Infectious Diseases: Gaps Remain in Surveillance Capabilities of State and Local Agencies
Published: 2003-09-24T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Recent challenges, such as the SARS outbreak and the anthrax incidents in the fall of 2001, have raised concerns about the nation's preparedness for a large-scale infectious disease outbreak or bioterrorism event. In order to be adequately prepared for such a major public health threat, state and local public health agencies need to have several basic capabilities, including disease surveillance systems, laboratory facilities, communication systems and a sufficient workforce. GAO was asked to examine the capacity of state and local public health agencies and hospitals to detect and report illnesses or conditions that may result from a large-scale infectious disease outbreak or bioterrorism event. This testimony is based largely on recent work, including a report on state and local preparedness for a bioterrorist attack; preliminary findings from current work on updates of bioterrorism preparedness at the state and local levels; and findings from a survey GAO conducted on hospital emergency department capacity and emergency preparedness.
section_title: What GAO Found
paragraphs: The efforts of public health agencies and health care organizations to increase their preparedness for infectious disease outbreaks and bioterrorism have improved the nation's ability to recognize such events. However, gaps remain in state and local disease surveillance systems, which are essential to public health efforts to respond to disease outbreaks or bioterrorist attacks. Other essential elements of preparedness include laboratory facilities, workforce, and communication systems. State and local officials report that they are addressing gaps in communication systems. However, there are still significant workforce shortages in state and local health departments. GAO also found that while contingency plans are being developed at the state and local levels, planning for regional coordination for disease outbreaks or bioterrorist events was lacking between states. The disease surveillance capacities of many state and local pubic health systems depend, in part, on the surveillance capabilities of hospitals. Whether a disease outbreak occurs naturally or due to the intentional release of a harmful biological agent by a terrorist, much of the initial response would occur at the local level, particularly at hospitals and their emergency departments. Therefore, hospital personnel would be some of the first healthcare workers with the opportunity to identify an infectious disease outbreak or a bioterrorist event. Most hospitals reported training their staff on biological agents and planning coordination efforts with public health entities; however, preparedness limitations may impact hospitals' ability to conduct disease surveillance. In addition, hospitals still lack the capacity to respond to large-scale infectious disease outbreaks. Also, most emergency departments across the country have experienced some degree of overcrowding, which could be exacerbated during a disease outbreak or bioterrorist event if persons with symptoms go to emergency departments for treatment.

section_title: Letter
paragraphs: I appreciate the opportunity to be here today to discuss the work we have  done on state and local preparedness to manage outbreaks of infectious  diseases, which may be naturally occurring or the product of bioterrorism.  In order to be adequately prepared for such a major public health threat,  state and local public health agencies need to have several basic  capabilities, including disease surveillance systems. Surveillance is public  health officials’ most important tool for detecting and monitoring both  existing and emerging infections. Effective surveillance can facilitate  timely action to control outbreaks and inform allocation of resources to  meet changing disease conditions. Without adequate surveillance, local,  state, and federal officials cannot know the true scope of existing health  problems and may not recognize new diseases until many people have  been affected.
Recent challenges, such as the SARS outbreak and the anthrax incidents  in the fall of 2001, have raised concerns about the nation’s preparedness to  manage a disease outbreak or a bioterrorist event should it reach large- scale proportions. Existing surveillance systems have weaknesses, such as  chronic underreporting and outdated laboratory facilities, which raise  concerns about the ability of state and local agencies to detect emerging  diseases or a bioterrorist event. As a result, state and local response  agencies and organizations have recognized the need to strengthen their  public health infrastructure and capacity. The improvements they are  making are intended to strengthen their ability to identify and respond to  major public health threats, including naturally occurring infectious  disease outbreaks and acts of bioterrorism.
To assist the Subcommittee in its consideration of our nation’s capacity to  detect and monitor an outbreak of an infectious disease, my remarks today  will focus on (1) the preparedness of state and local public health agencies  for responding to an infectious disease outbreak, and (2) the contributions  of hospitals to preparedness for an infectious disease outbreak.
