M. tuberculosis, the bacterium that causes TB, is spread from person to person, usually through coughing, sneezing, or speaking. TB disease occurs when the bacteria actively multiply in the lungs or other sites in the body. If left untreated, a person with TB disease can spread the bacteria to an average of 10 to 15 people each year. Also, without proper treatment, TB can be fatal. Because the bacteria that cause TB are naturally slow- growing, final confirmed diagnosis of TB disease, including a determination of drug resistance, can take from 6 to 16 weeks, according to CDC. This lengthy process, along with other factors, makes diagnosis of TB difficult. (Fig. 1 provides information about the characteristics of TB.) TB disease is treated with a combination of TB medications that must be taken regularly. Individuals who have TB bacteria that are not resistant to drugs can be treated with 6 to 9 months of the most effective medications. Those with TB bacteria that are resistant to at least two of the most effective medications (multiple-drug-resistant TB) require treatment for 18 to 24 months with other TB medications that are much less effective, usually have more negative side effects, and are more expensive. Nonadherence to the drug regimen can lead to the development of drug- resistant TB, which can be transmitted from a person with active disease to an uninfected person in the same way that non-drug-resistant TB is transmitted. If a person infected with a drug-resistant strain of TB develops TB disease, his or her strain will be drug resistant as well. Because adherence to treatment regimens is essential to prevent TB bacteria from becoming resistant to available medications, individuals diagnosed with TB disease in the United States are typically treated via directly observed therapy. In such therapy, patients take their medications in the presence of a health care provider, from several times a week to every day. Individuals enrolled in directly observed therapy are more likely to complete their treatment regimens. State and local health departments and federal agencies are to work together to prevent the spread of TB in the United States. In addition to day-to-day care and treatment for patients with TB disease, state and local health departments have the primary responsibility for TB control efforts. Each state health department has a state TB controller who oversees TB prevention and control programs in the local health departments, where in most cases their workers provide care and treatment for TB patients, including directly observed therapy. State and local health departments are to work closely with staff at CDC to alert them to problems as they arise and, if necessary, request CDC assistance with nonadherent individuals with TB. Individuals with or exposed to certain diseases, including TB disease, are also subject to state and federal isolation and quarantine authorities. State and local jurisdictions have the primary legal authority to issue isolation and quarantine orders, and consequently do not regularly involve the federal government when attempting to locate individuals who are or may become nonadherent to their drug regimens. Isolation and quarantine laws vary across states; officials in some states must obtain a court order or establish that a patient is not adhering to medical advice or treatment prior to issuance of an isolation order. Furthermore, states may vary in their enforcement of such orders. However, according to state and federal health officials, the majority of TB patients adhere to treatment recommendations, including remaining in isolation units in hospitals or in isolation at home until they are no longer infectious. HHS has largely delegated to CDC the task of preventing the introduction, transmission, and spread of communicable diseases, such as infectious TB, from foreign countries into the United States, including the ability to apprehend, detain, isolate, or conditionally release a person entering the United States believed to be infected with certain communicable diseases. CDC’s overall mission is to protect the health of all Americans through health promotion, disease prevention, and preparedness. CDC’s centers, divisions, and offices also develop and disseminate guidance to state and local health departments on federal recommendations and procedures for disease control and prevention. CDC also provides resources and funding and collaborates with U.S. and Mexican health agencies for TB care and treatment for U.S. or Mexican citizens who cross the U.S.-Mexico border frequently. Within CDC, the Division of Tuberculosis Elimination is responsible for directing TB prevention and control programs in the United States, formulating national TB policies and guidelines, and helping to control TB worldwide. The Division of Tuberculosis Elimination also provides programmatic consultation, technical assistance, outbreak response assistance, and laboratory support to state and local health departments, and provides technical assistance to TB programs in other countries by collaborating with international partners. CDC’s Division of Global Migration and Quarantine (DGMQ) is responsible for working to reduce illness and death from infectious diseases, such as TB, among immigrants, refugees, international travelers, and other mobile populations that cross international borders, as well as for preventing the introduction of infectious diseases into the United States and promoting the health of people living along the U.S. borders. To facilitate this work, DGMQ operates CDC’s 20 quarantine stations at U.S. ports of entry. Quarantine station officials are responsible for assessing whether ill persons can enter the country and determining what measures should be taken to prevent the spread of infectious diseases into the United States. Most of the quarantine stations are located in airports and work closely with state and local health departments and CBP officers at nearby or collocated ports of entry. DGMQ trains CBP officers on how to identify and respond to travelers, animals, and cargo that may pose an infectious disease threat. CDC’s Coordinating Office for Terrorism Preparedness and Emergency Response works under the Assistant Secretary for Preparedness and Response in HHS and is responsible for directing and coordinating CDC’s response to public health threats. This office operates the Director’s Emergency Operations Center (DEOC), which collects information about potential public health threats 24 hours a day, 7 days a week, and is the central location for CDC’s public health response activities for specific incidents. The DEOC is responsible for sharing information with, and if necessary, requesting additional resources from HHS through its Secretary’s Operations Center (SOC) during a response to a public health incident. The SOC, managed by HHS’s Office of the Assistant Secretary for Preparedness and Response, is the focal point for synthesis of critical public health and medical information on behalf of the U.S. government. Both the SOC and the DEOC are intended to provide a formal, central point of management and oversight at their respective agencies to enable senior agency officials and subject-matter experts to take advantage of agency resources and capabilities in responding to an incident. DHS is responsible for coordinating with federal, state, local, and private entities to secure the nation, prevent terrorist attacks within the United States, and provide emergency management and planning, among other activities. According to statute, DHS is to aid HHS in the enforcement of federal quarantine rules and regulations. The Office of Health Affairs (OHA), which began operations in April 2007, serves as DHS’s principal agent for medical and health matters. It is responsible for managing DHS’s biodefense programs, ensuring the nation’s health preparedness in the event of terrorism or natural disasters, and protecting the health of DHS’s workforce. Also, TSA, CBP, and the Office of Operations Coordination operate within DHS. TSA is responsible for ensuring the security of the national transportation network while ensuring the free movement of people and commerce. TSA has responsibility for safeguarding all modes of transportation, including strengthening the security of airport perimeters and restricted airport areas; screening passengers against terrorist watch lists, such as the No Fly list; and inspecting passengers, baggage, and cargo at over 400 commercial airports nationwide. TSA is tasked with preventing a public health threat on commercial air carriers through its broad authority to protect the transportation system against any threat that could endanger individuals during travel. TSA’s Freedom Center is the primary coordination point for the federal, state, and local agencies dealing with transportation security on a daily basis. A key part of CBP’s mission is to prevent the entry of terrorists into the United States. CBP screens people, conveyances, and goods entering the United States, while facilitating the flow of legitimate trade and travel into and out of the United States. CBP’s mission also includes carrying out traditional border-related responsibilities, including narcotics interdiction, enforcing immigration and customs laws, protecting the nation’s food supply and agriculture industry from pests and diseases, and enforcing trade laws. All travelers requesting to enter the United States, including U.S. citizens, are subject to examination. Individuals may be referred for enhanced inspection for a variety of reasons, such as criminal records, inclusion on a national registry for sex offenders, or prior immigration or customs violations, or may be randomly selected. As appropriate, CBP also conducts searches of people, merchandise, and conveyances entering or exiting the United States, to ensure that merchandise may be lawfully imported or exported and duties collected. CBP officers are responsible for conducting inspections to permit admissible individuals to enter the country. In general, U.S. citizens who demonstrate their citizenship are to be admitted, although those citizens believed to be