SARS Outbreak: Improvements to Public Health Capacity Are Needed for Responding to Bioterrorism and Emerging Infectious Diseases
Published: 2003-05-07T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: SARS has infected relatively few people nationwide, but it has raised concerns about preparedness for large-scale infectious disease outbreaks. The initial response to an outbreak occurs in local agencies and hospitals, with support from state and federal agencies, and can involve disease surveillance, epidemiologic investigation, health care delivery, and quarantine management. Officials have learned lessons applicable to preparedness for such outbreaks from experiences with other major public health threats. GAO was asked to examine the preparedness of state and local public health agencies and hospitals for responding to a large-scale infectious disease outbreak and the relationship of federal and state planning for an influenza pandemic to preparedness for emerging infectious diseases. This testimony is based on Bioterrorism: Preparedness Varied across State and Local Jurisdictions, GAO-03-373 (Apr. 7, 2003); findings from a GAO survey on hospital emergency room capacity (in Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities, GAO-03-460 (Mar. 14, 2003)) and on hospital emergency preparedness; and information updating Influenza Pandemic: Plan Needed for Federal and State Response, GAO-01-4 (Oct. 27, 2000).
section_title: What GAO Found
paragraphs: The efforts of public health agencies and health care organizations to increase their preparedness for major public health threats such as bioterrorism and the worldwide influenza outbreaks known as pandemics have improved the nation's capacity to respond to SARS and other emerging infectious disease outbreaks, but gaps in preparedness remain. Specifically, GAO found that there are gaps in disease surveillance systems and laboratory facilities and that there are workforce shortages. The level of preparedness varied across seven cities GAO visited, with jurisdictions that have had multiple prior experiences with public health emergencies being generally more prepared than others. GAO found that planning for regional coordination was lacking between states. GAO also found that states were developing plans for receiving and distributing medical supplies for emergencies and for mass vaccinations in the event of a public health emergency. GAO found that most hospitals lack the capacity to respond to large-scale infectious disease outbreaks. Most emergency departments have experienced some degree of crowding and therefore in some cases may not be able to handle a large influx of patients during a potential SARS or other infectious disease outbreak. Most hospitals across the country reported participating in basic planning activities for such outbreaks. However, few hospitals have adequate medical equipment, such as the ventilators that are often needed for respiratory infections such as SARS, to handle the large increases in the number of patients that may result. The public health response to outbreaks of emerging infectious diseases such as SARS could be improved by the completion of federal and state influenza pandemic response plans that address problems related to the purchase, distribution, and administration of supplies of vaccines and antiviral drugs during an outbreak. The Centers for Disease Control and Prevention has provided interim draft guidance to facilitate state plans but has not made the final decisions on plan provisions necessary to mitigate the effects of potential shortages of vaccines and antiviral drugs in the event of an influenza pandemic.

section_title: Letter
paragraphs: I appreciate the opportunity to be here today to discuss the work we have  done pertaining to the nation’s preparedness to manage major public  health threats, such as the emerging infectious disease known as SARS.  The initial response to an outbreak of infectious disease would occur at  the local level, with support from state and federal agencies, and could  involve disease surveillance, epidemiologic investigation, health care  delivery, and quarantine management. The SARS outbreak has not infected  large numbers of individuals in the United States, but it has raised  concerns about the nation’s preparedness to manage these components of  response should it, or other infections, reach large-scale proportions.
Public health officials and health care workers have learned lessons  applicable to preparedness for large-scale infectious disease outbreaks  from experiences with other major public health threats. Because of prior  worldwide influenza outbreaks—known as pandemics—federal and state  agencies have begun to focus special attention on planning for such  events. Similarly, following the anthrax incidents of fall 2001, the Congress  expressed concern that the nation may not be prepared to respond to a  large-scale bioterrorist event. State and local response agencies and  organizations have recognized the need to strengthen their infrastructure  and capacity to respond to bioterrorism. The improvements they are  making will also strengthen their ability to identify and respond to other  major public health threats, including naturally occurring infectious  disease outbreaks. Planning for a response to bioterrorism and influenza  pandemics targets the public health resources essential for a response to  emerging infectious diseases.
