Bioterrorism: Preparedness Varied across State and Local Jurisdictions
Published: 2003-04-07T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Much of the response to a bioterrorist attack would occur at the local level. Many local areas and their supporting state agencies, however, may not be adequately prepared to respond to such an attack. In the Public Health Improvement Act that was passed in 2000, Congress directed GAO to examine state and local preparedness for a bioterrorist attack. In this report GAO provides information on state and local preparedness and state and local concerns regarding the federal role in funding and improving preparedness. To gather this information, GAO visited seven cities and their respective state governments, reviewed documents, and interviewed officials. Cities are not identified because of the sensitive nature of this issue.
section_title: What GAO Found
paragraphs: State and local officials reported varying levels of preparedness to respond to a bioterrorist attack. Officials reported deficiencies in capacity, communication, and coordination elements essential to preparedness and response, such as workforce shortages, inadequacies in disease surveillance and laboratory systems, and a lack of regional coordination and compatible communications systems. Some elements, such as those involving coordination efforts and communication systems, were being addressed more readily, whereas others, such as infrastructure and workforce issues, were more resource-intensive and therefore more difficult to address. Cities with more experience in dealing with public health emergencies were generally better prepared for a bioterrorist attack than other cities, although deficiencies remain in every city. State and local officials reported a lack of adequate guidance from the federal government on what it means to be prepared for bioterrorism. They said they needed specific standards (such as how large an area a response team should be responsible for) to indicate what they should be doing to be adequately prepared. The need for federal guidance has continued to be an issue as states have proceeded in their planning and preparedness activities with funding from HHS. For example, in their progress reports to HHS in late 2002 two states reported that they were seeking guidance from HHS on assessing vulnerabilities for foodborne or waterborne diseases and preparedness steps they should take for these hazards. One of these states has declared that it could not make further efforts on testing for these types of diseases until it receives more guidance. State officials also expressed a desire for more sharing of best practices. Officials stated that, while each jurisdiction might need to adapt procedures to its own circumstances, time could be saved and needless duplication of effort avoided if there were better mechanisms for sharing strategies across jurisdictions. They stated that HHS was better positioned to know about different strategies that states were pursuing and they want information on the best practices.

section_title: Letter
paragraphs: Since the terrorist attacks of September 11, 2001, and the subsequent  anthrax incidents, there has been great concern about bioterrorism in the  United States. With this concern, there is growing recognition that the  unique characteristics of a bioterrorist attack, in contrast to a  conventional attack, would require additional response preparation and  coordination. Much of the response to a bioterrorist attack would occur at  the local level. The intentional 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 those who were not initially  exposed. Hospitals and their emergency departments, as well as private  physicians and nurses, would most likely be the first responders, as  victims began to seek treatment of their symptoms.
In order to be adequately prepared for a bioterrorist attack, state and local  response organizations need to have several basic capabilities, whether  they possess them directly or have access to them through regional  agreements. Health care providers, including emergency medical  personnel, need to be trained to recognize symptoms of diseases caused  by biological agents likely to be used in a bioterrorist attack (such as  anthrax and smallpox). Public health departments need to have the   appropriate infrastructure, including disease surveillance systems, in  place at the state and local levels to detect clusters of suspicious  symptoms or diseases in order to facilitate early detection of an attack 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. Hospitals need to have  adequate facilities and necessary staff to appropriately treat patients. All  organizations involved in the response must be able to communicate easily  with one another as events unfold and critical information is acquired. In  addition, plans that describe how state and local officials would manage  and coordinate an emergency response need to be in place and to have  been tested in an exercise, both at the state and local levels and at the  regional level.
It has been suggested, however, that many state and local areas may not  be adequately prepared to respond to and manage a bioterrorist attack.  For example, it has been reported that there is an ongoing shortage of  intensive care unit beds and isolation rooms, where infectious disease  patients are treated. In addition, a recent report has identified problems  with the public health infrastructure, particularly at the local level, and  stated that public health departments have generally been poorly funded.
The Department of Health and Human Services (HHS), the Federal  Emergency Management Agency (FEMA), and the Department of Justice  (DOJ) provide assistance to state and local governments in enhancing  preparedness for bioterrorism and for emergencies of all types. In  November 2002, the President signed the Homeland Security Act of 2002,  which established the Department of Homeland Security. As a result of  this legislation, FEMA and certain DOJ and HHS programs with  preparedness and response functions have been transferred to the new  department.
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 to prepare for and respond to a  bioterrorist attack. In this report, we are providing information on the  preparedness of state and local jurisdictions for responding to such an  attack, state and local bioterrorism response planning efforts, and state  and local concerns regarding the federal role in funding and improving  state and local preparedness.
To address our objectives, we conducted multiday site visits to seven  cities and their respective state governments from December 2001 through  March 2002, at a time when states were intensively planning for their  response to a future potential bioterrorist attack following the anthrax  incidents of the previous fall. Cities were selected to provide wide  variation in geographic location, population size, and experience with  natural disasters and large exercises. (See app. I for an overview of each  city we visited, including comparisons across several elements of  preparedness.) We do not identify these cities in this report because of the  sensitive nature of this issue. During the site visits, we interviewed  officials from state and local public health departments, local emergency  medical services, state and local emergency management agencies, local  fire and law enforcement agencies, and hospitals. For each city we visited,  we also reviewed copies of the state’s spring 2002 application for  bioterrorism-related funding through cooperative agreements with HHS’s  Centers for Disease Control and Prevention (CDC) and Health Resources  and Services Administration (HRSA). In addition, we reviewed the  progress reports on the CDC and HRSA cooperative agreements that were  submitted to HHS in late 2002 from the relevant states, covering the period  through October 31, 2002. Because of the events of the fall of 2001, and the  subsequent federal preparedness funding, changes were occurring at the  state and local levels with regard to bioterrorism preparedness during our  site visits and subsequent data collection. Changes have continued to  occur since our visits, and this report may not reflect all these changes. In  addition to making the state and local site visits and reviewing the  pertinent documents, we interviewed officials from federal agencies and  representatives from national public health associations, and we reviewed  reports, including reports of the Advisory Panel to Assess Domestic  Response Capabilities for Terrorism Involving Weapons of Mass  Destruction, concerning state and local preparedness for bioterrorism.  Because our focus was on the public health and medical consequences of  a bioterrorist event, we do not report on preparedness activities funded by  DOJ and FEMA in this study. (See app. II for details regarding our scope  and methodology.) We conducted our work from November 2001 through  April 2003 in accordance with generally accepted government auditing  standards.
subsections: section_title: Background
paragraphs: Initial response to a public health emergency 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. The federal government could also become involved in  investigating or responding to an incident. In addition, the federal  government provides funding and resources to state and local entities to  support preparedness and response efforts.
subsections: section_title: Response to a Bioterrorist Incident
paragraphs: Response to a release of a biological agent, whether covert or overt, would  generally begin at the local level, with the federal government becoming  involved as needed. Having the necessary resources immediately  available at the local level to respond to an emergency can minimize the  magnitude of the event and the cost of remediation. In the case of a covert  release of a biological agent, it could be hours or days before exposed  people start exhibiting signs and symptoms of the disease. Figure 1  presents the probable series of responses to such a bioterrorist incident.  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.