infected with or exposed to TB or other communicable diseases specified by Executive Order may be subject to isolation or quarantine immediately upon admission. Noncitizens seeking entry must establish that they are admissible under U.S. immigration law; those determined to have a communicable disease of public health significance are inadmissible, unless granted a waiver. During the inspection process, CBP officers are to use TECS—CBP’s computerized border screening and inspection system—in addition to other databases to assess admissibility and purpose for entering the country and to corroborate information. Individuals may be admitted or denied entry and returned to the country of origin. In addition, individuals may be detained temporarily pending an admissibility determination, detained for purposes of prosecuting a violation of U.S. law, or turned over to another law enforcement entity. (App. I provides more detailed information about the CBP inspection process.) In addition to electronic alerts available in databases, CBP officers also rely on be-on-the-lookout notices—which are similar to wanted posters, disseminated by CBP’s Office of Field Operations and hung at ports of entry—to identify individuals who pose potential threats attempting to enter the United States. The Commissioner’s Situation Room—CBP’s 24-hour, 7-day-a-week center for facilitating communication between CBP headquarters and the field offices—serves as the entry point for reporting of incidents from field offices. CBP also assists CDC quarantine station officials with the distribution of health risk information for the traveling public, such as notices that alert travelers to possible exposure to communicable diseases abroad and offer guidance on how to protect themselves. The DHS Office of Operations Coordination is responsible for monitoring the nation’s security on a daily basis and coordinating activities within DHS and with external entities, such as governors’ offices and law enforcement partners. Within the Office of Operations Coordination, the National Operations Center (NOC) serves as the focal point for these coordination efforts by collecting information about potential homeland security threats 24 hours a day, 7 days a week. The NOC serves as the primary hub for federal emergency and public health preparedness and response by combining and sharing information, communications, and operations coordination pertaining to the prevention of terrorist attacks and domestic emergency management with other federal, state, local, tribal, and nongovernmental emergency operations centers, including TSA’s Freedom Center and CBP’s Commissioner’s Situation Room. In October 2005, HHS and DHS signed a memorandum of understanding that was intended to provide a basis for federal cooperation to enhance the nation’s preparedness to prevent the introduction, transmission, and spread of quarantinable and serious communicable diseases, such as TB, from foreign countries into the United States. According to CBP officials, the memorandum was developed following the 2003 outbreak of severe acute respiratory syndrome (SARS) in order to prepare the departments for circumstances that would need a coordinated response. CDC is the designated agency with responsibility for HHS activities supported by the memorandum. CBP, Coast Guard, and Immigration and Customs Enforcement are the designated DHS agencies with responsibility for assisting CDC in the enforcement of isolation and quarantine authorities. Two TB incidents occurred in spring 2007. One involved a U.S. citizen who traveled by commercial airline internationally and subsequently reentered the United States at the Canadian border at the Champlain, New York, land port of entry. The other involved a Mexican citizen who crossed the U.S.-Mexico border multiple times at the El Paso, Texas, land port of entry. In both incidents, according to HHS, the individuals with TB did not follow the medical advice of federal, state, and local public health officials and instead continued to travel. In the incident involving the U.S. citizen, state and local health officials reported that once they determined that the U.S. citizen posed a public health threat, they orally recommended to him that he not travel and reviewed options to restrict his international travel. State and local health officials reported that from May 11 to May 13, they attempted to hand deliver a letter to the individual that emphasized the seriousness of drug- resistant TB and the potential threat he posed to others, and included a recommendation that he postpone his travel. However, according to CDC officials, state and local health officials reported that they were unable to deliver the letter because, unbeknownst to them, the individual had left the United States 2 days earlier than he had previously planned, despite advice not to travel. When federal public health officials became involved in the response, they contacted the individual overseas and made efforts to advise him about seeking treatment and how to return to the United States. Once CDC notified CBP of the incident, CBP entered an alert in TECS that provided instructions to detain the individual if he was encountered at any port of entry. However, HHS reported that the individual continued with his travel plans against medical advice. For example, when a CDC quarantine officer located the individual abroad and attempted to direct him to treatment in Europe, the individual changed his travel plans again, left his hotel, and did not contact CDC until he returned to the United States. Upon his return, according to HHS, CDC was able to contact him via cell phone and he agreed to undergo treatment for drug- resistant TB. (Fig. 2 provides more details about the incident involving the U.S. citizen and officials’ actions.) databases. Despite multiple searches by CBP, he was checked at the border approximately 20 times during April and May 2007, and was able to cross into the United States. According to officials from both agencies, the Mexican citizen did not turn over his visa when his physician initially requested it, which would have allowed CDC and CBP officials to locate information about him. On May 31, approximately a month after state and local health officials first notified federal officials of the incident, the Mexican citizen gave his visa to his physician. (Fig. 3 provides more details about the incident involving the Mexican citizen and officials’ actions.) Various factors—a lack of comprehensive procedures for information sharing and coordination as well as border inspection shortfalls—hindered the federal response to the two TB incidents. HHS and DHS lacked formal procedures for sharing information with each other. They had established a memorandum of understanding in October 2005 creating a broad agreement to communicate and coordinate during public health emergencies. However, the departments were unable to carry out the intent of the memorandum because they had not developed specific operational procedures to share information and coordinate their efforts to respond to events such as the two TB incidents. In addition, HHS had general procedures for sharing information about incidents of infectious diseases among senior managers at HHS and DHS through the agencies’ operations centers. However, HHS and CDC did not have procedures that outlined what assistance was available to them from DHS, particularly from CBP and TSA, and how to request it. The two departments also lacked internal procedures outlining how to share information and coordinate with senior officials within each department about the TB incidents to involve them in decision making, which resulted in senior officials not being able to ensure that resources were available to take appropriate action. In addition, CDC had not developed procedures to inform state and local health officials about the process for coordinating with CDC to determine whether federal isolation and quarantine authorities should be used to deter the travel of an individual with TB, causing the initial delay in the federal response. Furthermore, CBP had deficiencies in its traveler inspection process, which led to further delays in locating the individuals and deterring their travel. Despite the memorandum of understanding between HHS and DHS in place at the time of the incidents, the departments lacked comprehensive procedures needed to share information with each other and coordinate resources to deter cross-border travel of nonadherent individuals with infectious disease, such as TB. Our previous work has identified practices to enhance and sustain agency collaboration, including frequent communication among the agencies and the establishment of compatible policies, procedures, and other means of operating across agency boundaries. Additionally, Standards for Internal Control in the Federal Government calls for (1) management to ensure that there are adequate means of communicating with, and obtaining information from, external stakeholders that may have a significant impact on the agency achieving its goals and (2) effective communication flowing down, across, and up the organization to enable managers to carry out their internal control responsibilities. Finally, our work on emergency management outlines three basic elements that constitute effective preparedness and response to hazardous situations, including the spread of infectious diseases. The three basic elements are (1) leadership, where clear roles and responsibilities are effectively communicated and understood in order to facilitate rapid and effective decision making; (2) capabilities, for which plans are integrated and key players define what needs to be done, where, by whom, and how well; and (3) accountability, where officials work to ensure that resources are used appropriately for valid purposes, including developing operational plans that are tested and taking corrective action as needed. Although the memorandum of understanding outlined a broad agreement to promote information sharing in the event of a public health incident, it did not provide specific operational procedures for the departments and their