To assist the Subcommittee in its consideration of our nation’s capacity to  respond to a major public health threat such as SARS, my remarks today  will focus on (1) the preparedness of state and local public health agencies  for responding to a large-scale infectious disease outbreak, (2) the  preparedness of hospitals for responding to a large-scale infectious  disease outbreak, and (3) the relationship of federal and state planning for  an influenza pandemic to preparedness for emerging infectious diseases.
My testimony today is based largely on our recently released report on  state and local preparedness for a bioterrorist attack. For that report, we  conducted site visits to seven cities and their respective state  governments. We also reviewed each state’s spring 2002 applications for  bioterrorism preparedness funding distributed by 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 present some findings from a survey we  conducted on hospital emergency department capacity and emergency  preparedness, as well as some information updating our 2000 report on  federal and state planning for an influenza pandemic.
In summary, while the efforts of public health agencies and health care  organizations to increase their preparedness for major public health  threats such as influenza pandemics and bioterrorism have improved the  nation’s capacity to respond to SARS and other emerging infectious  disease outbreaks, gaps in preparedness remain. Specifically, we found  that there are gaps in disease surveillance systems and laboratory facilities  and that there are workforce shortages. The level of preparedness varied  across cities we visited, with jurisdictions that have had multiple prior  experiences with public health emergencies being generally more  prepared than others. We found that planning for regional coordination  was lacking between states. We also found that states were developing  plans for receiving and distributing medical supplies for emergencies and  for mass vaccinations in the event of a public health emergency.
We found that most hospitals across the country lack the capacity to  respond to large-scale infectious disease outbreaks. Most emergency  departments have experienced some degree of crowding and therefore in  some cases may not be able to handle a large influx of patients during a  potential SARS or other infectious disease outbreak. Although most  hospitals report participating in basic planning activities for such  outbreaks, few have adequate medical equipment, such as ventilators that  are often needed for respiratory infections such as SARS, to handle the  large increases in the number of patients that may result.
The public health response to outbreaks of emerging infectious diseases  such as SARS could be improved by the completion of federal and state  influenza pandemic response plans that address problems related to the  purchase, distribution, and administration of supplies of vaccines and  antiviral drugs during an outbreak. CDC has provided interim draft  guidance to facilitate state plans but has not made the final decisions on  plan provisions necessary to mitigate the effects of potential shortages of  vaccines and antiviral drugs in the event of an influenza pandemic.
subsections: section_title: Background
paragraphs: SARS is a respiratory illness that has recently been reported principally in  Asia, Europe, and North America. The World Health Organization reported  on May 5, 2003, that there were an estimated 6,583 probable cases  reported in 27 countries, including 61 cases in the United States. There  have been 461 deaths worldwide, none of which have been in the United  States. Of the 56 probable cases in the United States reported through  April 30, 2003, 37 (66 percent) were hospitalized, and 2 (4 percent)  required mechanical ventilation. Symptoms of the disease, which may be  caused by a previously unrecognized coronavirus, can include a fever,  chills, headache, other body aches, or a dry cough.
A Canadian official recently reported that more than 60 percent of  probable SARS cases in Canada, where the bulk of North American cases  have occurred, resulted from transmission to health care workers and  patients. Canada’s experience with managing the SARS outbreak has  shown that measures used to prevent and control emerging infectious  diseases appear to have been useful in controlling this outbreak. One of  the measures that it has undertaken to control the outbreak is isolating  probable cases in hospitals, including closing two hospitals to new  admissions. Other measures include isolating people, either in their  homes or in a hospital, who have had close contact with a SARS patient  and providing educational materials regarding SARS to people who have  traveled to locations of concern.
In order to be adequately prepared for a major public health threat such as  SARS 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 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.
Local health care organizations, including hospitals, are generally  responsible for the initial response to a public health emergency. In the  event of a large-scale infectious disease 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. In addition, hospitals would need  adequate stores of equipment and supplies, including medications,  personal protective equipment, quarantine and isolation facilities, and air  handling and filtration equipment.