My testimony today is based largely on our recent work, including a report  on state and local preparedness for a bioterrorist attack. For that report,  we conducted site visits in December 2001 through March 2002 to seven  cities and their respective state governments. We also reviewed each  state’s spring 2002 applications for bioterrorism preparedness funding to  the Department of Health and Human Services’ (HHS) Centers for Disease  Control and Prevention (CDC) and Health Resources and Services  Administration (HRSA), and each state’s fall 2002 progress report on the  use of that funding. In addition, I will discuss some preliminary findings  from our current work that provides updated information on the  preparedness of state and local public health agencies. For that work, we  are reviewing the summer 2003 applications and progress reports and  interviewing public health officials from 10 states and two major  municipalities. I also will present some findings from a survey we  conducted in 2002 on hospital emergency department capacity and  emergency preparedness. We conducted our work in accordance with  generally accepted government auditing standards.
In summary, state and local officials in the cities we visited reported  varying levels of public health preparedness to respond to outbreaks of  emerging infectious diseases such as SARS. They recognized gaps in  preparedness elements that have been difficult to address, including the  disease surveillance and laboratory systems and the response capacity of  the workforce. They also were beginning to address gaps in preparedness  elements such as communication. We found that planning for regional  coordination was lacking between states.
Because those with symptoms of an infectious disease might go to  emergency departments for treatment, hospital personnel would likely be  some of the first healthcare workers with the opportunity to identify an  infectious disease outbreak. Therefore, the disease surveillance capacities  of many state and local public health systems may depend, in part, on the  surveillance capabilities of hospitals. Most hospitals reported training their  staff and planning coordination efforts with other public health entities.  However, even with these preparations in place, hospitals lacked the  capacity to respond to large-scale infectious disease outbreaks.
subsections: section_title: Background
paragraphs: Infectious diseases include naturally occurring outbreaks, such as SARS,  as well as diseases from biological agents that are intentionally released by  a terrorist, such as smallpox. An infectious disease outbreak, either  naturally occurring or from an intentional release, may not be recognized  for a week or more because symptoms may not appear for several days  after the initial exposure, during which time a communicable disease  could be spread to those who were not initially exposed.
The initial response to an infectious disease of any type, including a  bioterrorist attack, is generally a local responsibility that could involve  multiple jurisdictions in a region, with states providing additional support  when needed. Figure 1 presents the probable series of responses to a  covert release of a biological agent. Just as in a naturally occurring  outbreak, exposed individuals would seek out local health care providers,  such as private physicians or medical staff in hospital emergency  departments or public clinics. Health care providers would report any  illness patterns or diagnostic clues that might indicate an unusual  infectious disease outbreak associated with the intentional release of a  biologic agent to their state or local health departments.
In order to be adequately prepared for emerging infectious diseases in the  United States, state and local public health agencies need to have several  basic capabilities, whether they possess them directly or have access to  them through regional agreements. Public health departments need to  have disease surveillance systems and epidemiologists to detect clusters  of suspicious symptoms or diseases in order to facilitate early detection of  disease and treatment of victims. Laboratories need to have adequate  capacity and necessary staff to test clinical and environmental samples in  order to identify an agent promptly so that proper treatment can be started  and infectious diseases prevented from spreading. All organizations  involved in the response must be able to communicate easily with one  another as events unfold and critical information is acquired, especially in  a large-scale infectious disease outbreak.
In the event of an outbreak, hospitals and their emergency departments  would be on the front line, and their personnel would take on the role of  first responders. Because hospital emergency departments are open 24  hours a day, 7 days a week, exposed individuals would be likely to seek  treatment from the medical staff on duty. Staff would need to be able to  recognize and report any illness patterns or diagnostic clues that might  indicate an unusual infectious disease outbreak to their state or local  health department. Hospitals would need to have the capacity and staff  necessary to treat severely ill patients and limit the spread of infectious  disease.
The federal government also has a role in preparedness for and response  to major public health threats. It becomes involved in investigating the  cause of a disease, as it did with SARS. In addition, the federal government  provides funding and resources to state and local entities to support  preparedness and response efforts. CDC’s Public Health Preparedness and  Response for Bioterrorism program provided funding through cooperative  agreements in fiscal year 2002 totaling $918 million to states and  municipalities to improve bioterrorism preparedness and response, as well  as other public health emergency preparedness activities. The funding  supported development and improvements in a number of areas CDC  considers critical to preparedness and response, including surveillance  capacity to rapidly detect outbreaks of illness that may be the result of  bioterrorism or other public health threats.