component agencies to share information with each other to respond to events such as the two TB incidents. In addition, HHS had general procedures for senior managers to share information about infectious diseases with senior DHS officials through their operations centers. However, we learned through discussions with DHS officials and from the HHS and CDC after-action reports that during the incident involving the U.S. citizen, HHS and CDC did not have procedures outlining what assistance was available from DHS, particularly from CBP and TSA, and how to request it. Some of the DHS capabilities that were unclear to HHS and CDC decision makers included CBP’s search capabilities for locating individuals and their travel itineraries, their travel histories, or both in order to stop cross-border travel; the availability of TECS and be-on-the-lookout notices through CBP, which could have assisted officers in identifying the individuals so that they could locate them at any U.S. port of entry; and TSA’s ability to prevent the individuals from flying into and out of the United States. Because CDC was unsure whether or how DHS could offer assistance for public health purposes, CDC did not request assistance from CBP until 4 days after state health department officials notified CDC of the incident. HHS and DHS also lacked procedures for sharing individual health information between the departments for public health incident response, including how broadly to share it, which delayed the federal response to the incidents. CDC and DHS officials we interviewed said that CDC was initially slow to provide this identifying information to TSA officials while the agencies were determining a course of action and whether TSA’s No Fly list could be used to prevent the U.S. citizen’s air travel, thus hindering their ability to locate and deter the individual from traveling. Public health and law enforcement authorities generally have different approaches to sharing such information, as reflected in their missions and responsibilities. According to CDC officials, in an effort to limit disclosure of individuals’ private medical information, agency staff generally refrain from sharing identifying information with each other, even when discussing a potential incident, preferring to refer to people and places as “the patient” or “hospital A.” On the other hand, CBP and TSA, as a law enforcement and security agency, respectively, need accurate and complete identifying information to locate and detain individuals. In the incident involving the U.S. citizen, CDC officials took several hours to provide the person’s name and health information after initially contacting DHS for assistance because they were unsure how the information was going to be used and protected. CDC’s hesitancy delayed CBP’s dissemination of a be-on-the-lookout notice and placement of an alert in TECS. CDC officials indicated that generalized concerns over the applicability of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Privacy Act restrictions on the sharing of individual information contributed to a delay in their sharing this information with DHS. However, as CDC has concluded, in this instance both laws appear to permit the disclosure to DHS, without patient authorization, of individually identifiable health information acquired for the purpose of controlling the spread of disease. According to CDC, there was a concern that the lack of procedures for sharing identifying and health information between agencies resulted in this information being disseminated over law enforcement channels more broadly than may have been necessary under the circumstances. In addition, concerns were raised that password protection for the information disseminated may have been insufficient. Along with a lack of comprehensive procedures for information sharing with each other, HHS and DHS lacked specific procedures for communicating across their respective component agencies about public health incidents, which contributed to uncertainty about whether and when CDC, TSA, or CBP should notify senior officials at HHS or DHS about potential incidents. According to Standards for Internal Control in the Federal Government, effective communication should occur in a broad sense with information flowing down, across, and up organizations. Lacking specific procedures, HHS and CDC officials used a “standard of reasonableness” that involves professional discretion as a basis for determining whether the individual posed a potential public health threat and when to notify senior officials. CDC officials told us that using this standard involves some subjective judgment. According to CDC, its quarantine station officials initially believed that the two TB incidents could be resolved locally without notifying senior officials, which led to delays in the federal response in both incidents. For example, in the U.S. citizen incident, senior officials at HHS and CDC were not notified by CDC quarantine station officials at the field office level about the incident early enough to ensure timely use of federal isolation and quarantine authorities to deter his travel. In addition, CBP and TSA lacked written procedures for internal communication regarding how to handle public health incidents and when to notify DHS senior officials about the efforts of officials in the field to respond to requests from CDC quarantine station officials. During this incident, CBP officials at the air port of entry became involved on May 22, but they did not notify DHS senior officials until May 24. In the incident involving the Mexican citizen, CBP officials at the land port of entry did not notify DHS senior officials until 14 days (April 16 to April 30) after CDC requested CBP assistance. CDC had not developed procedures to inform state and local health officials about the process for coordinating with CDC to determine whether federal isolation and quarantine authorities should be used to deter the travel of an individual with TB, causing the initial delay in the federal response. Although some information on federal isolation and quarantine authorities was available on CDC’s Web site, guidance on the process by which state and local health officials were to obtain federal assistance had not been developed. As a result, state and local health officials responding to the incident involving the U.S. citizen were uncertain how to request federal assistance and, prior to doing so, attempted but failed to contact the individual to deter him from traveling, ultimately contributing to the delay in the federal response. Eight days (May 10 to May 18) elapsed from when a state health department official discussed options for restricting the U.S. citizen’s international travel with a CDC quarantine station official, without confirming that a specific individual intended to travel, to when the state requested formal assistance from CDC. Officials from an association representing state and local health officials and CDC officials stated that many state and local health officials are not aware of federal isolation and quarantine authorities and how they are to be implemented and enforced. CDC is preparing further guidance to clarify the implementation and enforcement of these authorities. Deficiencies in CBP’s traveler inspection operations further contributed to the delay in federal efforts to locate the two individuals with TB and direct them to treatment. When responding to HHS’s request for assistance to deter the U.S. citizen from traveling, CBP issued a TECS alert to determine when the U.S. citizen planned to return to the United States. When he crossed the border at a land port of entry after having flown into Canada, the CBP officer queried the individual’s travel documents in TECS to check against law enforcement systems for outstanding warrants, or criminal or administrative violations, and to assist with determining admissibility into the United States. However, the officer ignored the electronic alert and instructions to refer the individual for further inspection, in violation of CBP procedures. Instead, the CBP officer cleared the TECS alert and allowed the individual to enter the country without the required further inspection. When responding to the incident involving the Mexican citizen, CDC and CBP officials did not know that they had received incomplete or inaccurate biographic information or both. As a result, at the time of the incidents, a TECS database search would not prompt a “match” if incomplete or inaccurate biographic information was used for a query. According to CBP officials, incomplete and inaccurate information delayed the identification of the individual by over 1 month and allowed him to travel into the United States approximately 20 times after CDC first notified CBP to look for and deter him. According to CBP officials, they realized within a day of initiating the TECS searches that the identifying information was incomplete because the searches did not produce a travel history, which typically shows an individual’s travel in and out of the United States. Also, the searches of visa databases, which could have provided more information about his identity, did not produce any information on the individual, who was said to be a frequent traveler. Once CBP officers realized that the Mexican citizen’s identifying information was incomplete, they contacted CDC the next day to confirm the identifying information and told CDC officials that they suspected that the information was incomplete. According to agency officials, 4 days after CDC first notified CBP about the Mexican citizen, CDC notified CBP that some of the biographic information from the Mexican citizen’s medical records was inaccurate. Using corrected information, CBP immediately revised the TECS alert and the local be-on- the-lookout notice; however, when a new TECS search still did not produce information, CBP contacted CDC. Although CDC had made attempts, it did not obtain accurate and complete biographic information. On May 31, about 6 weeks after CDC first contacted CBP officials, the Mexican citizen gave his border-crossing card, a type of visa, to his physician. CDC was then able