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 the disease, as it is doing 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. 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. In March 2003, HHS announced that the CDC and  HRSA programs would provide funding of approximately $870 million and  $498 million, respectively, for fiscal year 2003. Among the other public  health emergency response resources that the federal government  provides is the Strategic National Stockpile, which contains  pharmaceuticals, antidotes, and medical supplies that can be delivered  anywhere in the United States within 12 hours of the decision to deploy.
Just as was true with the identification of the coronavirus as the likely  causative agent in SARS, deciding which influenza viral strains are  dominant depends on data collected from domestic and international  surveillance systems that identify prevalent strains and characterize their  effect on human health. Antiviral drugs and vaccines against influenza are  expected to be in short supply if a pandemic occurs. Antiviral drugs, which  can be used against all forms of viral diseases, have been as effective as  vaccines in preventing illness from influenza and have the advantage of  being available now. HHS assumes shortages of antiviral drugs and  vaccines will occur in a pandemic because demand is expected to exceed  current rates of production. For example, increasing production capacity  of antiviral drugs can take at least 6 to 9 months, according to  manufacturers.
section_title: State and Local Officials Reported Varying Levels of Public Health Preparedness for Infectious Disease Outbreaks
paragraphs: In the cities we visited, state and local officials reported varying levels of  public health preparedness to respond to outbreaks of diseases such as  SARS. They recognized gaps in preparedness elements such as  communication and were beginning to address them. Gaps also remained  in other preparedness elements that have been more difficult to address,  including the disease surveillance and laboratory systems and the  response capacity of the workforce. In addition, we found that the level of  preparedness varied across the cities. Jurisdictions that had multiple prior  experiences with public health emergencies were generally more prepared  than those with little or no such experience prior to our site visits. We  found that planning for regional coordination was lacking between states.  In addition, states were working on plans for receiving and distributing the  Strategic National Stockpile and for administering mass vaccinations.
subsections: section_title: Progress Has Been Made in Elements of Public Health Preparedness, But Gaps Remain
paragraphs: States and local areas were addressing gaps in public health preparedness  elements, such as communication, but weaknesses remained in other  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.
subsections: section_title: Communication
paragraphs: 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 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.
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, 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.
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  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.
Officials in the states we visited 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 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. 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 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. 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.
section_title: Level of Preparedness Varied across Cities We Visited
paragraphs: We found that the overall level of public health 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.
Even the cities that were better prepared were not strong in all elements.  For example, one city reported that communications had been effective  during public health emergencies and that the city had an active disease  surveillance system. However, officials reported gaps in laboratory  capacity. 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 a public health emergency.
section_title: Planning for Regional Coordination Was Lacking between States
paragraphs: Response organization officials were concerned about a lack of planning  for regional coordination between states of the public health response to  an infectious disease outbreak. As called for by the guidance for the CDC  and HRSA funding, all of the states we visited 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: States Have Begun Planning for Receiving and Distributing Items from the Strategic National Stockpile and for Administering Mass Vaccinations
paragraphs: States have begun planning for use of the Strategic National Stockpile. To  determine eligibility for the CDC funding, applicants were required to  develop interim plans to receive and manage items from the stockpile,  including mass distribution of antibiotics, vaccines, and medical materiel.  However, having plans for the acceptance of the deliveries from the  stockpile is not enough. Plans have to include details about dividing the  materials that are delivered in large pallets and distributing the  medications and vaccines.
Of the seven states we visited, five states had completed plans for the  receipt and distribution of items from the stockpile. One state that was  working on its plan stated that it would be completed in January 2003.  Only one state had conducted exercises of its stockpile distribution plan,  while the other states were planning to conduct exercises or drills of their  plans sometime in 2003.