Local and state health departments would collect and monitor data, such  as reports from health care providers, for disease trends and outbreaks.  Clinical samples would be collected for laboratorians to test for  identification of illnesses. Epidemiologists in the health departments  would use the disease surveillance systems to provide for the ongoing  collection, analysis, and dissemination of data to identify unusual patterns  of disease.
The federal government could also become involved, as needed, in  investigating or responding to an incident. For certain high-risk diseases,  such as the Ebola virus, sample testing would be done at a federal  Biosafety Level 4 laboratory equipped to handle dangerous and exotic  biological agents. CDC has one such laboratory for testing of these  dangerous agents. CDC also provides state and local jurisdictions with  assistance on epidemiological investigations and treatment advice. Other  federal agencies may also assist state and local jurisdictions in the  investigation of and response to bioterrorism and other public health  emergencies.
section_title: HHS Funding for State and Local Bioterrorism Preparedness
paragraphs: Prior to January 2002, HHS distributed funds for bioterrorism  preparedness through two main programs. From 1999 to through 2001 it  funded state and local health departments through CDC’s Bioterrorism  Preparedness and Response Program. From 1996 through 2001 it provided  funding to local jurisdictions, targeting police, firefighters, emergency  medical responders, hospitals, and public health agencies through the  Metropolitan Medical Response System (MMRS) of the Office of  Emergency Response (OER), formerly the Office of Emergency  Preparedness, which was transferred to the Department of Homeland  Security on March 1, 2003. CDC and HRSA are expanding or developing  programs to help state and local governments, as well as hospitals and  other health care entities, improve preparedness for and response to  bioterrorism and other emergencies.
In January 2002, HHS announced the allocation of $1.1 billion through  CDC, HRSA, and OER for state and local bioterrorism preparedness. This  funding supports three separate but related efforts—CDC’s Public Health  Preparedness and Response for Bioterrorism program, HRSA’s  Bioterrorism Hospital Preparedness Program, and OER’s MMRS program.  States applying for funding through cooperative agreements under CDC’s  Public Health Preparedness and Response for Bioterrorism program and  HRSA’s Bioterrorism Hospital Preparedness Program were required to  submit bioterrorism preparedness plans to HHS by April 15, 2002. All 50  states and four major municipalities  applied for and received funding  through these cooperative agreements. The noncompetitive cooperative  agreements provide that CDC and HRSA funds must be used to  supplement and not supplant any current federal, state, and local funds  that would otherwise be used for bioterrorism and other public health  preparedness activities and that these activities should be coordinated  with any MMRS programs in the jurisdiction. Also in 2002, additional  funding was appropriated for expanding the National Pharmaceutical  Stockpile, renamed the Strategic National Stockpile, and supporting  bioterrorism-related research at the National Institutes of Health’s  National Institute of Allergy and Infectious Diseases.
To determine eligibility for the funding, CDC required the applicants to submit plans for  use of the funds in six focus areas: preparedness planning and readiness assessment,  surveillance and epidemiology capacity, laboratory capacity for biological agents,  communications and information technology, risk communication and health information  dissemination, and education and training. Each focus area included critical capacities that  had to be addressed. These are the core expertise and infrastructure elements that need to  be in place as soon as possible to enable a public health system to prepare for and respond  to bioterrorism and other infectious disease outbreaks. An example of a critical capacity  under the laboratory capacity for biological agents focus area is to develop and implement  a jurisdiction-wide program to provide rapid and effective laboratory services in support of  the response to public health threats and emergencies.
In November 2002, HHS released supplemental guidance for implementing the new  National Smallpox Vaccination Program. These guidelines state that recipients are  encouraged to use funds made available through the CDC cooperative agreements to plan  and implement this program and should redirect the funding as necessary. respond to bioterrorist attacks. The department released the first 20  percent of these funds to states and the municipalities within weeks of the  January announcement. HHS identified 17 “critical benchmarks” (14 for  the CDC funding and 3 for the HRSA funding) that officials were required  to address in their application plans. HHS used the critical benchmarks to  screen application plans for approval before it released the remaining 80  percent of the CDC and HRSA funding. The benchmarks for the CDC  program included such activities as designating an executive director of  the state bioterrorism preparedness and response program, developing an  interim plan to receive and manage items from the Strategic National  Stockpile, and preparing a time line for the development of regional plans  to respond to bioterrorism. In addition, CDC is allowing states to use this  funding to address preparedness efforts between states and in regions that  border a foreign country. The benchmarks for the HRSA program included  development of a timeline for developing and implementing a regional  hospital plan for dealing with a potential epidemic involving at least 500  patients. HHS requires progress reports from the states at approximately  6-month intervals to provide oversight of CDC and HRSA programs and to  determine future funding. The remaining funds that were allocated for  state and local preparedness in January 2002 supported OER’s MMRS  program.
section_title: State and Local Officials Reported Varying Levels of Bioterrorism Preparedness
paragraphs: State and local officials reported varying levels of preparedness to respond  to a bioterrorist attack. They recognized deficiencies in preparedness and  were beginning to address them. We found that the states and cities we  visited were making greater progress in certain elements of preparedness  than in others. Some elements, such as those involving coordination  efforts and communication systems, were being addressed more readily,  whereas others, such as infrastructure and workforce issues, were more  resource-intensive and therefore more difficult to address. The level of  preparedness varied across the cities, with jurisdictions that had multiple  prior experiences with public health emergencies generally being more  prepared than the other cities, which had little or no such experience prior  to our site visits.
subsections: section_title: Progress Was Made in Elements of Preparedness Related to Coordination and Communication
paragraphs: The cities we visited generally made greater progress in coordination and  communication preparedness than in other elements of preparedness.  Coordination efforts where progress was made included participation by  relevant government and private sector officials in meetings to discuss  how to work together in an emergency and participation in joint training  exercises. Communication efforts included the purchase and  implementation of new communication systems and development of  procedures for communicating with the public and the media. Despite  these advances, deficiencies in coordination and communication  remained.