to provide CBP with the complete and accurate biographic information, and DHS took possession of his card, thus preventing further crossing. With the accurate information from the Mexican citizen’s documents, DHS officials located his travel history in TECS on May 31, determined that he had crossed the southern border 21 times from April 16 through May 31, and entered an accurate alert in TECS. HHS and DHS have implemented various procedures and tools intended to address deficiencies identified by the 2007 TB incidents. However, CBP has not implemented TECS modifications that might further help officers identify individuals who have been diagnosed with TB at ports of entry. In addition, CDC has not yet to completed efforts to inform state and local health officials about the existence of the new procedures and tools or how to successfully use them in order to facilitate requesting federal assistance and ensure that new procedures and tools are used appropriately. Finally, HHS and DHS have identified additional actions that need to be taken to further strengthen the departments’ ability to respond to incidents involving individuals with TB who intend to travel. However, as of September 2008, HHS and DHS had not finalized plans for completing these actions. HHS and DHS officials—including officials from CDC, CBP, and TSA—met in June 2007 to develop new procedures and tools to determine how DHS might be able to help HHS respond to public health incidents, develop a framework for coordinating with each other during responses to public health incidents, and ensure the appropriate level of agency involvement and use of agency resources. To help promote enhanced information sharing across and within both departments, HHS and DHS developed new procedures for HHS to request assistance from DHS. These new procedures are consistent with practices identified in our past work for enhancing and sustaining agency collaboration and for establishing leadership, capabilities, and accountability for preparedness and response. They are also consistent with Standards for Internal Control in the Federal Government, which calls for management to ensure that there are adequate means of communicating internally and with external stakeholders. Under the new procedures, HHS officials at field offices, such as quarantine stations and ports of entry, are to notify headquarters officials when a TB or other public health incident develops, whereupon these officials are to make requests to DHS headquarters to task TSA and CBP officials at ports of entry with taking action to interdict individuals with TB and other infectious diseases at the borders. HHS prepares written requests for assistance that include the information DHS needs to respond, such as the individual’s name, date of birth, and action to be taken if the individual is encountered. DHS and HHS have also included safeguards designed to ensure the privacy of the individual in the request for assistance process. The request for assistance form is received only by appropriate HHS and DHS officials responsible for responding to and completing requests, and officials from both departments send the written requests via e-mail, as password-protected documents. CDC and DHS officials said that the new procedures for information sharing are also intended to allow the agencies to take advantage of existing procedures, resources, and capabilities while maintaining the close professional relationships between CDC and CBP officers at ports of entry. DHS, particularly TSA and CBP, has also worked with HHS, particularly CDC, to implement new tools intended to deter the cross-border travel of individuals with infectious TB. Specifically, TSA modified an existing tool—the No Fly list—to create a Do Not Board list for infectious air travelers who are nonadherent with treatment and intend to travel. The Do Not Board list is a roster of individuals whom CDC requests be denied boarding onto a commercial airline flight into, out of, or within the United States because they pose a potential public health threat to passengers, air carriers, or the transportation system. CDC’s criteria for placement of an individual on the Do Not Board list include public health officials’ belief that (1) the individual has an a communicable disease that would constitute a public health threat if he or she were allowed to travel by airplane; (2) the individual is unaware of, or will become nonadherent to, public health recommendations regarding treatment or other instructions; and (3) the individual intends to travel by airplane. According to CDC officials, the agency requests removal of an individual from the list when state or local health officials confirm that the individual has undergone sufficient treatment to be determined noninfectious. HHS officials said that the list is reviewed at least monthly. TSA maintains the Do Not Board list, which is separate from other watch lists for air carriers, such as the No Fly list used to prevent known terrorists from boarding airplanes, but functions in a similar manner. TSA sends the Do Not Board list to domestic and foreign air carriers on a daily basis as an addendum to the No Fly list. U.S. air carriers are to screen all passengers against the Do Not Board list (regardless of the flight’s origination or destination). International carriers are to screen passengers who are arriving in or departing from the United States but not passengers traveling outside the United States. HHS and DHS officials said they believe that the request for assistance process and the Do Not Board list could be used to address travelers with other infectious diseases, though CDC officials said the most likely use would be for travelers with infectious TB. Although the Do Not Board list was created in response to the incident involving the U.S. citizen, officials said that individuals with infectious diseases other than TB, such as measles, SARS, or a strain of influenza with pandemic potential, could be placed on the Do Not Board list if they met the criteria. Generally, CDC expects that it could use the new procedures and tools in instances where health officials have identified infectious individuals who have a substantial risk to expose others and there is a strong belief by health officials that an infected individual intends to travel. However, according to CDC officials, the use of the Do Not Board list to prevent travel by individuals with other infectious diseases would be less likely because they would become ill more quickly and feel too unwell to travel, be more visibly ill, and recover more quickly than individuals with TB. In addition, CDC officials said that the Do Not Board list requires careful review of individual cases. In the event of a large disease outbreak, CDC’s ability to look at individual cases to place them on the Do Not Board list would be limited, officials said. CBP also created and implemented a new TECS public health alert (1 week after the U.S. citizen reentered the country) to help ensure that DHS is able to assist CDC in locating individuals with infectious diseases, including TB, who are attempting to enter the United States. According to CBP officials, prior to the TB incidents, TECS public health alerts were indistinguishable from other types of alerts and information on how to manage an individual with infectious disease, including TB, was not prominently displayed in the alert. Now, when CDC requests CBP assistance for individuals who intend to travel against medical advice, if the individual’s license, passport, visa, or other identifying document or biographical information is scanned or manually entered into TECS, the new TECS public health alert is displayed prominently on the CBP officer’s computer screen, with specific instructions for the officer to isolate the individual and contact CDC immediately. As with the Do Not Board list, federal officials must know an individual has an infectious disease, including TB, to place a public health alert in TECS. Furthermore, according to CBP officials, if the identifying information provided to physicians or recorded in health records does not match the information entered in visa databases, visas and other travel documents generated from these databases will not produce a match when queried and CBP officers will not know to detain the individual, as in the case involving the Mexican citizen. Furthermore, if an individual’s information (passport or visa) is not scanned or manually entered into TECS when he or she enters the United States, officers will not discover the public health alert and will not detain the individual. CBP also took other actions to strengthen TECS computer screening mechanisms and search capabilities for public health alerts. These changes were intended to ensure that CBP officers at ports of entry adhere to agency protocols and instructions for all TECS alerts, either public health or otherwise. At the time of the incident involving the U.S. citizen, the CBP officer who admitted the individual into the country was able to bypass the requirement to refer individuals for further inspection because there was no supervisory review. According to CBP officials, to prevent this, CBP upgraded TECS computer programming so that all TECS public health alert matches are automatically sent to terminals where referrals receive supervisory review intended to ensure that individuals receive the required additional inspection and referral to CDC. With this change, officers are no longer able to override the public health alert in TECS without first diverting the individual for further screening. The public health alert can only be overridden in TECS once the individual has cleared the more detailed inspection (called secondary inspection). In addition, CBP enhanced computer search capabilities for TECS public health alerts. According to CBP officials, in the incident involving the Mexican citizen, the officer who entered the TECS alert did not use varying combinations of the biographic information during his search because he believed that the information CDC provided was accurate. According to CBP officials, as of May 2008, when a public health