HRSA’s Bioterrorism Hospital Preparedness Program provided funding  through cooperative agreements in fiscal year 2002 of approximately   $125 million to states and municipalities to enhance the capacity of  hospitals and associated health care entities to respond to bioterrorist  attacks. Earlier this month, HHS announced that approximately   $870 million and $498 million have been provided for fiscal year 2003  through the CDC and HRSA programs, respectively, to states and  municipalities to continue these efforts.
section_title: Despite Improvements, Gaps Remain in Disease Surveillance Capabilities of State and Local Public Health Agencies
paragraphs: In the cities we visited, state and local officials reported varying levels of  public health preparedness to respond to outbreaks of emerging infectious  diseases such as SARS. They recognized gaps in preparedness elements  that have been difficult to address, including the disease surveillance and  laboratory systems and the response capacity of the workforce. They also  were beginning to address gaps in preparedness elements such as  communication. We found that planning for regional coordination was  lacking between states.
subsections: section_title: Progress Has Been Made in Elements of Public Health Preparedness, but Gaps Remain
paragraphs: States and local areas had weaknesses in some public health preparedness  elements, including the disease surveillance and laboratory systems and  the response capacity of the workforce. Gaps in capacity often are not  amenable to solution in the short term because either they require  additional resources or the solution takes time to implement. States and  local areas were addressing gaps in communication.
subsections: section_title: Surveillance Systems
paragraphs: State and local officials for the cities we visited in early 2002 recognized  and were attempting to address inadequacies in their surveillance systems.  Local officials were concerned that their surveillance systems were  inadequate to detect a bioterrorist event, and all of the states we visited  were making efforts to improve their disease surveillance systems. Six of  the cities we visited used a passive surveillance system to detect  infectious disease outbreaks. However, passive systems may be  inadequate to identify a rapidly spreading outbreak in its earliest and most  manageable stage because, as officials in three states noted, there is  chronic underreporting and a time lag between diagnosis of a condition  and the health department’s receipt of the report. To improve disease  surveillance, six of the states and two of the cities we visited were  developing surveillance systems using electronic databases. Several cities  were also evaluating the use of nontraditional data sources, such as  pharmacy sales, to conduct surveillance. Three of the cities we visited  were attempting to improve their surveillance capabilities by  incorporating active surveillance components into their systems. For our  ongoing work, state and local officials told us that their surveillance  systems had improved somewhat. The officials reported that CDC funds  have enabled them make some of these improvements in their surveillance  systems, including the development of Web-based disease reporting and  active surveillance systems.
section_title: Laboratory Facilities
paragraphs: Officials from all of the states we visited in early 2002 reported problems  with their public health laboratory systems and said that they needed to be  upgraded. All states were planning to purchase the equipment necessary  for rapidly identifying a biological agent. State and local officials in most  of the areas that we visited told us that the public health laboratory  systems in their states were stressed, in some cases severely, by the  sudden and significant increases in workload during the anthrax incidents  in the fall of 2001. During these incidents, the demand for laboratory  testing was significant even in states where no anthrax was found and  affected the ability of the laboratories to perform their routine public  health functions. Following the incidents, over 70,000 suspected anthrax  samples were tested in laboratories across the country. According to  preliminary data from our interviews and review of 2003 progress reports,  officials reported that CDC funds enabled them to make improvements to  their laboratory infrastructure, including upgrading their laboratory  facilities, purchasing reagents and equipment, and improving their  capability to test for select biologic agents.