Most of the cities we visited had made efforts to improve coordination  among the response organizations. Experience from public health  emergencies, especially the terrorist attacks of September 11, 2001, and  the subsequent anthrax incidents, provided momentum for local response  organizations—including fire departments, emergency medical services,  law enforcement, public health departments, emergency management  agencies, and hospitals—to improve coordination. Organizations, such as  hospitals, that previously were not substantially involved increased their  participation in preparedness meetings and agreements. Further, most of  the states we visited reported having established better links between the  public health departments and the hospitals since the September 11, 2001,  terrorist attacks and the subsequent anthrax incidents than had previously  existed. For example, after September 11, 2001, a hospital in one of the  cities reported that the public health department had given it a telephone  number to reach public health officials 24 hours a day, 7 days a week.
In many aspects, the anthrax incidents in October 2001 were exercises in  cooperation between the health care community and traditional first  responders. Many cities were inundated with calls about suspicious  packages and powders. In several of the cities we visited, public health  officials reported working with police and fire officials to create a system  to determine which specimens were most suspicious. These triage systems  greatly reduced the number of costly full-emergency responses. For  example, during the height of the public’s concern about anthrax, one city,  which was experiencing as many as 75 to 90 reports of a white powder per  day, decided against sending out a complete hazardous materials unit for  every report. Instead it sent a team consisting of a fire official, a hazardous  materials official, a police official, and a public health official and this  team made an initial assessment of whether the full team was needed to  respond.
Coordination improved not only horizontally, that is, across different  entities within jurisdictions, but also vertically, that is, between local and  state agencies. According to their progress reports, all of the states we  visited used the 2002 federal funding in part to identify needs and  coordinate and integrate information technology systems. In all of these  states, emergency management communication systems were integrated  both vertically between state and local agencies and horizontally between  local government and hospitals. Only one of these states reported in its  progress report to HHS that it continued to have major difficulties in  improving coordination across different governmental levels because its  communication system was not capable of sending and receiving critical  health information.
In addition, we found that officials were beginning to address  communication problems. For example, six of the seven cities we visited  were examining how communication would take place in an emergency.  Many cities have purchased communication systems that allow officials  from different organizations to communicate with one another in real  time. Officials in one area told us that the fire and police departments in  their area had incompatible radio systems and, consequently, were unable  to communicate directly. This locality intended to install a compatible  radio system. It was also considering purchasing wireless communication  and messaging devices because of their success in other jurisdictions on  September 11, 2001.
State officials reported that they were beginning to make progress in  developing procedures for communication. Responding to the anthrax  incidents revealed a number of communication issues. For example, state  and local agency officials identified problems with how information about  the anthrax incidents was given to the public. These problems included  not always getting facts about anthrax out quickly, not explaining what  was occurring, and releasing inconsistent messages. Officials in one city  told us that they set up an advisory group of retired media personnel to  help them examine how they could use the media to help convey their  message. Following a chemical exercise, public health officials in the same  city realized that better lines of communication were needed. In response,  members of the core bioterrorism team were issued pagers so that they  could be contacted more easily. In addition, two states we visited reported  to HHS that the outbreaks of West Nile virus in summer 2002 provided  successful tests of their communication capabilities.
In addition to these improvements, the 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 a  bioterrorism incident as well as other emergency health events and  disease surveillance. Goals of the HAN program include providing high- speed Internet connectivity, broadcast capacity for emergency  communication, and distance-learning infrastructure for training.
Despite these improvements, deficiencies in communication and  coordination remained. For example, while four of the states we visited  said in their progress reports that they had completed integrating all of  their jurisdictions into HAN, two states had not yet achieved CDC’s goal to  cover 90 percent of the state’s population. One of these states reported  that, although it had developed a plan for emergency communication with  the public, local needs were still being assessed. This state reported that  coordination across multiple governmental levels was problematic and  time-consuming, and progress in meeting goals for planning was slow. In  addition, as of November 2002, only two of the states we visited reported  that they had conducted preparedness exercises that encompassed all  jurisdictions in the state. According to the states’ progress reports, all  states we visited intended to conduct exercises on at least some portion of  their various preparedness plans, such as the plan for receiving and  distributing the Strategic National Stockpile, in 2003.
section_title: Progress in Improving Preparedness Capacity Lagged
paragraphs: In contrast to the improvements made in coordination and  communication, progress related to the response capacity of the  workforce, the surveillance and laboratory systems, and hospitals  generally lagged. Deficiencies 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.
subsections: section_title: Workforce
paragraphs: At the time of our site visits, shortages in personnel existed in state and  local public health departments, laboratories, and hospitals and were  difficult to remedy. Officials from state and local health departments told  us that staffing shortages were a major concern. One official from a state  health department said that local health departments in his state were able  to handle the additional work generated by the anthrax incidents only by  putting aside their normal daily workload. Local officials also stated that  their normal daily workload suffered when staff were diverted from their  usual responsibilities to work on bioterrorism response planning. Local  officials recognized that diverting staff from their usual duties is  appropriate in a time of crisis but were concerned about the impact on  their other public health responsibilities over the longer term. Two of the  states and cities that we visited were particularly concerned that they did  not have enough epidemiologists to do the appropriate investigations in an  emergency. One state department of public health we visited had lost  approximately 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.
Shortages in laboratory and hospital personnel were also cited. Officials in  one city noted that they had difficulty filling and maintaining laboratory  positions. People that accepted the positions often left the health  department for better-paying positions. Five of the states we visited  reported shortages of hospital medical staff, including nurses and  physicians, necessary to increase response capacity in an emergency.  Increased funding for hiring staff cannot necessarily solve these shortages  because for many types of positions, such as laboratorians, there are not  enough trained individuals in the workforce. According to the Association  of Public Health Laboratories, training laboratorians to provide them with  the necessary skills will take time and require a strategy for building the  needed workforce.