alert is entered into TECS, the system is now programmed to create multiple public health alerts on variations of specific types of the biographic information entered. However, CBP officials told us that the TECS programming changes do not create variations on other combinations of an individual’s available biographic information. A CBP official told us that CBP could further modify TECS to create public health alerts using different combinations of other available biographic information, but CBP had not explored the feasibility of making this change and had not examined whether the benefits of conducting these additional searches on other types of biographic information offset the cost of a possible increase in the time needed to process individuals through busy ports of entry. According to CBP, a slight increase in the time needed to conduct inspections, especially at land ports of entry, can result in substantial traveler delays and traffic congestion. Nonetheless, without exploring whether the costs of conducting searches on these other combinations of biographic information exceed the benefits, DHS may be missing an opportunity to enhance its ability to detect persons with known cases of infectious disease and deter them from entering the United States. These changes to TECS notwithstanding, CBP’s ability to identify individuals who are the subject of public health alerts—and ultimately deter their cross-border travel—largely depends on CBP officers’ compliance with prescribed inspection procedures. In November 2007, we reported on weaknesses in inspection procedures at U.S. ports of entry. We said that CBP had taken action to address weaknesses in 2006 inspection procedures, such as not verifying the citizenship and admissibility of each traveler, that contributed to failed inspections. However, our follow-up work conducted months after CBP’s actions showed that weaknesses still existed. In July 2007, CBP issued detailed procedures for conducting inspections, including requiring field office managers to assess compliance with these procedures. However, CBP had not established an internal control to ensure that field office managers share their assessments with CBP headquarters to help ensure that the new procedures are consistently implemented across all ports of entry and reduce the risk of failed traveler inspections. We recommended that CBP implement internal controls to help ensure that field office directors communicate to agency management the results of their monitoring and assessment efforts so that agencywide results can be analyzed and necessary actions taken to ensure that new traveler inspection procedures are carried out in a consistent way across all ports of entry. CBP agreed with our recommendation and stated that it has begun to take action to address it. A CBP official told us that CBP intends to finalize the results of field office assessments in October 2008. Figure 4 shows the flow of requests for assistance from HHS to DHS, together with the steps each agency takes to prepare, submit, and complete these requests. Step-by-step procedures for each agency are explained in table 1. The departments and their component agencies were able to test how the new procedures worked in practice because information provided by HHS for the period May 2007 to February 2008 showed that HHS coordinated with DHS to request assistance for 72 actions to place individuals on, or remove them from, the Do Not Board list, or to place or remove public health alerts in TECS. Of these 72 requests, 21 were to add an individual to the Do Not Board list. Table 2 shows the number of requests for assistance CDC prepared for HHS to submit to DHS by type of request in this period. All requests were for individuals with TB disease who fit the criteria jointly established by CDC and DHS. In reviewing these requests for assistance, we found that actions were typically completed within 24 hours of the time CDC initiated the request. According to DHS officials, all requests were considered high priority and were addressed. We also determined that CDC’s requested assistance complied with its criteria and included CDC contact information and detailed instructions, such as how CBP officers should protect themselves and others if they encounter the individual. Although CDC has made some efforts to educate health officials, according to CDC officials the agency has not yet completed all actions to provide information to health officials who work with individuals with TB about the new procedures and tools, or about the criteria for adding individuals to or removing them from the Do Not Board list or TECS. For example, CDC has presented information on the Do Not Board list at various conferences and association meetings, such as the June 2008 meeting of the state epidemiologists association and the November 2007 meeting of its advisory council for TB elimination. Additionally, CDC has used the Morbidity and Mortality Weekly Report—a publication CDC makes available on its Web site at no charge—to provide state and local officials with information about the criteria for placement on or removal from the Do Not Board list or TECS. The article describing the criteria was published in a September 2008 issue. However, other CDC actions to inform state and local officials have yet to be completed. CDC plans to publish a companion product to the Morbidity and Mortality Weekly Report article, which would consist of a letter notifying officials of the publication and a guidance document describing the new tools and procedures that would be sent via e-mail to state and local health officials. According to CDC officials, the companion product will also be posted on CDC’s Web site, and CDC will host Web-based seminars for state and local TB programs. According to health officials, HHS requests for DHS assistance to deter individuals with TB from traveling originate primarily with state and local health officials, such as TB controllers, state and local health department staff, and public and private physicians, who typically have primary contact with individuals with TB and are more likely to be aware that an individual might be planning to travel. Knowledge of the new procedures and tools among these officials could prevent delays in accessing federal assistance, as occurred with the U.S. citizen. According to CDC officials, some health officials should already be familiar with the new procedures because a number of them helped CDC develop the criteria to determine whether an individual with TB should be removed from the Do Not Board list or TECS. Furthermore, CDC officials said they believe that state and local health department officials should be aware of the changes because of CDC’s close relationships with their professional associations. These associations have a role in promoting national policy and serving as liaisons between local, state, and territorial and federal health departments. However, an official with one such association said that staff independently discovered the new procedures and tools, while staff from another association told us that they were not aware of them. Additionally, information about the new procedures and tools may be especially important for those states with lower relative numbers of TB cases, which may have less experience in accessing federal assistance. Moreover, providing information about the criteria for new procedures and tools can help ensure that state and local health officials can use them appropriately. For example, in one case, an individual with TB who had been added to the Do Not Board list presented a letter from county health officials to airline staff stating that he no longer posed a health risk to other travelers. Because county health officials did not follow the correct procedure to notify CDC and request the individual’s removal from the Do Not Board list, he was not allowed to board his flight. As of September 2008, the two departments had not finalized plans for completing additional actions they identified that are intended to further strengthen their ability to respond to incidents involving individuals with TB who intend to travel. HHS and DHS officials told us that this was because their proposals for the additional work were undergoing internal department review, required implementation over time, or required further coordination with other departments and their component agencies. It is unclear how much additional work is needed because the departments did not have detailed plans and time frames for completing these actions. Without these plans and time frames, HHS and DHS will not have fulfilled the actions they identified as necessary to strengthen their ability to respond to and prevent the cross-border travel of individuals with infectious TB. HHS and DHS officials said that they planned to meet in the fall of 2008 to further address the additional actions that need to be taken. Examples of some incomplete actions that require cross-agency coordination include the following: HHS, in conjunction with CDC and DHS, plans to develop a training module for its personnel to increase awareness of existing agency capabilities, available resources, procedures for requesting assistance, and communication protocols, according to the department’s after-action report on the U.S. citizen incident. HHS officials said that while the agency may have specific procedures in place, they may be applied inconsistently if officials in field offices are unaware of them. However, these officials did not specify how they would coordinate with CDC and DHS to finalize plans to develop or conduct the training. CDC recommended that DGMQ, which operates the quarantine stations at ports of entry, provide training and materials on infection control for communicable diseases to CBP officers stationed at the ports of entry. Specifically, DGMQ planned to give CBP officers small cards with information on the use of personal protective equipment and procedures for isolating individuals with suspected or confirmed infectious diseases at ports of entry, to accompany officers’ personnel badges. However, according to DGMQ officials, CDC’s progress on this