Officials in the states we visited in 2002 were working on other solutions  to their laboratory problems. States were examining various ways to  manage peak loads, including entering into agreements with other states  to provide surge capacity, incorporating clinical laboratories into  cooperative laboratory systems, and purchasing new equipment. One state  was working to alleviate its laboratory problems by upgrading two local  public health laboratories to enable them to process samples of more  dangerous pathogens and by establishing agreements with other states to  provide backup capacity. Another state reported that it was using the  funding from CDC to increase the number of pathogens the state  laboratory could diagnose. The state also reported that it has worked to  identify laboratories in adjacent states that are capable of being reached  within 3 hours over surface roads. In addition, all of the states reported  that their laboratory response plans had been revised to cover reporting  and sharing laboratory results with local public health and law  enforcement agencies.
section_title: Workforce
paragraphs: At the time of our early 2002 site visits, shortages in personnel existed in  state and local public health departments and laboratories and were  difficult to remedy. Officials from state and local health departments told  us that staffing shortages were a major concern. Two of the states and  cities that we visited were particularly concerned that they did not have  enough epidemiologists to do the appropriate investigations in an  emergency. Officials at one state department of public health we visited  said that the department had lost approximately one-third of its staff  because of budget cuts over the past decade. This department had been  attempting to hire more epidemiologists. Barriers to finding and hiring  epidemiologists included noncompetitive salaries and a general shortage  of people with the necessary skills.
Workforce capacity issues may also hinder implementation of infectious  disease control measures. For example, the shortage of epidemiologists  could grow worse if, in the event of a severe outbreak, existing health care  workers became infected as a result of their more frequent exposure to a  contaminated environment or became exhausted working longer hours.  Workforce shortages could be further exacerbated because of the need to  conduct contact tracing. According to World Health Organization officials,  an individual infected with SARS came in contact with, on average, 30 to  40 people in Asian countries—all of whom had to be contacted and  informed of their possible exposure.
During our site visits in early 2002, shortages in laboratory personnel were  also cited. Officials in one city noted that they had difficulty filling and  maintaining laboratory positions and that people that accepted the  positions often left the health department for better-paying positions.  Increased funding for hiring staff cannot necessarily solve these shortages  in the near term because for many types of laboratory positions there are  not enough trained individuals in the workforce. According to the  Association of Public Health Laboratories, training laboratory personnel to  provide them with the necessary skills will take time and require a strategy  for building the needed workforce. For our current work updating these  findings, many of the state and local officials we interviewed cited  shortages in trained epidemiologists or laboratory personnel as persistent.
In 2002, state and local officials told us that sustained funding would be  necessary to address one important need—hiring and retaining needed  staff. They told us they would be reluctant to hire additional staff unless  they were confident that the funding would be sustained and staff could be  retained. These statements are consistent with the findings of the Advisory  Panel to Assess Domestic Response Capabilities for Terrorism Involving  Weapons of Mass Destruction, which recommended that federal support  for state and local public health preparedness and infrastructure building  be sustained at an annual rate of $1 billion for the next 5 years to have a  material impact on state and local governments’ preparedness for a  bioterrorist event. We have noted previously that federal, state, and local  governments have a shared responsibility in preparing for terrorist attacks  and other disasters. However, prior to the infusion of federal funds, few  states were investing in their public health infrastructure.
section_title: Communication
paragraphs: We found that officials were beginning to address communication  problems. For example, six of the seven cities we visited in early 2002  were examining how communication would take place in a public health  emergency. Many cities had purchased communication systems that allow  officials from different organizations to communicate with one another in  real time. In addition, state and local health agencies were working with  CDC to build the Health Alert Network (HAN), an information and  communication system. The nationwide HAN program has provided  funding to establish infrastructure at the local level to improve the  collection and transmission of information related to public health  preparedness. Goals of the HAN program include providing high-speed  Internet connectivity, broadcast capacity for emergency communication,  and distance-learning infrastructure for training. For our current work, our  preliminary review of the 2003 progress reports from 12 jurisdictions  shows that 11 reported that over 90 percent of their population was  covered by HAN.
section_title: Some State and Local Contingency Planning Underway, but Regional Coordination Is Lacking
paragraphs: As part of the effort to prepare for a possible outbreak of an infectious  disease, there is contingency planning at the state and local levels. Health  departments, for instance, are in the process of developing contingency  response plans for SARS. The SARS preparations have been modeled after  a checklist designed for pandemic influenza. To facilitate these  preparations, the Association of State and Territorial Health Officials and  the National Association of County and City Health Officials, in  collaboration with CDC, published a checklist for state and local health  officials to use in the event of a SARS resurgence. The checklist  encompasses a broad spectrum of preparedness activities, such as legal  issues related to isolation and quarantine, strategies for communicating  information to health care providers, and suggestions for ensuring other  community partners such as law enforcement and school officials are  prepared.