Three states cited ongoing shortages of personnel, which they were  addressing in their progress reports. Two states had reported that they  plan to hire veterinarians to assist in their preparedness efforts. One of  these two states also noted difficulties in recruiting personnel when there  was no guarantee of funding beyond the current year, meaning that  prospective employees may not be offered permanent positions. Another  state, however, has had success in hiring epidemiologists.
section_title: Surveillance Systems and Laboratory Facilities
paragraphs: State and local officials for the cities we visited recognized and were  attempting to address inadequacies in their surveillance systems and  laboratory facilities. Local officials were concerned that their surveillance  systems were inadequate to detect a bioterrorist event. 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 electronic  surveillance systems. In one city we visited, the public health department  received clinical information electronically from existing hospital  databases, which required no additional work by the hospitals. 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  example, one city asked six hospitals to participate in a type of active  system in which the public health department obtains information from  the hospitals and conducts ongoing analysis of the data to search for  certain combinations of signs and symptoms. The city also had an active  surveillance system for influenza.
However, work to improve surveillance systems has proved challenging.  For example, despite initiatives to develop active surveillance systems, the  officials in one city considered event detection to be a weakness in their  system, in part because they did not have authority to access hospital  information systems. In addition, various local public health officials in  other cities reported that they lacked the resources to sustain active  surveillance.
Officials from all of the states we visited reported problems with their  public health laboratory systems and said that they needed to be  upgraded. All states were planning to purchase the equipment necessary  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.  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. Public health laboratories in some areas  quickly ran out of space for testing and storing samples. State and local  officials had to rely on laboratory assistance at the federal level, and CDC  received over 6,000 anthrax-related samples and had to operate its  anthrax-testing laboratory 24 hours a day, 7 days a week and open an  additional laboratory to test all the samples. Eighty-five percent of state  and territorial public health laboratories reported that the need to perform  bioterrorism testing during the anthrax incidents had a negative impact on  their ability to do routine work, delaying testing for tuberculosis, sexually  transmitted diseases, and other infectious diseases.
Further, public health laboratories have a minimal association with private  laboratories (that is, laboratories that are associated with private hospitals  or are independent) or sometimes lack ties to laboratories in other states  that could serve as a backup to ensure timely testing of samples. One state  we visited had one state public health laboratory, no backup laboratory,  and no written agreements with neighboring states to provide support. A  task force of the Association of Public Health Laboratories has written  that a lack of close ties can lead to a lack of communication and a lack of  coordination of laboratory testing, both of which are needed to support  public health interventions. All states we visited recognized these  problems and, in their progress reports to HHS, reported that they were  using the funds to improve the Laboratory Response Network.
According to their progress reports, officials in the states we visited were  working on solutions to their laboratory problems. States were examining  various ways to manage peak loads, including training additional staff in  the newest bioterrorism response methods, 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 providing  training on protocols for handling bioterrorist agents, upgrading two local  public health laboratories to Biosafety Level 3 laboratories, and  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  were revised to cover reporting and sharing laboratory results with local  public health and law enforcement agencies.
section_title: Hospitals
paragraphs: Federal, state, and local officials were concerned that hospitals might not  have the capacity to accept and treat sudden, large increases in the  number of patients, as might be seen in a bioterrorist attack. Hospital,  state, and local officials reported that hospitals needed additional  equipment and capital improvements—including medical stockpiles,  personal protective equipment, decontamination facilities, quarantine and  isolation facilities, and air handling and filtering equipment—to enhance  preparedness.
The resources that hospitals would require for responding to a bioterrorist  attack with mass casualties are far greater than what are needed for  everyday performance. Meeting these needs fully would 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 utilized at a particular facility. Although hospitals may not be able  to fully meet all preparedness needs, they can take action to increase their  preparedness by developing plans for their internal emergency response  operations, and some hospital officials reported taking these initial  actions. For example, officials at one hospital we visited appointed a  bioterrorism coordinator and developed plans for taking care of the  families of hospital staff, transporting patients to the hospital, and  communicating during an emergency. However, from its assessments of  hospital capacity, one of the states we visited reported that only 11  percent of its hospitals could readily increase their capacity for treating  patients with communicable diseases requiring isolation, such as  smallpox. Another state reported that most of its hospitals have little or no  capacity for isolating patients diagnosed with or being tested for  communicable diseases. A third state was working with the state hospital  association to provide every hospital in the state with portable  decontamination units.
Efforts have been made to assist hospitals in preparing for bioterrorism.  For example, the hospital association in one city we visited was  developing a set of recommendations, based on the American Hospital  Association checklist, along with cost estimates, for health care facilities  to improve their preparedness. The association’s recommendations  included that each hospital have a 3-day supply of basic personal  protective equipment (such as gloves, gowns, and shoe covers) on hand  for staff, a 3-day supply of specified pharmaceuticals, emergency power, a  loud speaker or other mechanism to communicate with a large group of  converging casualties outside of the hospital entrance, and an external  decontamination facility capable of handling 50 victims per hour. These  guidelines give hospitals criteria by which they can measure their  preparedness and, in turn, improve their internal emergency response  operation plans.
In their progress reports to HHS, all the states we visited discussed a  number of activities they were undertaking with the HRSA funding to  increase hospital preparedness. These included hiring state hospital  bioterrorism program coordinators and medical directors, exploring the  feasibility of coordinating hospitals’ bioterrorism emergency planning  across states, and supplying selected hospitals with biohazard suits and  decontamination systems.
section_title: Level of Preparedness Varied across Cities We Visited
paragraphs: We found that the overall level of bioterrorism preparedness varied by  city. In the cities we visited, we observed that those cities that had  recurring experience with public health emergencies, including those  resulting from natural disasters, or with preparation for National Security  Special Events, such as political conventions, were generally more  prepared than cities with little or no such experience. Cities that had dealt  with multiple public health emergencies in the past might have been  further along because they had learned which organizations and officials  need to be involved in preparedness and response efforts and moved to  include all pertinent parties in the efforts. Experience with natural  disasters raised the awareness of local officials regarding the level of  public health emergency preparedness in their cities and the kinds of  preparedness problems they needed to address. For example, in one city  we visited, officials found that emergency operations center personnel  became separated from one another during earthquakes and had trouble  staying in contact. These problems made decision making difficult. The  officials told us that the personnel needed to learn how to use their radio  system more effectively. (See app. I for details concerning preparedness  by city.)
