Public Health Preparedness: Response Capacity Improving, but Much Remains to Be Accomplished
Published: 2004-02-12T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The anthrax incidents in the fall of 2001 and the severe acute respiratory syndrome (SARS) outbreak in 2002-2003 have raised concerns about the nation's ability to respond to a major public health threat, whether naturally occurring or the result of bioterrorism. The anthrax incidents strained the public health system, including laboratory and workforce capacities, at the state and local levels. The SARS outbreak highlighted the challenges of responding to new and emerging infectious disease. The current influenza season has heightened concerns about the nation's ability to handle a pandemic. GAO was asked to examine improvements in state and local preparedness for responding to major public health threats and federal and state efforts to prepare for an influenza pandemic. This testimony is based on GAO's recent report, HHS Bioterrorism Preparedness Programs: States Reported Progress but Fell Short of Program Goals for 2002, GAO-04- 360R (Feb. 10, 2004). This testimony also updates information contained in GAO's report on federal and state planning for an influenza pandemic, Influenza Pandemic: Plan Needed for Federal and State Response, GAO- 01-4 (Oct. 27, 2000).
section_title: What GAO Found
paragraphs: Although states have further developed many important aspects of public health preparedness, since April 2003, no state is fully prepared to respond to a major public health threat. States have improved their disease surveillance systems, laboratory capacity, communication capacity, and workforce needed to respond to public health threats, but gaps in each remain. Moreover, regional planning between states is lacking, and many states lack surge capacity--the capacity to evaluate, diagnose, and treat the large numbers of patients that would present during a public health emergency. Although states are developing plans for receiving and distributing medical supplies and material for mass vaccinations from the Strategic National Stockpile in the event of a public health emergency, most of these plans are not yet finalized. HHS has not published the federal influenza pandemic plan, and most of the state plans have not been finalized. In 2000, GAO recommended that HHS complete the national plan for responding to an influenza pandemic, but according to HHS, the plan is still under review. Absent a federal plan, key questions about the federal role in the purchase, distribution, and administration of vaccines and antiviral drugs during a pandemic remain unanswered. HHS reports that most states continue to develop their state plans despite the lack of a federal plan.

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. The anthrax incidents in the fall of 2001, the SARS  outbreak in 2002-2003, and the recent incidents involving ricin have raised  concerns about the nation’s ability to respond to a major public health  threat, whether naturally occurring or the result of bioterrorism. The  anthrax incidents strained the public health system, including surveillance  and laboratory capacities as well as the workforce, at the state and local  levels. The SARS outbreak highlighted the challenges in responding to  new and emerging infectious disease—especially when the ability to  identify the disease and a vaccine for preventing it are lacking. The  current influenza season has heightened concerns about our nation’s  ability to handle a pandemic. The Congress has recognized the need to  strengthen the nation’s ability to respond to such threats and has  increased appropriations for federal, state, and local public health  preparedness efforts. The Department of Health and Human Services  (HHS) has been developing a national plan for responding to an influenza  pandemic.
As you requested, to assist the Committee in its consideration of our  nation’s ability to respond to a major public health threat, whether  naturally occurring or the result of bioterrorism, my remarks today will  focus on (1) state and local preparedness for responding to major public  health threats and (2) federal and state efforts to prepare for an influenza  pandemic.
My testimony today updates testimony that we provided to you in April  2003 and is based largely on work we conducted for our recently released  report on HHS’s programs that support state and local preparedness for  bioterrorism and other public health threats. For that report, we reviewed  each state’s progress report on the use of bioterrorism preparedness  funding distributed in 2002 by HHS’s Centers for Disease Control and  Prevention (CDC) and Health Resources and Services Administration  (HRSA). The progress reports covered the period through August 30, 2003,  for CDC’s program and through July 1, 2003, for HRSA’s program. For that  report we also interviewed officials from 10 states, 1 local health  department within each of these states, and 2 major metropolitan areas  directly funded by CDC and HRSA. My testimony today also updates  information provided in our October 2000 report on federal and state  planning for an influenza pandemic. To update that information, in  February 2004, we spoke with officials from CDC and HHS’s National  Vaccine Program Office. We conducted our work in accordance with  generally accepted government auditing standards.
In summary, although states have further developed many important  aspects of public health preparedness, since I testified before you in April  2003, no state is fully prepared to respond to a major public health threat.  States have improved their disease surveillance systems, laboratory  capacity, communication capacity, and workforce needed to respond to  public health threats, but gaps in each remain. Moreover, regional planning  between states is lacking, and many states lack surge capacity—the  capacity to evaluate, diagnose, and treat the large numbers of patients that  would present during a public health emergency. Although states are  developing plans for receiving and distributing medical supplies and  material for mass vaccinations from the Strategic National Stockpile in the  event of a public, most of these plans are not yet finalized.