During our 2002 site visits, however, we found that response organization  officials were concerned about a lack of planning for regional  coordination between states during an infectious disease outbreak. As  called for by the guidance for the CDC and HRSA funding, all of the states  we visited in 2002 organized their planning on the basis of regions within  their states, assigning local areas to particular regions for planning  purposes. A concern for response organization officials was the lack of  planning for regional coordination between states. A hospital official in  one city we visited said that state lines presented a “real wall” for planning  purposes. Hospital officials in one state reported that they had no  agreements with other states to share physicians. However, one local  official reported that he had been discussing these issues and had drafted  mutual aid agreements for hospitals and emergency medical services.  Public health officials from several states reported developing working  relationships with officials from other states to provide backup laboratory  capacity.
section_title: Hospital Preparedness Improved, but Limitations in Response Capacity Remain
paragraphs: Because those with symptoms of an infectious disease might go to  emergency departments for treatment, hospital personnel would likely be  some of the first healthcare workers with the opportunity to identify an  emerging infectious disease outbreak. Therefore, the disease surveillance  capacities of many state and local public health systems may depend, in  part, on the surveillance capabilities of hospitals. Most hospitals reported  training their staff and planning coordination efforts with other public  health entities. However, even with these preparations in place, hospitals  lacked the capacity to respond to large-scale infectious disease outbreaks.
subsections: section_title: Hospitals Provide Vital Disease Surveillance Capacity
paragraphs: The disease surveillance capacities of many state and local public health  systems may depend, in part, on the surveillance capabilities of hospitals.  During the recent SARS outbreak in North America, for instance, hospital  emergency rooms played an important role in identifying those who had  the disease. According to hospital officials in California and New York,  hospital emergency room or other waiting room staff routinely used  questionnaires to screen incoming patients for fever, cough, and travel to a  country with active cases of SARS. They said that hospitals’ signs in  various locations generally used by incoming patients and visitors also  asked individuals to identify themselves to hospital staff if they met these  criteria. In Toronto, which experienced a much greater prevalence of  SARS than the United States, everyone entering a hospital was required to  answer screening questions and to have their temperature checked before  they were allowed to enter.
section_title: Most Hospitals Reported Planning and Training Efforts, but Fewer Than Half Have Participated in Drills or Exercises
paragraphs: In our survey of over 2,000 metropolitan hospitals, most reported that  they have provided training to staff on biological agents, but fewer than  half have participated in drills or exercises related to bioterrorism. Most  hospitals we surveyed reported providing training about identifying and  diagnosing symptoms for the six biological agents identified by the CDC as  most likely to be used in a bioterrorist attack. At least 90 percent of  hospitals reported providing training for two of these agents—smallpox  and anthrax—and approximately three-fourths of hospitals reported  providing training about the other four—plague, botulism, tularemia, and  hemorrhagic fever viruses.
Our hospital survey found that 4 out of 5 hospitals reported having a  written emergency response plan for large-scale infectious disease  outbreaks. Of the hospitals with emergency response plans, most include a  description of how to achieve surge capacity for obtaining additional  pharmaceuticals, other supplies, and staff. In addition, almost all hospitals  reported participating in community interagency disaster preparedness  committees.
At the time of our site visits between December 2001 and March 2002, we  found that hospitals were beginning to coordinate with other local  response organizations and collaborate with each other in local planning  efforts. Hospital officials in one city we visited told us that until September  11, 2001, hospitals were not seen as part of a response to a terrorist event  but that city officials had come to realize that the first responders to a  bioterrorism incident could be a hospital’s medical staff. Officials from the  state began to emphasize the need for a local approach to hospital  preparedness. They said, however, that it was difficult to impress the  importance of cooperation on hospitals because hospitals had not seen  themselves as part of a local response system. The local government  officials were asking them to create plans that integrated the city’s  hospitals and addressed such issues as off-site triage of patients and off- site acute care.