All the cities we visited had to respond to suspected anthrax incidents in  fall 2001; however, each city found different deficiencies in its capabilities.  The anthrax incidents presented challenges for jurisdictions across the  country, not just in the communities where anthrax was found. Among the  problems that surfaced during the anthrax incidents, for example, were  several dealing with coordination across agencies and communication  among departments and jurisdictions and with the public. A local official  reported that there was no mechanism to coordinate the public  information, medical recommendations, and epidemiologic assessments  throughout the state and neighboring areas and that this created  considerable confusion and frustration for the public and medical  community. In addition, officials in several states became aware of  different types of limitations in their state and local communication  capabilities during the anthrax incidents. For example, in one rural state,  which had no confirmed anthrax cases but numerous false alarms, the  state public health department faxed messages containing critical  information to hospitals throughout the state. Officials in the department  realized that this one-way system was insufficient because they also  needed to be able to receive communications rapidly. They were able to  increase their communication capabilities by setting up a 24-hour toll-free  telephone number staffed by officials, who could respond to questions  from hospitals. In another state, public health laboratory officials found  that it was difficult for many facilities to print files received from CDC  because their Internet connections were inadequate. Ultimately, the state  created CD-ROMs containing the protocols describing how to deal with  suspected anthrax samples, and a state public health official drove more  than 500 miles across the state to deliver them.
One of the cities we visited, which had experienced a large natural disaster  in the late 1990s, was in the early stages of bioterrorism preparedness.  This city is in a predominantly rural state, which started receiving funds  for establishing a HAN system for public health information in fiscal year  2002. There were five epidemiologists at the state level and none at the  local level, so the city depended on the state to determine when a disease  investigation was warranted. The state had a limited passive surveillance  system, with plans for a more elaborate, active surveillance system.
In contrast, another city we visited was much further along in bioterrorism  preparedness. In addition to dealing with natural disasters and other  public health emergencies, the city had also prepared for and hosted a  National Security Special Event. The state had been receiving funding for  HAN since 1999. Epidemiologists were employed at the state and local  levels. The city had a passive surveillance system, and it also had an active  surveillance system for influenza, which has symptoms similar to those of  the early stages of diseases attributable to several likely bioterrorist  agents, such as anthrax.
Even the cities that were better prepared were not strong in all elements.  For example, one city had successfully developed an integrated approach  to preparedness in which multiple organizations, both governmental and  nongovernmental, examined where terrorist attacks are likely to occur,  how they could be mitigated, and what resources were necessary. City  officials also reported that communications had been effective during  public health emergencies and that the city had an active disease  surveillance system. However, officials also reported deficiencies in  laboratory capacity and said that hospitals had not received sufficient  bioterrorism response training. Another one of the better-prepared cities  was connected to HAN and the Epidemic Information Exchange (Epi-X),  and all county emergency management agencies in the state were linked.
However, the state did not have written agreements with its neighboring  states for responding to an emergency, and a major hospital in the city we  visited lacked sufficient equipment for a bioterrorism response.
section_title: State and Local Jurisdictions and Response Organizations Made Progress in Developing Preparedness Plans, but Regional Plans Remained Undeveloped
paragraphs: State and local jurisdictions and response organizations made progress in  developing plans to improve their preparedness. They had begun to  include bioterrorism in their agencies’ overall emergency operation plans,  and preparing the application plans for HHS funding helped states focus  their planning efforts. In addition, hospitals, which were beginning to be  seen as part of a local response system, were starting to participate in  local response planning. While progress was made in local planning,  regional planning between states lagged. A regional response to a  bioterrorist attack would potentially require the mutual participation of  officials from neighboring states or, in several instances, a neighboring  country, yet some states lacked such coordination with their neighboring  states and country and had not participated in joint response planning.
subsections: section_title: State and Local Jurisdictions Had Increased Bioterrorism Planning Efforts
paragraphs: At the time of our site visits, although most of the cities and states we  visited had emergency operation plans, many of these plans did not  specifically address the unique requirements of response to a bioterrorist  attack. However, many of the response organizations in these cities and  states had begun to develop emergency operation plans that include  bioterrorism response. Officials from all of these response organizations  stated that planning for a bioterrorist incident is difficult because they do  not know what it means to be prepared and therefore are not sure if their  plans will be adequate.
At the time of our site visits, all seven states were in the stage of “planning  to plan” for bioterrorism. While all of these states had previously taken  steps to assess the readiness levels of their localities, they continued to  need further assessments. For example, most were doing some  assessments of capacity, such as assessments of hospital capacity and  equipment. Although some of these efforts were time-consuming because  of the need to develop assessment tools, such as surveys, the information  on needs and current status is essential for the states to be able to plan.
Preparing the application plans for HHS helped states to identify problems  in bioterrorism preparedness by requiring them to address specified  preparedness focus areas. In the application process, states were required  to assess their capabilities in the focus areas and discuss how they  planned to address their deficiencies. For example, under the surveillance  and epidemiologic capacity focus area in its application plan for CDC  funding, one state we visited identified a lack of adequate staffing,  expertise, and resources. Officials reported in the plan that the department  of public health was developing regional medical epidemiology teams,  each of which would include a part-time practicing physician and a full- time epidemiologist, with enough teams to cover all the regions in the  state. These teams would establish ongoing relationships with area  hospital infection control programs, emergency departments, and other  health care providers. Another state reported in its HRSA application plan  that it did not have the capability to track resources, supplies, and the  distribution of patients at the regional level. It planned to expand an  existing electronic tracking system to track each hospital’s capacity,  resources, and patient distribution on a real-time basis.
section_title: Hospitals Were Beginning to Recognize Need for Inclusion in Local Planning
paragraphs: At the time of our site visits, we found that hospitals were beginning to  coordinate with other local response organizations and collaborate with  each other in local planning efforts. Hospital officials in one city we visited  told us that until September 11, 2001, hospitals were not seen as part of a  response to a terrorist event but that the city 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.