recommendation was delayed because of several factors, including the need to negotiate with the CBP officers’ union, which DGMQ did not foresee. DGMQ officials told us that they had coordinated with the CBP officers’ union, but they did not have a specific date for when they planned to issue the cards, which are still under agency review. CDC is collaborating with the Department of State and other agencies, that are developing policies and procedures for using federal resources to assist in transporting citizens and legal residents involved in a public health incident abroad back to the United States. In the incident involving the U.S. citizen, CDC did not use its plane to fly the individual from Europe to the United States because the agency did not want to expose the crew and any other passengers to TB. According to CDC, while the agency worked to develop alternate suggestions for travel or medical care for the U.S. citizen overseas, he once again traveled against medical advice. CDC officials we spoke with said that the agency was in the process of equipping the CDC plane with appropriate medical equipment to transport individuals with infectious respiratory diseases. However, officials said that activities related to the transport of U.S. citizens back into the country require continued coordination with the Department of State, which has primary responsibility for assisting U.S. citizens abroad, and the Department of Defense, which has appropriate medical equipment available. According to DHS officials, HHS and DHS need to further examine issues related to ensuring that the distribution of personal and medical information of individuals with communicable diseases who pose potential public health threats is limited to protect privacy, while at the same time conducting the necessary public health and law enforcement activities to deter their travel and direct them to treatment. Officials from both departments told us that they are concerned that a perceived lack of procedures for safeguarding personal information could provide a disincentive for an individual both to disclose his or her illness and to seek treatment. DHS has recommended convening subject-matter experts in patients’ rights and the rights of the public to be protected from potential exposure to infectious diseases to determine appropriate procedures for law enforcement officers who assist HHS in locating nonadherent individuals. DHS officials said that the chief privacy officers for HHS and DHS have begun to work together to address this issue. According to CDC officials, both departments have activities under way to assess the effectiveness of the new procedures and tools. Specifically, they plan to conduct performance monitoring of the new request for assistance procedures and tools, discuss how information sharing and coordination could be further improved, and develop an annual report based on after- action reports that analyzes trends and identifies potential improvements in agency response. In addition, both departments are evaluating the new procedures and tools based on TB incidents as they arise. According to CDC officials, the agency is conducting some performance monitoring of the new procedures and tools, such as tracking the number of individuals who are being placed on and removed from the Do Not Board list and the time lapse between when HHS submits a request for assistance to DHS and when DHS completes the request. CDC officials review this information during monthly staff meetings to identify areas for improvement. In addition, CDC officials said that the request for assistance procedures would be included as part of a measure that will be monitored by its Division of Emergency Operations. This division regularly monitors about 60 protocols for operations at any one time to find ways to improve the performance of the protocols. CDC officials also stated that they plan to implement CDC’s secure data network to transmit written requests for assistance between the departments, as opposed to the current method of e-mailing requests as password-protected documents, to improve security and decrease processing time. According to HHS and DHS officials, they communicate on a monthly and weekly basis to discuss changes made to procedures and tools as a result of the 2007 TB incidents and their continued applicability to responding to TB cases, as well as issues related to information sharing for responding to such cases. For example, these officials reported that in addition to the initial June 2007 meeting, they hold in-person monthly meetings to help officials refine the new procedures and tools as necessary to better address potential limitations in future incident response. For example, during these meetings, officials discuss what information DHS needs to complete an HHS request for assistance to ensure that the appropriate action is taken. Officials said that they also use these meetings as an opportunity to discuss the differences in the approaches CDC, TSA, and CBP officials have toward public health incidents, such as the agencies’ practices for sharing identifying information. Officials from HHS, CDC, and DHS’s OHA also reported that they communicate by phone and e-mail several times a week to discuss the status of current requests for assistance and other public health issues that may require DHS assistance. According to CDC and DHS officials, this informal and frequent contact encourages information sharing across the departments and their component agencies, allowing them to better understand and effectively address issues. CDC officials said that they plan to develop an annual compilation report analyzing all after-action reports, including those for TB, that were completed in the previous year. Analysis of these reports, which is to generally include summaries of the events and observations for improvement, allow CDC officials to identify trends, review progress over time, and determine recommendations for broad agency improvement for future public health response. CDC plans to issue the first annual compilation report for those after-action reports completed in 2008, but has not set a target date for issuance. As of September 2008, CDC officials told us that the first compilation report would not include the incident involving the U.S. citizen, and would only include those incidents occurring after August 2008. According to HHS and DHS officials, they are using the departments’ responses to subsequent TB cases as opportunities to revise the new procedures and tools and develop skills to help enhance their response to future TB incidents. Internal control standards for the federal government call for agencies to assess the quality of performance over time so that deficiencies can be identified and addressed. CDC and DHS officials said that they view each use of the request for assistance procedures and tools as a “natural exercise” that provides an opportunity to identify areas for improvement and refine the procedures and tools as necessary. For example, according to DHS officials, CDC officials responded to DHS feedback by increasing the level of detail about the medical condition of the individual included on requests submitted to DHS while simultaneously increasing the privacy protections of the identifying information provided on the forms. Also, after subsequent incidents, CDC officials determined that it was necessary to specify which agency officials should participate in the conference calls that include CDC, state, and local officials to determine whether an individual with an infectious disease, such as TB, who intended to travel justified a need to request assistance from DHS. According to HHS officials, the agency’s coordination with DHS for more than 70 requests for assistance since the 2007 TB incidents also has helped agency officials become familiar with their roles in the information-sharing process that is outlined in the new procedures. The new procedures and tools that HHS and DHS established in the wake of the spring 2007 incidents involving the two individuals with drug- resistant TB have improved federal interagency information sharing and coordination for responding to TB incidents and could lay the foundation for continuing improvement in responding to future TB incidents. In addition, as a result of the collaboration between HHS and DHS in making these changes, each department now has a clearer view of how the other’s mission and approach to public health incidents differs from its own, which could further enhance their ability to collaborate in responding not only to similar TB incidents but also to other future public health threats. Despite DHS’s progress in enhancing TECS so that CBP officials can better identify individuals via electronic public health alerts, this enhancement is applicable only for some types of biographic information, but not others. Not exploring the costs and benefits of further modifying TECS to create public health alerts based on variations of additional types of biographic information may result in missed opportunities to locate persons subject to public health alerts and deter them from entering the United States. Additionally, HHS and DHS have more opportunities to improve their information-sharing efforts in responding to future TB incidents. For example, unless state and local health officials are informed and educated about the new tools and procedures, delays in accessing federal assistance, like those encountered during the two TB incidents, could persist. Specifically, without wide dissemination of the procedures for placing individuals with TB on, or removing them from, the Do Not Board list, or for placing or removing a public health alert in TECS, state and local health officials may not be aware of the federal assistance at their disposal for use in locating individuals with TB who are nonadherent with treatment and may intend to travel against medical advice. Additionally, state and local health officials who have limited knowledge of these changes and no previous experience in working with federal officials at the field office level may encounter difficulties in using the new procedures and