HHS has not published the federal influenza pandemic plan, and most of  the state plans for influenza have not been finalized. In 2000, we  recommended that HHS complete the national plan for responding to an  influenza pandemic, but according to HHS, the plan is still under review.  Absent a federal plan, key questions about the federal role in the purchase,  distribution, and administration of vaccines and antiviral drugs during a  pandemic remain unanswered. HHS reports that most states continue to  develop their state plans despite the lack of a federal plan.
subsections: section_title: Background
paragraphs: The initial response to a public health emergency—for instance an  outbreak of an infectious disease—generally occurs at the local and state  levels and could involve disease surveillance, laboratory testing,  epidemiologic investigation, communication, and health care treatment.  As a public health emergency develops, each plays a critical role in an  effective response. Local and state health departments collect and monitor  data, such as reports from clinicians, for disease trends and evidence of an  outbreak. Laboratory personnel test clinical and environmental samples  for possible exposures and identification of illnesses. Epidemiologists in  the health departments use disease surveillance systems to detect clusters  of suspicious symptoms or diseases in order to facilitate early detection of  disease and treatment of victims. Public health officials provide needed  information to the clinical community, other responders, and the public  and implement control measures to prevent additional cases from  occurring. Health care providers treat patients and limit the spread of  infectious disease. All these response activities require a workforce that is  sufficiently skilled and adequate in number.
The federal government provides funding and resources to state and local  entities to support preparedness and response efforts. For example, in  fiscal year 2002 CDC’s Public Health Preparedness and Response for  Bioterrorism cooperative agreement program provided approximately  $918 million to states to improve bioterrorism preparedness and response  as well as other public health emergency preparedness capacities.  Similarly, HRSA’s Bioterrorism Hospital Preparedness cooperative  agreement program provided approximately $125 million to states in fiscal  year 2002 to enhance the capacity of hospitals and associated health care  entities to respond to bioterrorist attacks. HHS renewed these cooperative  agreements for the period of August 31, 2003 through August 30, 2004. For  these renewed agreements, CDC’s program and HRSA’s program  distributed about $870 million and about $498 million, respectively. Among  the other resources that the federal government provides is the Strategic  National Stockpile, which contains pharmaceuticals and medical supplies  that can be delivered to the site of a public health emergency anywhere in  the United States within 12 hours of the decision to deploy them.
The federal government also supports preparedness efforts for an  influenza pandemic. HHS’s National Vaccine Program Office is responsible  for the development of federal plans for vaccine and immunization  activities and coordinating these efforts among federal agencies. To foster  state and local planning, HHS issued interim planning guidance for the  states in 1997 that outlined general federal and state responsibilities during  an influenza pandemic. HHS expects that if a pandemic occurs, both the  vaccines that are used to prevent influenza and the antiviral drugs that are  used to treat influenza will be in short supply. The guidance discussed  certain key issues related to limited supplies of the influenza vaccine and  antiviral drugs—for instance the amount of vaccine and antiviral drugs  that will be purchased at the federal level; the division of responsibility  between the public and private sectors for the purchase, distribution, and  administration of these supplies during a pandemic; and priorities for  vaccinating population groups, such as health workers and public health  personnel involved in the pandemic response, and persons traditionally  considered to be at increased risk of severe influenza illness and mortality.
section_title: States Have Further Developed Important Aspects of Public Health Preparedness, but Additional Work Is Needed
paragraphs: States reported that as of the summer of 2003 they have made  improvements in their preparedness to respond to major public health  threats, but no aspect of preparedness has been fully addressed by all of  the states. Specifically, although states have strengthened their disease  surveillance systems, laboratory capacity, communications, workforce,  surge capacity, regional coordination across state borders, and readiness  to utilize the Strategic National Stockpile, all of these important aspects of  preparedness require additional work.
subsections: section_title: Disease Surveillance Systems
paragraphs: Although some states have made improvements to their disease  surveillance systems, the nation’s ability to detect and report a disease  outbreak is not uniformly strong across all states. For example, about half  of the states reported that their health departments are capable of  receiving and evaluating urgent disease reports on a 24-hour-per-day,   7-day-per-week basis; however, few states reported having the ability to  rapidly detect an outbreak of an influenza-like illness in the state.  Similarly, few states reported efforts to strengthen links between their  public health and animal surveillance systems and the veterinary  community in order to monitor diseases in animals that may be spread to  humans, such as the West Nile virus.
section_title: Laboratory Capacity
paragraphs: States have increased their capacity to test and identify specimens and  improve laboratory security, although laboratory capacity is not uniformly  robust in all states. All states participate in CDC’s Laboratory Response  Network, a network of local, state, federal, and international laboratories  that are equipped to respond to biological and chemical terrorism,  emerging infectious diseases and other public health threats. However,  only about half of the states reported that they have at least one public  health laboratory within the state that has the appropriate instrumentation  and appropriately trained staff to conduct certain tests for rapidly  detecting and correctly identifying biological agents. About half of the  states reported that they had a facility with a biosafety level sufficient to  handle such agents as anthrax. About half the states also reported that  laboratory security within the state is consistent with HHS guidelines,  which include recommendations for protecting laboratory personnel and  preventing the unauthorized removal of dangerous biologic agents from  the laboratory.