section_title: Most Emergency Departments Have Experienced Some Degree of Crowding
paragraphs: Our survey of metropolitan hospitals found that most emergency  departments have experienced some degree of overcrowding. Persons  with symptoms of infectious disease would potentially go to emergency  departments for treatment, further stressing these facilities. The problem  of overcrowding is much more pronounced in some hospitals and areas  than in others. In general, hospitals that reported the most problems with  crowding were in the largest metropolitan statistical areas (MSA) and in  the MSAs with high population growth. For example, in fiscal year 2001,  hospitals in MSAs with populations of 2.5 million or more had about 162  hours of diversion (an indicator of crowding), compared with about 9  hours for hospitals in MSAs with populations of less than 1 million. Also,  the median number of hours of diversion in fiscal year 2001 for hospitals in  MSAs with a high percentage population growth was about five times that  for hospitals in MSAs with lower percentage population growth.
Hospitals in the largest MSAs and in MSAs with high population growth  that have reported crowding in emergency departments may have  difficulty handling a large influx of patients during a potential infectious  disease outbreak, especially if this outbreak occurred in the winter months  when the incidence of influenza is quite high. For example, public health  officials with whom we spoke said that in the event of a large-scale SARS  outbreak, entire hospital wards may need to be used as separate SARS  isolation facilities. Moreover, certain hospitals within a community may  need to be designated as SARS hospitals.
section_title: Concluding Observations
paragraphs: Efforts at the state and local level have improved the ability to identify and  respond to infectious disease outbreaks and bioterrorism. These  improvements have included upgrades to laboratory facilities and  communication systems. Hospitals have also begun planning and training  efforts to respond to large-scale infectious disease outbreaks. Despite  these improvements, gaps in preparedness remain. We found that some  disease surveillance systems may be inadequate, that there are shortages  of key personnel in some localities, and that most hospital emergency  departments across the country have experienced some degree of  overcrowding, which could be exacerbated during a disease outbreak.
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.
section_title: Contact and Staff Acknowledgments
paragraphs: For further information about this testimony, please contact Janet  Heinrich at (202) 512-7119. Angela Choy, Krister Friday, Martin T. Gahart,  Gay Hee Lee, and Deborah Miller also made key contributions to this  statement.
section_title: Related GAO Products
paragraphs: Hospital Preparedness: Most Urban Hospitals Have Emergency Plans  but Lack Certain Capacities for Bioterrorism Response. GAO-03-924.  Washington, D.C.: August 6, 2003.
Severe Acute Respiratory Syndrome: Established Infectious Disease  Control Measures Helped Contain Spread, But a Large-Scale Resurgence  May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003.
Bioterrorism: Information Technology Strategy Could Strengthen  Federal Agencies’ Abilities to Respond to Public Health Emergencies.  GAO-03-139. Washington, D.C.: May 30, 2003.
SARS Outbreak: Improvements to Public Health Capacity are Needed for  Responding to Bioterrorism and Emerging Infectious Diseases.  GAO-03-769T. Washington, D.C.: May 7, 2003.
Smallpox Vaccination: Implementation of National Program Faces  Challenges. GAO-03-578. Washington, D.C.: April 30, 2003.
Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have  Improved Public Health Response Capacity, but Gaps Remain.   GAO-03-654T. Washington, D.C.: April 9, 2003.
Bioterrorism: Preparedness Varied across State and Local Jurisdictions.  GAO-03-373. Washington, D.C.: April 7, 2003.
Hospital Emergency Departments: Crowded Conditions Vary among  Hospitals and Communities. GAO-03-460. Washington, D.C.: March 14,  2003.
Homeland Security: New Department Could Improve Coordination but  Transferring Control of Certain Public Health Programs Raises  Concerns. GAO-02-954T. Washington, D.C.: July 16, 2002.
Homeland Security: New Department Could Improve Biomedical R&D  Coordination but May Disrupt Dual-Purpose Efforts. GAO-02-924T.  Washington, D.C.: July 9, 2002.
Homeland Security: New Department Could Improve Coordination but  May Complicate Priority Setting. GAO-02-893T. Washington, D.C.: June  28, 2002.
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.
This is a work of the U.S. government and is not subject to copyright protection in the  United States. It may be reproduced and distributed in its entirety without further  permission from GAO. However, because this work may contain copyrighted images or  other material, permission from the copyright holder may be necessary if you wish to  reproduce this material separately.