tools. Furthermore, HHS and DHS have identified additional actions that they need to take to further strengthen their ability to respond to incidents involving individuals with TB who intend to travel, including some actions that require cross-agency coordination for completion. However, the departments have not developed an action plan for ensuring that these multiagency efforts are accomplished. Absent a clear plan with associated time frames for completing cross-agency actions, the departments may not be accountable for taking the corrective actions and ensuring that all identified deficiencies are mitigated. To ensure continuing improvements in HHS’s and DHS’s new procedures and tools developed in response to the 2007 TB incidents and to improve awareness of these changes, we are making the following three recommendations. We recommend that the Secretary of DHS direct CBP to determine whether the benefits exceed the costs of enhancing TECS capabilities when creating public health alerts to include variations on other types of biographic information that could further enhance its ability to locate individuals who are subject to public health alerts and, if so, to implement this enhancement. We also recommend that the Secretary of HHS and the Secretary of DHS work together to continue to inform and educate state and local health officials about the new procedures and tools and develop plans with time frames for completing additional actions that require cross-agency coordination to respond to future TB incidents. We requested comments on a draft of this report from HHS and DHS. Both departments provided written comments in letters dated September 24, 2008, and September 30, 2008, respectively, which are summarized below and reprinted in appendixes II and III. HHS and DHS generally agreed with our recommendations. With regard to our first recommendation on enhancing TECS capabilities to include variations on other types of biographic information, DHS said that CBP has completed a cost-benefit analysis and determined that this enhancement would increase to an unmanageable level the number of possible alerts requiring further research by CBP officers and increase delays at ports of entry. However, in response to our recommendation, CBP is drafting a policy and new procedures that when implemented will require that officers (1) review an individual’s biographic information when entering public health alerts to determine whether variations on this information could produce an accurate public health alert and, if so, (2) create a new public health alert based on the variation of this biographic information. CBP believes that this approach will enhance capabilities without causing delays, although we believe that it will be important to monitor implementation to ensure that the approach provides the intended results. With regard to our second recommendation, HHS and DHS stated that they were working together on efforts that, once completed, will help to ensure that state and local health officials are better informed about the new procedures and tools. Finally, HHS and DHS stated that they were working to address our third recommendation to develop plans with time frames for completing the remaining actions that require cross-agency coordination, but did not address whether they were developing plans with time frames for completing the other remaining additional actions. We believe that absent these plans, there is no guarantee the departments will complete these actions that are important for ensuring full cross- agency coordination in response to future TB and other public health incidents. In commenting on a draft of this report, HHS stated that it disagreed with our assessment of “the lack of agency coordination.” However, we found that following the incidents HHS and DHS had identified coordination deficiencies in their responses, which they deemed serious enough to require the development of new procedures and tools. DHS also raised two issues regarding our findings related to CBP. First, DHS noted that CBP field locations often receive and handle requests from CDC regarding individuals with communicable diseases and that CBP officials at the time handled the incident involving the Mexican citizen at the local level according to existing protocols. Second, CBP wished to clarify that although procedures have been “fine-tuned” since the incident occurred, CBP believes that the procedures in place at the time of the incidents were comprehensive. We maintain that the fact that CBP created new standard operating procedures for communicating with HHS and for restricting international travel of persons with such public health concerns is evidence that the protocols and procedures in place at the time were not comprehensive or effective. HHS and DHS also provided technical comments. We have amended our report to incorporate these clarifications where appropriate. As agreed with your offices, unless you publicly release its contents earlier, we plan no further distribution of this report until 30 days after its issuance date. At that time, we will send copies to the Secretary of Health and Human Services and the Secretary of Homeland Security. Additional copies will be sent to other interested congressional committees. In addition, the report will be available at no charge on the GAO Web site at http://www.gao.gov. If you or your staff members have any questions about this report, please contact Cynthia A. Bascetta at (202) 512-7114 or bascettac@gao.gov, or Eileen R. Larence at (202) 512-6510 or larencee@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made contributions to this report are listed in appendix IV. U.S. Customs and Border Protection (CBP), a component agency of the Department of Homeland Security (DHS), is the agency in charge of inspecting individuals seeking to enter the United States at air, land, and sea ports of entry. Each day, over 1 million individuals, both non-U.S. citizens and U.S. citizens, seek entry into the United States. In addition to determining whether these individuals are eligible to enter the country, CBP officers perform a wide range of law enforcement duties, such as screening cargo for weapons or illegal goods, preventing narcotics and agricultural pests from entering the country, and identifying and arresting persons with criminal warrants. Nearly 75 percent of all border crossings are at land ports of entry, and nearly 95 percent are at air or land ports. (See fig. 5.) According to CBP officials, the inspection of individuals arriving at air and land ports of entry is described as a layered process designed to ensure management, control, and security of U.S. borders while facilitating the flow of millions of legitimate individuals and goods into the United States. Officers are trained in customs and immigration law, law enforcement techniques, and agricultural requirements and must be able to carefully observe individuals, while using available tools, equipment, and support, in order to make sound decisions on whether to admit, detain, or deny entry to a traveler. CBP policies and procedures for inspecting individuals at all ports of entry require officers to determine the nationality of individuals and their admissibility, that is, whether they are eligible to enter the country. Because most individuals attempting to enter the country through ports of entry have a legal basis for doing so, a streamlined screening procedure referred to as primary inspection is used to process those individuals who can readily be identified as admissible. Persons whose admissibility cannot be readily determined may be subjected to a more detailed review called secondary inspection. This involves a closer inspection of travel documents and possessions, additional questioning by CBP officers, and cross-references through multiple law enforcement databases, including the Treasury Enforcement Communications System (TECS), to verify the traveler’s identity, background, and purpose for entering the country, and to detect any violations or risks to the public. In secondary inspection, an officer makes the final determination to admit the traveler, deny admission, or take other actions (such as releasing the traveler to another law enforcement entity for prosecution) based upon the results of the inspection. When possible, CBP officers also rely on canine and antiterrorism task force teams to conduct discretionary inspections of travelers throughout the inspection process. Although the procedures for inspecting individuals are generally the same at air and land ports of entry, there are differences that are due to variations in the ports’ operational environments. The procedures for inspecting individuals at air ports of entry differ from those at land ports of entry because commercial airlines are required to electronically transmit passenger manifest information to CBP through the Advanced Passenger Information System prior to the departure of international flights either from the United States or from other countries that are bound for the United States. This advance manifest information allows CBP time to conduct prescreening by querying a variety of law enforcement databases, including TECS and other types of alerts, to detect lookout records and warnings for various violations before individuals enter the country. Upon arrival in the United States at an air port of entry, however, individuals undergo the same general process in primary and secondary inspection as they do at land ports of entry. During primary inspection, individuals arriving by air must present documentation of citizenship and admissibility, such as a U.S. passport, permanent resident card, or foreign passport containing a visa issued by the Department of State. CBP officers must take physical possession of identification and match the photo with the individual, request declaration of residence, obtain an oral declaration concerning length of stay, ascertain purpose or intent of travel, and obtain a binding written customs declaration. However, unlike procedures at land ports of entry, CBP officers perform TECS queries during primary inspection on all individuals to