section_title: Communication
paragraphs: Although improving, communication, both among those involved in  responding to a major public health threat—such as public health officials,  health care providers, and emergency management agencies—and with  the public, remains a challenge. CDC’s Health Alert Network has been  expanded—most of the states reported that the local health departments  that cover at least 90 percent of their populations are involved in this  network. However, many states reported that they were still in the  process of assessing their communication needs. Although about half the  states have a plan for educating the public about the risks posed by  bioterrorism and other public health threats, few states have mechanisms  in place for communicating with the general public during an incident  about such issues as when it is necessary to go to the hospital.
section_title: Workforce
paragraphs: States have increased the number of personnel essential to public health  preparedness, but concerns about workforce shortages remain. Most of  the states reported that the bioterrorism preparedness funding from CDC  allowed each to appoint an executive director of its bioterrorism  preparedness and response program, to designate a response coordinator,  and to hire at least one epidemiologist for each metropolitan area with a  population greater than 500,000. However, most states continue to have  staffing concerns. As we have reported previously, some state and local  health officials have had difficulty finding and hiring epidemiologists and  laboratory personnel. The ability to hire and retain personnel in these  areas is still a concern for state and local health officials, who identify  workforce shortages as a long-term challenge to their preparedness  efforts.
section_title: Surge Capacity
paragraphs: Most states lack surge capacity—that is, the capacity to respond to the  large influx of patients that could occur during a public health emergency.  For example, few states reported that they had the capacity to evaluate,  diagnose, and treat 500 or more patients involved in a single incident.  Furthermore, no state reported having protocols in place for augmenting  personnel in response to large influxes of patients, and few states reported  having plans for sharing clinical personnel among hospitals. In addition,  few states reported having the capacity to rapidly establish clinics to  immunize or provide treatment to large numbers of patients.
section_title: Regional Planning
paragraphs: Few states have regional plans in place that would coordinate the  response among states during a public health emergency, and state  officials remain concerned about a lack of regional planning across state  borders. Few states have completed regional response plans for incidents  of bioterrorism and other public health threats and emergencies. Most of  the states that do have such plans have not established training programs  to support their plans or mechanisms to test their plans.
section_title: Strategic National Stockpile
paragraphs: Most state plans for using the Strategic National Stockpile in the event of a  public health emergency have not been fully developed. All states have  prepared preliminary plans for the receipt and management of stockpile  materials, but only about a third of the states have plans that outline how  they would distribute antibiotics, chemical/nerve agent antidotes, and  other materials to areas within the state.
section_title: The Federal Influenza Plan Has Not Been Finalized, but State Planning and Other Efforts Continue
paragraphs: Federal officials have not finalized plans for responding to an influenza  pandemic, and state influenza pandemic response plans are in various  stages of completion.
As we have reported previously, federal officials have drafted but not  finalized the federal influenza pandemic plan. In 2000, we recommended  that HHS complete the national plan for responding to an influenza  pandemic, but HHS reported recently that the plan was still under review  within HHS. However, HHS is taking other steps to prepare for an  influenza pandemic. For example, CDC has increased the supply of  ventilators and added an antiviral drug to the Strategic National Stockpile.  HHS is also coordinating with other federal partners, such as the  Department of Agriculture, to improve the nation’s ability to respond to  public health emergencies involving the veterinary and agricultural  sectors.
Despite the absence of a finalized, federal response plan for an influenza  pandemic, states are developing their own response plans. According to  HHS officials, as of February 2004, 15 states have final or draft plans, and  34 states are actively working on plans. In these plans, states have had to  make assumptions about what the federal role during an influenza  pandemic will be. It is still unclear whether the private sector, the public  sector, or both will have responsibility for purchasing and distributing  vaccines and antiviral drugs. Some states have assumed that vaccine  supply will be under the control of the federal government, while others  have assumed that it will not. States have also made different assumptions  about who will pay for vaccines, antiviral medications, and related  supplies.
section_title: Concluding Observations
paragraphs: States have taken many actions to improve their ability to respond to a  major public health threat, but no state has reported being fully prepared.  Federal plans for the purchase, distribution, and administration of  vaccines and drugs in response to an influenza pandemic still have not  been finalized, complicating the efforts of states to develop their state  plans and heightening concern about our nation’s ability to respond  effectively to an influenza pandemic. States are more prepared now, but  much remains to be accomplished.
Mr. Chairman, this completes my prepared statement. I would be happy to  respond to any questions you or other Members of the Committee may  have at this time.
section_title: Contact and Acknowledgments
paragraphs: For further information about this testimony, please contact Janet  Heinrich at (202) 512-7119. Angela Choy, Maria Hewitt, Krister Friday,  Nkeruka Okonmah, and Michele Orza also made key contributions to this  statement.
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