In addition, five states reported on their plans for mass vaccinations and  seven states reported on their plans for large-scale administration of  smallpox vaccine in response to an outbreak. Some states we visited had  completed plans for mass vaccinations, whereas other states were still  developing their plans. The mass vaccination plans were generally closely  tied to the plans for receiving and administering the stockpile. In addition,  two states had completed smallpox response plans, which include plans  for administering mass smallpox vaccinations to the general population,  whereas four of the other states were drafting plans. The remaining state  was discussing such a plan. However, only one of the states we visited has  tested in an exercise its plan for conducting mass smallpox vaccinations.
section_title: Most Hospitals Lack Response Capacity for Large-Scale Infectious Disease Outbreaks
paragraphs: We found that most hospitals lack the capacity to respond to large-scale  infectious disease outbreaks. Persons with symptoms of infectious disease  would potentially go to emergency departments for treatment. Most  emergency departments across the country have experienced some degree  of crowding and therefore in some cases may not be able to handle a large  influx of patients during a potential SARS outbreak. In addition, although  most hospitals across the country reported participating in basic planning  activities for large-scale infectious disease outbreaks, few have acquired  the medical equipment resources, such as ventilators, to handle large  increases in the number of patients that may result from outbreaks of  diseases such as SARS.
subsections: section_title: Most Emergency Departments Have Experienced Some Degree of Crowding
paragraphs: Our survey 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.
Diversion varies greatly by MSA. Figure 1 shows each MSA and the share  of hospitals within the MSA that reported being on diversion more than 10  percent of the time—or about 2.4 hours or more per day—in fiscal year  2001. Areas with the greatest diversion included Southern California and  parts of the Northeast. Of the 248 MSAs for which data were available,  171 (69 percent) had no hospitals reporting being on diversion more than  10 percent of the time. By contrast, 53 MSAs (21 percent) had at least one- quarter of responding hospitals on diversion for more than 10 percent of  the time.
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 SARS  outbreak, especially if this outbreak occurred in the winter months when  the incidence of influenza is quite high. Thus far, the largest SARS  outbreaks worldwide have primarily occurred in areas with dense  populations.
section_title: Most Hospitals Reported Planning and Training Efforts, but Fewer Than Half Have Participated in Drills or Exercises
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 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.
In our survey of over 2,000 hospitals, 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.
Our survey showed that hospitals have provided training to staff on  biological agents, but fewer than half have participated in 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.
section_title: Most Hospitals Lack Adequate Equipment, Facilities, and Staff Required to Respond to a Large-Scale Infectious Disease Outbreak
paragraphs: Most hospitals lack adequate equipment, isolation facilities, and staff to  treat a large increase in the number of patients for an infectious disease  such as SARS. To prevent transmission of SARS in health care settings,  CDC recommends that health care workers use personal protective  equipment, including gowns, gloves, respirators, and protective eyewear.  SARS patients in the United States are being isolated until they are no  longer infectious. CDC estimates that patients require mechanical  ventilation in 10 to 20 percent of SARS cases.
In the seven cities we visited, hospital, state, and local officials reported  that hospitals needed additional equipment and capital improvements— including medical stockpiles, personal protective equipment, quarantine  and isolation facilities, and air handling and filtering equipment—to  enhance preparedness. Five of the states we visited reported shortages of  hospital medical staff, including nurses and physicians, necessary to  increase response capacity in an emergency. One of the states we visited  reported that only 11 percent of its hospitals could readily increase their  capacity for treating patients with infectious diseases requiring isolation,  such as smallpox and SARS. Another state reported that most of its  hospitals have little or no capacity for isolating patients diagnosed with or  being tested for infectious diseases.
According to our hospital survey, availability of medical equipment varied  greatly between hospitals, and few hospitals seemed to have adequate  equipment and supplies to handle a large-scale infectious disease  outbreak. While most hospitals had, for every 100 staffed beds, at least 1  ventilator, 1 personal protective equipment suit, or 1 isolation bed, half of  the hospitals had, for every 100 staffed beds, fewer than 6 ventilators, 3 or  fewer personal protective equipment suits, and fewer than 4 isolation  beds.
section_title: Key Federal Decisions for Influenza Pandemic Planning Could Facilitate Response to Emerging Infectious Diseases
paragraphs: The completion of final federal influenza pandemic response plans that  address the problems related to the purchase, distribution, and  administration of supplies of vaccines and antiviral drugs during a  pandemic could facilitate the public health response to emerging  infectious disease outbreaks. CDC has provided interim draft guidance to  facilitate state plans but has not made the final decisions on plan  provisions necessary to mitigate the effects of potential shortages of  vaccines and antiviral drugs. Until such decisions are made, the timeliness  and adequacy of response efforts may be compromised.