Government officials, health care association representatives, and hospital  officials in many of the areas that we visited stated that hospitals had  become more interested in these issues and more involved in planning  efforts than prior to September 11, 2001. They noted that health care  providers in hospitals gained an awareness of the seriousness of the threat  of bioterrorism and began to ask for information, lectures, and  presentations of their cities’ emergency plans. Hospital representatives, as  well as state and local officials, told us that hospital personnel were more  interested in attending training on biological agents and that hospitals had  formed better connections with local public health departments in many  areas. We also found that some hospitals were starting to collaborate with  one another on planning efforts.
section_title: Regional Planning Was Lacking between States
paragraphs: Response organization officials were concerned about a lack of planning  for regional coordination between states. As called for by the guidance for  the cooperative agreements, all of the states we visited organized their  planning on a regional basis, assigning local areas to particular regions for  planning purposes. However, the state-defined regions encompassed areas  within the state only. A concern for response organization officials was the  lack of planning for regional coordination between states and with a  neighboring country of the public health response to a bioterrorist attack.  With regard to coordination efforts 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 border issues and had drafted  mutual aid agreements for hospitals and emergency medical services.  Public health officials from several states reported developing working  relationships with officials from other states to provide backup laboratory  capacity.
States varied with regard to the intensity of their coordination efforts with  a neighboring country. Officials in one state told us that the state lacked  the needed coordination with the foreign country that it borders, but they  reported in the state’s CDC application plan that workforce plans and  infectious disease surveillance and reporting are the two priorities for the  state with the neighboring country. The emergency management officials  in the city we visited in that state reported that the border guards knew  and informally coordinated with one another. Officials in this state  reported in the state’s CDC application plan that some of the state’s  hospitals employed people from the foreign country and so hospital  staffing could be problematic if borders were closed during an emergency.  However, officials in another state that we visited reported good regional  partnerships with the foreign country that it borders. In fact, the state  officials noted that the needs of a metropolitan area in the neighboring  country would be evaluated and integrated into the state plan. In addition,  the state reported in its progress report that it was developing an  agreement with the neighboring country to provide laboratory surge  capacity.
section_title: State and Local Officials Expressed Concerns regarding Federal Funding and Lack of Guidance
paragraphs: State and local officials and hospital officials expressed concerns about  the distribution and sustainability of federal bioterrorism preparedness  funding, as well as about a lack of guidance on what it means to be  prepared for a bioterrorism event. State and local officials we met with  disagreed about whether federal funding for bioterrorism preparedness  should flow through the state or go directly to the local jurisdictions.  Hospital officials reported that federal funding from OER’s MMRS  program in their cities had not always been shared with them in the past.  In addition, state and local officials reported that sustainability in funding  over several years would be beneficial to all jurisdictions. State and local  officials requested more specific federal guidance on what constitutes  adequate preparedness. State officials also requested more sharing of best  practices to assist them in closing the remaining gaps in preparedness.
subsections: section_title: Funding Concerns Were Related to Distribution and Sustainability
paragraphs: State and local officials expressed several concerns regarding the federal  funding provided for state and local bioterrorism preparedness both  before and after September 11, 2001. These concerns were related to the  distribution and sustainability of these funds.
subsections: section_title: Distribution
paragraphs: State and local officials we met with disagreed about whether federal  funding for bioterrorism preparedness should flow through the state or go  directly to the local jurisdictions. Local officials suggested that some  funding should be allocated directly to local governments because it  would be more efficient since the state would not withhold a percentage  for its own use. However, state officials told us that if funds went directly  to the local level, it would be difficult for them to direct the funding to the  areas of greatest need within the states. In addition, state officials reported  that when money flows through the states they can control purchases of  emergency response equipment to ensure compatibility across regions of  the state.
Progress reports to HHS from the seven states we visited showed great  variability in the speed with which the states committed funds provided  through the CDC cooperative agreements, in part because of the differing  state requirements for distribution. Two of the states had obligated more  than 70 percent of the funding they received from HHS as of fall 2002,  while two other states had obligated only about 20 percent of their funds  as of the same time, with the remaining three states obligating percentages  between these figures. Some states reported that they needed to arrange  for grants or take other actions before they could transfer any of the funds  to local jurisdictions.
Hospital officials also raised concerns about the distribution of federal  funding for preparedness. In a national survey, 62 percent of hospital  officials said that a lack of awareness of federally sponsored preparedness  programs was a factor in not participating in preparedness programs. In  addition, hospital officials that we spoke with in two cities added that  federal funding from OER’s MMRS program in their cities had not been  shared with hospitals in the past. The HRSA program may help alleviate  these problems. It has led to increased coordination among government  agencies, which may lead to an increased awareness of the funding  opportunity it provides. In addition, the HRSA guidance on funding under  the cooperative agreement requires that approximately three-quarters of  the funding be spent directly on or in hospitals, community health clinics,  and other health care systems. HRSA also requires states to undertake  certain initial state-level tasks that would not involve costs to the  hospitals, including designating a hospital bioterrorism preparedness  coordinator, establishing a statewide advisory committee, and conducting  a needs assessment. In their progress reports to HHS, all states we visited  reported that the HRSA funding was being used primarily to support such  initial state-level activities, including conducting assessments, developing  plans, and hiring state-level personnel. HHS recently stated that most, if  not all, states have now determined how funding will be awarded to  hospitals, community health clinics, and other health care systems.
During our site visits, state officials also expressed concerns in light of the  budget shortfalls and cuts they were experiencing. Officials from one state  expressed concern that the 2002 funding from HHS might be used to  supplant state funding instead of supplementing it, because of general  budgetary cutbacks in the state, although such use is expressly prohibited  by the funding agreements. An official from another state told us that the  funding that its state public health laboratory received in 2002 from CDC  for bioterrorism preparedness was not enough to offset the general cuts in  the state budget for the public health laboratory. We were not able to  determine whether any of the state funds were supplanted by the HHS  funding.
section_title: Sustainability
paragraphs: The public health infrastructure depends on sustained and consistent  investment, yet in the past the funding has been viewed as unsystematic.
In fiscal year 2002, states were experiencing budget shortfalls (as a  percentage of general fund revenues) that were worse than after the  recession of the early 1990s ended, and shortfalls in 2003 were expected  to be even worse. The influx of federal funds for bioterrorism  preparedness made it possible for jurisdictions to undertake new efforts in  this area, at a time when other public health programs were experiencing  cutbacks.
