Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have Improved Public Health Response Capacity, but Gaps Remain
Published: 2003-04-09T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Following the bioterrorist events of the fall of 2001, there has been concern that the nation may not be prepared to respond to a major public health threat, such as the current outbreak of Severe Acute Respiratory Syndrome (SARS). Whether a disease outbreak occurs naturally or is due to the intentional release of a harmful biological agent by a terrorist, much of the initial response would occur at the local level, particularly hospitals and their emergency departments. Efforts to plan for worldwide influenza pandemics are useful for understanding public health preparedness for other large-scale outbreaks. GAO was asked to examine (1) the preparedness of state and local public health agencies and organizations 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) federal and state efforts to prepare for an influenza pandemic. This testimony is based on GAO's report, Bioterrorism: Preparedness Varied across State and Local Jurisdictions, GAO-03-373 (Apr. 7, 2003), a survey of hospitals GAO conducted to assess their level of emergency preparedness, and information updating GAO's prior 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: The efforts of state and local public health agencies to prepare for a bioterrorist attack have improved the nation's capacity to respond to infectious disease outbreaks and other major public health threats, but gaps in preparedness remain. GAO found workforce shortages and gaps in disease surveillance and laboratory facilities. The level of preparedness varied across cities GAO visited. Jurisdictions that have had multiple prior experiences with public health emergencies were generally more prepared than others. GAO found that regional planning was generally lacking between states but that states were developing their own plans for receiving and distributing medical supplies for emergencies, as well as plans for mass vaccinations in the event of a public health emergency. GAO found that many hospitals lack the capacity to respond to large-scale infectious disease outbreaks. Most hospitals across the country reported participating in basic planning activities for large-scale infectious disease outbreaks and training staff about biological agents. However, most hospitals lack adequate equipment, isolation facilities, and staff to treat a large increase in the number of patients that may result. Federal and state officials have not finalized plans for responding to pandemic influenza. These plans do not consistently address problems related to the purchase, distribution, and administration of supplies of vaccines and antiviral drugs that may be needed during a 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. The initial response to an outbreak of infectious disease  would occur at the local level, with support from the state, whether the  outbreak was naturally occurring or due to the intentional release of a  harmful biological agent by a terrorist. Just as in a bioterrorist attack, a  naturally occurring outbreak could involve public health officials in  disease surveillance, epidemiologic investigation, health care delivery,  and quarantine management. Because of prior worldwide influenza  outbreaks—known as pandemics—federal and state agencies have  focused special attention on planning how to address such events, and  these efforts are useful for understanding public health preparedness for  other large-scale outbreaks. The outbreak of Severe Acute Respiratory  Syndrome (SARS) has not infected large numbers of individuals in the  United States, but it has raised concerns about the nation’s preparedness  should it, or other infections, reach pandemic proportions.
Following the bioterrorist events of the fall of 2001, Congress expressed  concern that the nation may not be prepared to respond to a major public  health threat such as a large-scale outbreak of an infectious disease. State  and local response agencies and organizations have recognized the need to  strengthen their infrastructure and capacity to respond to a bioterrorist  attack. The improvements they are making will also strengthen their  ability to identify and respond to other major public health threats,  including naturally occurring large-scale infectious disease outbreaks.
Planning for a response to bioterrorism and influenza pandemics targets  the public health resources essential for a response to other infectious  diseases.
To assist the Committee in its consideration of our nation’s capacity to  respond to a major public health threat, 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) federal and state efforts to prepare for an  influenza pandemic.