In the most recent version of its pandemic influenza planning guidance for  states, CDC lists several key federal decisions related to vaccines and  antiviral drugs that have not been made. These decisions include  determining the amount of vaccines and antiviral drugs that will be  purchased at the federal level; the division of responsibility between the  public and the private sectors for the purchase, distribution, and  administration of vaccines and drugs; and how population groups will be  prioritized and targeted to receive limited supplies of vaccines and drugs.  In each of these areas, until federal decisions are made, states will not be  able to develop strategies consistent with federal action.
The interim draft guidance for state pandemic plans says that resources  can be expected to be available through federal contracts to purchase  influenza vaccine and some antiviral agents, but some state funding may  be required. The amounts of antiviral drugs to be purchased and  stockpiled are yet to be determined, even though these drugs are available  and can potentially be used for both treatment and prevention during a  pandemic.
CDC has indicated in its interim draft guidance that the policies for  purchasing, distributing, and administering vaccines and drugs by the  private and public sectors will change during a pandemic, but some  decisions necessary to prepare for these expected changes have not been  made. During a typical annual influenza response, influenza vaccine and  antiviral drug distribution is primarily handled directly by manufacturers  through private vendors and pharmacies to health care providers. During a  pandemic, however, CDC interim draft guidance indicates that many of  these private-sector responsibilities may be transferred to the public  sector at the federal, state, or local levels and that priority groups within  the population would need to be established for receiving limited supplies  of vaccines and drugs.
State officials are particularly concerned that a national plan has not been  issued with final recommendations for how population groups should be  prioritized to receive vaccines and antiviral drugs. In its interim draft  guidance, CDC lists eight population groups that should be considered in  establishing priorities among groups for receiving vaccines and drugs  during a pandemic. The list includes such groups as health care workers  and public health personnel involved in the pandemic response, persons  traditionally considered to be at increased risk of severe influenza illness  and mortality, and preschool and school-aged children.
Although state officials acknowledge the need for flexibility in planning  because many aspects of a pandemic cannot be known in advance, the  absence of more detail leaves them uncertain about how to plan for the  use of limited supplies of vaccine and drugs. In our 2000 report on the  influenza pandemic, we recommended that HHS determine the capability  of the private and public sectors to produce, distribute, and administer  vaccines and drugs and complete the national response plan. To date,  only limited progress has been made in addressing these  recommendations.
section_title: Concluding Observations
paragraphs: Many actions taken at the state and local level to prepare for a bioterrorist  event have enhanced the ability of state and local response agencies and  organizations to manage an outbreak of an infectious disease such as  SARS. However, there are significant gaps in public health surveillance  systems and laboratory capacity, and the number of personnel trained for  disease detection is insufficient. Most emergency departments across the  country have experienced some degree of overcrowding. Hospitals have  begun planning and training efforts to respond to large-scale infectious  disease outbreaks, but many hospitals lack adequate equipment, medical  stockpiles, personal protective equipment, and quarantine and isolation  facilities. Federal and state plans for the purchase, distribution, and  administration of supplies of vaccines and drugs in response to an  influenza pandemic have still not been finalized. The lack of these final  plans has serious implications for efforts to mobilize the distribution of  vaccines and drugs for other infectious disease outbreaks.
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 me at (202)  512-7119. Robert Copeland, Marcia Crosse, Martin T. Gahart, Deborah  Miller, Roseanne Price, and Ann Tynan also made key contributions to this  statement.
section_title: Related GAO Products
paragraphs: 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.
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