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: State and Local Officials Requested Specific Federal Benchmarks for Adequate Preparedness and Sharing of Best Practices
paragraphs: Officials we spoke with at both the state and the local levels requested  more federal guidance and sharing of best practices to assist them in  closing the remaining gaps in preparedness. Officials from response  organizations in every state we visited reported a lack of guidance from  the federal government on what it means to be prepared for bioterrorism.  In the past, CDC has made efforts to develop guidance for state and local  public health officials on bioterrorism preparedness. For example, in its  core capacity project of 2001, CDC developed criteria to provide guidance  on developing the bioterrorism preparedness capacity of state and local  public health systems. However, these criteria were broad and  nonspecific. State and local officials told us they needed specific  benchmarks (such as how large an area a response team should be  responsible for) to indicate what they should be doing to be adequately  prepared. Local officials were turning to state officials for guidance, and  state officials wanted to be able to turn to the federal government.
Response organizations have been hindered in their efforts to prepare for  bioterrorism because they do not know what agents pose the most  credible threat, which makes it difficult to know when they are prepared.  There have been federal efforts to devise lists of threats, but as we  reported, these efforts have been fragmented, as is evident in the  different biological agent threat lists that were developed by federal  departments and agencies. In addition, medical organizations have  historically not been recipients of intelligence regarding threat  information. The Institute of Medicine and the National Research Council  have stated that this practice needs to be changed.
The need for federal guidance has continued to be an issue as states have  proceeded in their planning and preparedness activities using the HHS  funding. For example, in their progress reports to HHS in late 2002, two of  the states we visited reported that they were seeking guidance from HHS  on assessing vulnerabilities for foodborne or waterborne diseases and  preparedness steps they should take for these hazards. One of these states  declared that it could not make further efforts on testing for waterborne or  agricultural diseases until it received more guidance. States also reported  needing guidance in such areas as using the CDC emergency notification  systems.
State and local officials were interested in receiving detailed guidance  from HHS to be able to better assess their progress and develop realistic  time frames. One state we visited wrote in its progress report that CDC’s  development of pre-event guidelines for use of the vaccinia vaccine for  smallpox would be crucial for providing consistent practices nationwide.
It also wrote that it would be useful to have an approved method for  evaluating laboratory response to ensure that minimum standards were  being met. Two other states wrote that they would like CDC to provide  guidance for developing emergency operation plans.
CDC has begun to provide more detailed guidance in some areas. For  example, it is developing standards for the National Electronic Disease  Surveillance System, which serves as the foundation for many states’  bioterrorism information systems. Under this system, standards are being  developed to ensure uniform data collection and electronic reporting  practices across the nation. Another initiative that is providing guidance  on communication is CDC’s Public Health Information Network. This  network is intended to build on and integrate existing public health  communication systems and will include public health data standards to  ensure the compatibility of the communication systems used by the health  care community and federal, state, and local public authorities. In  addition, CDC has made efforts in developing new laboratory protocols.  One state noted that CDC’s efforts have been of the highest standard, and  the protocols received have been designed for easy implementation at the  state level.
Officials at the state level also expressed a desire for more sharing of best  practices. Officials stated that although each jurisdiction might need to  adapt procedures to its own circumstances, time could be saved and  needless duplication of effort avoided if there were better mechanisms for  sharing strategies across jurisdictions. They contended that HHS was  positioned to know about different strategies that states were pursuing.  For example, one state wrote in its progress report that it would be useful  for HHS to provide information on syndromic surveillance systems that  were operational. In its progress report, another state wrote that it had  requested the portions of other states’ application plans related to risk  communication and health information dissemination. The state wanted to  include its Native American population in preparedness planning and was  looking for best practices on how to involve tribal governments in  planning.
Some officials particularly expressed a desire for increased information  sharing of best practices among state and local jurisdictions on various  types of training. Many jurisdictions were developing training programs to  increase bioterrorism preparedness. One state official told us during our  visit that his agency needed training material on handling incidents, but he  did not want to duplicate others’ efforts by developing his own materials.  In their progress reports, five of the seven states we visited indicated that  they would like CDC’s help in obtaining training information. One state  wrote that establishing national standards for training and training aids for  laboratories would minimize the need for individual states or regions to  develop their own materials. Another state requested assistance with  Strategic National Stockpile and smallpox education and training  materials, and a third state requested training videos or videos of tabletop  exercises to study. One state suggested that it would be useful for CDC to  organize an Internet site and teleconferences among states to facilitate  information sharing.
section_title: Conclusions
paragraphs: As concerns about bioterrorism and other public health emergencies,  including newly emerging infectious diseases such as West Nile virus, have  surfaced over the past few years, cities across the nation have been  working to increase their preparedness for responding to such events. An  essential first step for cities was to recognize some of the deficiencies that  existed in their public health infrastructures and how these would affect  their ability to respond to a bioterrorism event.
Cities have recognized and begun to work on deficiencies in elements of  coordination, communication, and capacity necessary for bioterrorism  preparedness. Progress in addressing capacity issues has lagged behind  progress in other areas, in part because finding solutions to deficiencies in  capacity can be complicated by the magnitude of the resource needs. For  example, the resources that hospitals would require for responding to a  biological attack would be greater than what are normally needed. Local  authorities can shift resources between functions and plan for ways to  expand capacity in an emergency. However, shifting resources between  functions can cause serious problems if the emergency is an extended one  and other important responsibilities are not being met. Needs for  additional capacity for responding to bioterrorism emergencies must be  balanced with preparedness for all types of emergencies and must not  detract from meeting the everyday needs of cities for emergency care.  Regional plans can help address capacity deficiencies by providing for the  sharing across localities of resources that, while adequate for everyday  needs, may be in short supply on a local level in an emergency.
Our observations of state and local preparedness for bioterrorism in  selected cities bring certain other needs into focus as well. First, there is  not yet a consensus on what constitutes adequate preparedness for a  public health emergency, including a bioterrorist incident, at the state and  local levels. There have been some efforts to provide guidelines for  hospital preparedness, but specific standards for state and local  preparedness are lacking. Officials from state and local response  organizations expressed a need for specific benchmarks from the federal  government, which could lead to consistent standards across all states.  This could also facilitate needed regional planning across state  boundaries.