identify potential matches to lookouts and warnings that were detected through the prescreening process. When an officer determines through primary inspection that additional questioning or inspection is required, individuals are referred to secondary inspection along with individuals who are matched to a TECS alert or warning as detected through the prescreening process. CBP officers face a greater challenge to identify and screen individuals at land ports of entry, in part because of the lack of advance traveler information and the high volume of travelers who can arrive by vehicle or on foot at virtually any time. Given these challenges, CBP officers rely heavily on observation and interview skills to be able to quickly detect suspicious activity or potential violations that may render a person inadmissible. During primary inspection, CBP officers are directed to conduct inspections on all travelers. As part of that inspection process, CBP officers are to perform TECS queries on as many travelers as feasible. All vehicles are queried in TECS using license plate readers installed in primary inspection vehicle lanes. For pedestrian lanes, the traveler’s name can be machine read from the travel document or manually keyed into TECS by the CBP officer. For vehicles, CBP officers frequently inspect multiple travelers entering in a single vehicle, and TECS queries are generally conducted on the individuals and the vehicle data. In addition, CBP officers visually examine the vehicle and inspect car passengers, verify license plate information, and monitor for the presence of radioactive material, among other tasks. For vehicles, CBP officers frequently inspect multiple travelers entering in a single vehicle, and the TECS queries are generally conducted on the individuals and on the vehicle. If necessary, CBP officers are to refer the travelers and their vehicle for secondary inspection. In addition to screening millions of travelers during primary and secondary inspection, CBP officers are responsible for observing all travelers for obvious signs and symptoms of quarantinable and communicable diseases, such as (1) fever, which could be detected by a flushed complexion, shivering, or profuse sweating; (2) jaundice (unusual yellowing of skin and eyes); (3) respiratory problems, such as severe cough or difficulty breathing; (4) bleeding from the eyes, nose, gums, or ears or from wounds; and (5) unexplained weakness or paralysis. However, CBP officials emphasized that CBP officers are not medically trained or qualified to physically examine or diagnose illness among arriving travelers. There are three general scenarios in which CBP officers encounter ill persons who are in need of medical attention or who may pose a public health threat: In the most common scenario, CBP officers encounter an individual who discloses that he/she needs medical attention for various health reasons. CBP officers suspect an individual may need medical attention or may pose a public health risk to others (e.g., individual exhibits obvious signs and symptoms of illness, such as fever, weakness, or both, as observed by officers). CBP officers encounter an individual who is an exact match to a public health alert in TECS and may pose a public health risk to others. In all three scenarios, CBP protocols require officials, at a minimum, to isolate the person while notifying officials at CDC and, depending on the circumstance, to contact the designated local public health authorities (e.g., hospitals and emergency medical personnel). Each port of entry is supplied with personal protective equipment, including masks and gloves, and inspecting officers must use this equipment in dealing with travelers suspected of having communicable or quarantinable illnesses, as well as while handling the individuals’ documents and belongings. CBP officers are responsible for coordinating with CDC to provide assistance in identifying arriving individuals from areas with known communicable disease outbreaks. In addition to the contacts named above, Karen Doran, Assistant Director; John Mortin, Assistant Director; George Bogart; Frances Cook; Katherine Davis; Shana Deitch; Jennifer DeYoung; Raymond Griffith; Catherine Kim; Maren McAvoy; Carolina Morgan; Roseanne Price; Janay Sam; Jessica Smith; and Ellen Wolfe made significant contributions to this report. Border Security: Despite Progress, Weaknesses in Traveler Inspections Exist at Our Nation’s Ports of Entry. GAO-08-329T. Washington, D.C.: January 3, 2008. Global Health: U.S. Agencies Support Programs to Build Overseas Capacity for Infectious Disease Surveillance. GAO-07-1186. Washington, D.C.: September 28, 2007. Border Security: Security Vulnerabilities at Unmanned and Unmonitored U.S. Border Locations. GAO-07-884T. Washington, D.C.: September 27, 2007. Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer Federal Leadership Roles and an Effective National Strategy. GAO-07-781. Washington, D.C.: August 14, 2007. Global Health: Global Fund to Fight AIDS, TB and Malaria Has Improved Its Documentation of Funding Decisions but Needs Standardized Oversight Expectations and Assessments. GAO-07-627. Washington, D.C.: May 7, 2007. Border Security: Continued Weaknesses in Screening Entrants into the United States. GAO-06-976T. Washington, D.C.: August 2, 2006. Emergency Preparedness: Some Issues and Challenges Associated with Major Emergency Incidents. GAO-06-467T. Washington, D.C.: February 23, 2006. Results-Oriented Government: Practices That Can Help Enhance and Sustain Collaboration among Federal Agencies. GAO-06-15. Washington, D.C.: October 21, 2005. Emerging Infectious Diseases: Review of State and Federal Disease Surveillance Efforts. GAO-04-877. Washington, D.C.: September 30, 2004. Global Health: Challenges in Improving Infectious Disease Surveillance Systems. GAO-01-722. Washington, D.C.: August 31, 2001. Public Health: Trends in Tuberculosis in the United States. GAO-01-82. Washington, D.C.: October 31, 2000. Managing for Results: Barriers to Interagency Coordination. GAO/GGD-00-106. Washington, D.C.: March 29, 2000. Standards for Internal Control in the Federal Government. GAO/AIMD-00-21.3.1. Washington, D.C.: November 1999.

Summary: In spring 2007, the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS), and state and local health officials worked together to interdict two individuals with drug-resistant infectious tuberculosis (TB) from crossing U.S. borders and direct them to treatment. Concerns arose that HHS's and DHS's responses to the incidents were delayed and ineffective. GAO was asked to examine (1) the factors that affected HHS's and DHS's responses to the incidents, (2) the extent to which HHS and DHS made changes to response procedures as a result of the incidents, and (3) HHS's and DHS's efforts to assess the effectiveness of changes made as a result of the incidents. GAO reviewed agency documents and interviewed officials about the procedures in place at the time of the incidents and changes made since. Various factors--a lack of comprehensive procedures for information sharing and coordination and border inspection shortfalls--hindered the federal response to the two TB incidents. GAO's past work and federal internal control standards call for collaborative communication and coordination across agencies; communication flowing down, across, and up agencies to help managers carry out their internal control responsibilities; and effective leadership, capabilities, and accountability to ensure effective preparedness and response to hazardous situations. HHS and DHS finalized a memorandum of understanding in October 2005 intended to promote communication and coordination in response to public health incidents, but they had not fully developed operational procedures to share information and coordinate their efforts. Thus, HHS and DHS lost time locating or identifying the individuals to interdict them at the U.S. border. Also, HHS lacked procedures to coordinate with state and local health officials to determine when to use federal isolation and quarantine authorities, which further contributed to the delay in the federal response to one of the incidents. Finally, DHS had deficiencies in its process for inspecting individuals at the border, which caused delays in locating the individuals with TB. HHS and DHS have subsequently implemented procedures and tools intended to address deficiencies identified by the incidents, consistent with GAO's past work and internal control standards, but the departments could take additional steps to enhance their ability to respond to future TB incidents. Since the 2007 incidents, HHS and DHS have developed formal procedures for HHS to request DHS's assistance, and DHS has (1) developed a watch list for airlines to identify individuals with TB and other infectious diseases who are to be stopped from traveling and (2) revised its border inspection process to include a requirement that individuals with TB identified by HHS be subject to further inspection. DHS has also enhanced its process for creating public health alerts based on some variations of biographic information (e.g., name, date of birth, or travel document information), but has not explored the benefits of creating these alerts based on other variations, which impeded DHS's ability to interdict one of the individuals at the border. In addition, HHS has not yet completed efforts to provide information on changes in procedures to state and local health officials, who typically originate requests for assistance, to help mitigate delays in accessing federal assistance. HHS and DHS identified additional actions that need to be taken to further strengthen their response, but have not developed plans for completing them. HHS and DHS have activities under way to assess the effectiveness of the new procedures and tools, including performance monitoring and cross-agency meetings to discuss and revise the new procedures and tools based on actual experiences. HHS and DHS have coordinated on more than 70 requests for assistance since the 2007 incidents through February 2008; officials said they view each incident as a test of the efficacy of their responses.