percent of  hospitals could handle 10 or more patients per hour through a 5-minute  decontamination shower per 100 staffed beds, and fewer than 10 percent  had 10 or more isolation beds per 100 staffed beds. Almost 40 percent of  the hospitals had fewer than two PPE suits per 100 staffed beds, and  almost 10 percent had fewer than two ventilators per 100 staffed beds.  Hospital officials have told us that bioterrorism preparedness is expensive  and they are reluctant to create capacity that is not needed on a routine  basis and may never be needed at a particular facility.
section_title: Concluding Observations
paragraphs: As concerns about bioterrorism have intensified over the past few years,  hospitals across the nation have been working to increase their  preparedness for responding to such events. The staff and equipment that  hospitals would require to respond to a bioterrorist attack with mass  casualties are far greater than what are needed for everyday performance.  Meeting those needs fully could be extremely difficult because  bioterrorism preparedness is expensive and hospitals are reluctant to  create capacity that is not needed on a routine basis and may never be  used. In addition, along with a hospital’s ability to meet the routine needs  of the community, needs for additional capacity for responding to  bioterrorism emergencies must be balanced with the need to be prepared  for all types of emergencies. Hospital officials have recognized that their  facilities are an essential component of our nation’s bioterrorism  preparedness and have begun planning and training efforts to increase  their response capacity. Most hospitals, however, still lack equipment,  medical stockpiles, and quarantine and isolation facilities for even a small- scale response. The additional funding that is to be provided under the  National Bioterrorism Hospital Preparedness Program in fiscal year 2003  can be used to help hospitals address these issues. The additional  guidance from HHS, in response to our earlier recommendations, may also  be helpful in assisting hospitals to better determine what specific response  capacities they need to ensure.
section_title: Comments from the American Hospital Association
paragraphs: Representatives from the American Hospital Association provided oral  comments on a draft of this report. The officials generally agreed with our  findings and stated that this was a good and useful report providing  helpful information on hospital preparedness. They commended us for the  high response rate to the survey, stating that this provided a more  comprehensive picture of hospital activities than was available elsewhere.  The officials suggested that the report make greater reference to the lack  of specific benchmarks for hospitals to use in planning, provide additional  context on the range of possible events that hospitals must consider in  their planning, and refer readers more specifically to prior GAO  recommendations on bioterrorism preparedness. We have added  additional material to clarify these points. The officials also provided  technical remarks, which we have incorporated where appropriate.
We are sending copies of this report to the Secretary of HHS, the  Administrator of HRSA, and other interested officials. We will also provide  copies to others upon request. In addition, the report will be available at  no charge on GAO’s Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please call me at  (202) 512-7119. Key contributors are listed in appendix III.
section_title: Appendix I: Selected Results of GAO Survey of Hospitals Regarding Hospital Preparedness for Bioterrorism
paragraphs: This appendix describes the characteristics of the short-term, nonfederal,  general medical and surgical hospitals in metropolitan statistical areas  (MSA) in the United States that had emergency departments in 2000 that  we surveyed, and summarizes results by state. We sent the questionnaires  to 2,041 hospitals that met these criteria—20 did not have emergency  departments in fiscal year 2001 or were closed, for a total of 2,021  hospitals. We obtained responses to the survey from 1,489 hospitals, for an  overall response rate of about 74 percent. However, 7 of these hospitals  did not return the section of the survey addressing emergency  preparedness, leaving 1,482, for a response rate of about 73 percent for the  questions of concern for the current report. We weighted responses to  adjust for a lower response rate from investor-owned (for-profit) hospitals  to provide estimates representative of the entire universe of 2,021  hospitals in MSAs.
The following tables show selected survey information on the  characteristics of the survey universe (table 3), response rates for  hospitals by state for all states and the District of Columbia (table 4),  planning and coordination activities (tables 5 through 8), and training  activities (tables 9 and 10), for states that had at least 10 hospitals respond  and a response rate of at least 50 percent (tables 4-10). All data in tables  are weighted to provide estimates for the universe of 2,021 hospitals in  MSAs.
section_title: Appendix II: Scope and Methodology
paragraphs: Between May and September 2002 we surveyed more than 2,000 short- term, nonfederal, general medical and surgical hospitals with emergency  departments located in metropolitan statistical areas (MSAs). Survey  hospitals were located in the 50 states and the District of Columbia.
The survey questionnaire contained three parts. The first and second parts  addressed emergency room functioning, and the third part addressed  hospital preparedness for bioterrorism. We reported our survey findings  on emergency room functioning in March 2003. We conducted our work  between May 2002 and July 2003 in accordance with generally accepted  government auditing standards.
Of the initial universe of 2,041 hospitals that met the selection criteria,   18 had closed by 2002 and 2 did not have emergency departments in fiscal  year 2001, resulting in a final universe of 2,021 hospitals. We sent our  questionnaire to these hospitals and conducted follow-up mailings and  telephone follow-up calls to nonrespondents. We obtained responses to  the survey from 1,489 hospitals, for an overall response rate of about 74  percent. However, 7 of these hospitals did not return the section of the  survey addressing emergency preparedness, leaving 1,482, for a response  rate of about 73 percent for the questions of concern for the current  report.
We analyzed the response rates by hospital size, type of ownership, and  teaching status to assess if there was differential response among various  categories of hospitals. The only statistically significant disproportionate  response was from for-profit hospitals. Therefore we weighted responses  to adjust for a lower response rate from investor-owned (for-profit)  hospitals to provide estimates representative of the entire universe of  2,021 hospitals in MSAs. Using the information provided by surveyed  hospitals, we described the extent of emergency preparedness for  bioterrorist incidents. We also examined the relationships between the  extent of hospital bioterrorism preparedness and size of hospital as  indicated by the number of inpatient staffed beds.
Questions in the survey focused on preparedness to respond to a  bioterrorist event. Some of the responses are applicable more broadly to  preparedness for all types of terrorist events, as well as for natural  disasters or naturally occurring disease outbreaks. However, because the  focus of this work was bioterrorism preparedness, we did not ask more  detailed questions on other types of preparedness.
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, George Bogart, Jennifer Cohen,  Robert Copeland, Susan Lawes, Deborah Miller, and Roseanne Price made  key contributions to this report.
section_title: Related GAO Products
paragraphs: 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.
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.