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 initial findings from a survey we  conducted of hospitals to assess their level of emergency preparedness,  which we will more fully report later, and from 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 prepare for a bioterrorist attack have improved the  nation’s capacity to respond to infectious disease outbreaks and other  major public health threats, gaps in preparedness remain. More  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 regional planning was  lacking between states, but states were developing their own plans for  receiving and distributing medical supplies for emergencies, and for mass  vaccinations in the event of a public health emergency. We found that  many hospitals lack the capacity to respond to large-scale infectious  disease outbreaks. Although most hospitals across the country report  participating in basic planning activities for such outbreaks, few have  adequate medical equipment, such as ventilators, needed to handle the  large increases in the number of patients that may result. Federal and state  influenza pandemic response plans, another component of public health  preparedness, are in various stages of completion and do not consistently  address the problems related to the purchase, distribution, and  administration of supplies of vaccines and antiviral drugs during a  pandemic.
subsections: section_title: Background
paragraphs: In order to be adequately prepared for a major public health threat, 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 as well as at the regional level.
Local health care organizations, including hospitals, are generally  responsible for the initial response to a public health emergency, be it a  bioterrorist attack or a naturally occurring infectious disease outbreak. 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. 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.
Officials view influenza vaccine as the cornerstone of efforts to prevent  and control annual influenza outbreaks as well as pandemic influenza.  Deciding which viral strains to include in the annual influenza vaccine  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 will occur in a pandemic because  demand is expected to exceed current rates of production and 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 Diseases Outbreaks
paragraphs: In the cities we visited, state and local officials reported varying levels of  public health preparedness to respond to an infectious disease outbreak.  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 response capacity of the workforce and the disease surveillance and  laboratory systems. 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  regional planning was lacking between states. States were working on  their own 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 response capacity of the workforce  and the disease surveillance and laboratory systems. 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, including  preparedness for a bioterrorism incident. 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 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 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: 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: Regional Planning 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 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 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  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: Our recent work shows that progress in improving public health response  capacity has lagged in hospitals. 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 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 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.
According to 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 these hospitals with emergency response  plans, most include a description of how to achieve surge capacity for  obtaining additional pharmaceuticals, other supplies, and staff. 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. 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. While at least 90 percent of  hospitals reported providing training for smallpox and anthrax,  approximately three-fourths of hospitals reported providing training about  plague, botulism, tularemia, and hemorrhagic fever viruses. Fewer than  half the hospitals reported participating in drills or exercises related to  bioterrorism.
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 at least 1 ventilator per 100 staffed  beds, 1 personal protective equipment suit per 100 staffed beds, or an  isolation bed per 100 staffed beds, half of the hospitals had less than 6  ventilators per 100 staffed beds, 3 or fewer personal protective equipment  suits per 100 staffed beds, and less than 4 isolation beds per 100 staffed  beds.
section_title: Officials Have Been Slow to Finalize Plans for Federal and State Response to an Influenza Pandemic
paragraphs: Federal and state influenza pandemic response plans, another important  component to public health preparedness, are in various stages of  completion and do not consistently address the problems related to the  purchase, distribution, and administration of supplies of vaccines and  antiviral drugs during a pandemic. CDC has provided interim draft  guidance to facilitate state plans, but final federal decisions necessary to  mitigate the effects of potential shortages of vaccines and antiviral drugs  have not been made. Until such decisions are made, the timeliness and  adequacy of response efforts may be compromised.
subsections: section_title: Federal and State Pandemic Response Plans Are Not Finalized
paragraphs: Federal and state officials have not finalized plans for responding to  pandemic influenza. To foster state and local pandemic planning and  preparedness, CDC first issued interim planning guidance in draft form to  all states in 1997, outlining general federal and state planning  responsibilities. Thirty-four states are actively preparing a pandemic  response plan, and many are integrating these plans with existing state  plans to respond to natural or man-made disasters, such as floods or a  bioterrorist attack. Although to a certain extent planning efforts for other  emergencies can be used for pandemic response, additional planning is  important to deal with specific aspects of a pandemic response. This  includes developing plans to address the large-scale emergency needs of  an entire population, including mass distribution and administration of  limited vaccines and drugs, with an uncertain amount of available  resources.
section_title: Key Federal Decisions Are Unresolved
paragraphs: 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 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 theoretically 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 sector 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 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.