Second, we noted several instances in which cities found solutions to  deficiencies that they identified. For example, cities developed methods  for triaging samples during the anthrax incidents. Federal mechanisms for  sharing innovations and other resources, such as fact sheets on infectious  diseases and training materials, could prevent states and cities from  having to develop solutions to common problems individually. The federal  government could take additional steps to assist these states and cities in  efficiently and effectively increasing their preparedness.
section_title: Recommendations for Executive Action
paragraphs: To help state and local jurisdictions better prepare for a bioterrorist  attack, we recommend that the Secretary of Health and Human Services,  in consultation with the Secretary of Homeland Security,    develop specific benchmarks that define adequate preparedness for a  bioterrorist attack and can be used by state and local jurisdictions to  assess and guide their preparedness efforts and    develop a mechanism by which solutions to problems that have been used  in one jurisdiction can be evaluated by HHS and, if appropriate, shared  with other jurisdictions.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS and the Department of  Homeland Security. HHS submitted written comments, which are  reprinted in appendix III. HHS said the report provides an informative  assessment of preparedness for bioterrorism and other public health  emergencies at the state and local levels. HHS concurred with our  recommendations. The liaison from the Department of Homeland Security  provided oral comments noting the department’s concurrence with the  draft report and the recommendations.
In its comments, HHS stated that it is taking steps to address the concerns  we identified. For example, the department noted that both CDC and  HRSA will issue guidance that will emphasize coordination of planning on  a regional level. HHS also stated that CDC and HRSA will be developing  guidelines and templates to assist states in identifying specific  benchmarks and that the Office of the Assistant Secretary for Public  Health Emergency Preparedness will be leading an effort to create a  repository of best practices.
HHS noted that it has been a year since our site visits and that during that  period both state and local health departments have made further strides  in their efforts to achieve preparedness for bioterrorism and other public  health emergencies. We noted in the draft report that we include  information obtained from state officials several months after our site  visits. As we also noted in the draft report, we recognize that changes  continue to occur. However, many of the problems we identified will  require sustained efforts, and HHS said that it is now taking steps that are  intended to facilitate further progress.
HHS also provided technical comments, which we incorporated where  appropriate.
We are sending copies of this report to the Secretary of Health and Human  Services and the Secretary of Homeland Security, 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. Another contact and key contributors are listed in  appendix IV.
section_title: Appendix I: Bioterrorism Preparedness in Seven Case Cities
paragraphs: Table 1 provides comparisons across several elements of preparedness for  each of the seven cities we visited. The purpose of this table is to provide  additional context for the discussion in the report and some understanding  of the strengths and weaknesses of each city in preparing for a bioterrorist  attack and how these strengths and weaknesses vary among the cities. The  information in this table was obtained from December 2001 through March  2002. The cities have continued to make changes to improve their  bioterrorism preparedness; however, this table does not reflect those  changes.
section_title: Appendix II: Scope and Methodology
paragraphs: We visited seven cities selected to provide wide variation in geographic  location, population size, and experience with natural disasters and large  exercises. Recommendations from experts, including officials from the  Department of Health and Human Services (HHS) Office of Emergency  Response and the National Association of County and City Health  Officials, were also considered in the selection of cities. We also visited  each city’s state government. The cities visited are not identified in this  report because of the sensitive nature of the issue.
During the multiday site visits, which we conducted from December 2001  through March 2002, we interviewed officials from state and local public  health departments, local emergency medical services, state and local  emergency management agencies, local fire and law enforcement  agencies, and hospitals and national public health care associations. We  asked them about their activities related to preparing for and responding  to bioterrorism, lessons learned from past natural disasters and the  anthrax incidents in October 2001, past and current federal funding for  helping state and local agencies prepare for bioterrorism, and gaps and  weaknesses as well as strengths and successes in their readiness for  bioterrorism. We reviewed copies of the bioterrorism preparedness plans  states sent to HHS in spring 2002 for cooperative agreement funding from  the Centers for Disease Control and Prevention (CDC) and the Health  Resources and Services Administration (HRSA). In addition, to update our  data, we obtained follow-up information from state and local officials and  reviewed the 6-month progress reports on the CDC and HRSA cooperative  agreements that were submitted to HHS in late 2002 from the relevant  states, covering the period through October 31, 2002. Because our focus  was on the public health and medical consequences of a bioterrorist event,  we do not report on preparedness efforts funded by the Department of  Justice and the Federal Emergency Management Agency in this study.
The results of our visits cannot be generalized to the entire country. In  addition, the hospitals we included in our site visits were chosen based on  recommendations of local public health officials and hospital associations.  This resulted in a mix of private and public hospitals, but because of the  selection method, the results cannot be generalized to all hospitals in the  areas we visited.
We interviewed officials from HHS’s Office of the Assistant Secretary for  Public Health Emergency Preparedness regarding its efforts to improve  state and local preparedness for responding to a bioterrorist incident.
We reviewed reports from the Advisory Panel to Assess Domestic  Response Capabilities for Terrorism Involving Weapons of Mass  Destruction and reports from several associations, including the American  Hospital Association, the National Association of County and City Health  Officials, and the American College of Emergency Physicians. We  conducted interviews with representatives from several associations,  including the American Hospital Association, the Association of State and  Territorial Health Officials, and the National Governors Association. We  also reviewed a report by the U.S. Conference of Mayors about local costs  associated with bioterrorism preparedness. In addition, we examined the  President’s budget request for bioterrorism preparedness for fiscal year  2003.
Because of the events of the fall of 2001, and the subsequent federal  preparedness funding, changes were occurring at the state and local levels  with regard to bioterrorism preparedness during our site visits and  subsequent data collection. Changes have continued to occur and this  report may not reflect all these changes.
We conducted our work from November 2001 through April 2003 in  accordance with generally accepted government auditing standards.
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, George Bogart, Barbara Chapman,  Robert Copeland, Deborah Miller, and Roseanne Price made key  contributions to this report.
section_title: Related GAO Products
paragraphs: Chemical and Biological Defense: Observations on DOD’s Risk  Assessment of Defense Capabilities. GAO-03-137T. Washington, D.C.:  October 1, 2002.
Anthrax Vaccine: GAO’s Survey of Guard and Reserve Pilots and  Aircrew. GAO-02-445. Washington, D.C.: September 20, 2002.
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.
Chemical and Biological Defense: Improved Risk Assessment and  Inventory Management Are Needed. GAO-01-667. 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.
Chemical and Biological Defense: Program Planning and Evaluation  Should Follow Results Act Framework. GAO/NSIAD-99-159. Washington,  D.C.: August 16, 1999.
Combating Terrorism: Observations on Biological Terrorism and Public  Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16,  1999.