Infectious diseases include naturally occurring outbreaks, such as SARS, as well as diseases from biological agents that are intentionally released by a terrorist, such as smallpox. An infectious disease outbreak, either naturally occurring or from an intentional release, may not be recognized for a week or more because symptoms may not appear for several days after the initial exposure, during which time a communicable disease could be spread to those who were not initially exposed. The initial response to an infectious disease of any type, including a bioterrorist attack, is generally a local responsibility that could involve multiple jurisdictions in a region, with states providing additional support when needed. Figure 1 presents the probable series of responses to a covert release of a biological agent. Just as in a naturally occurring outbreak, exposed individuals would seek out local health care providers, such as private physicians or medical staff in hospital emergency departments or public clinics. Health care providers would report any illness patterns or diagnostic clues that might indicate an unusual infectious disease outbreak associated with the intentional release of a biologic agent to their state or local health departments. In order to be adequately prepared for emerging infectious diseases in the United States, state and local public health agencies need to have several basic capabilities, whether they possess them directly or have access to them through regional agreements. Public health departments need to have disease surveillance systems and epidemiologists to detect clusters of suspicious symptoms or diseases in order to facilitate early detection of disease and treatment of victims. Laboratories need to have adequate capacity and necessary staff to test clinical and environmental samples in order to identify an agent promptly so that proper treatment can be started and infectious diseases prevented from spreading. All organizations involved in the response must be able to communicate easily with one another as events unfold and critical information is acquired, especially in a large-scale infectious disease outbreak. In the event of an 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. 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 a disease, as it did 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. The funding supported development and improvements in a number of areas CDC considers critical to preparedness and response, including surveillance capacity to rapidly detect outbreaks of illness that may be the result of bioterrorism or other public health threats. 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. Earlier this month, HHS announced that approximately $870 million and $498 million have been provided for fiscal year 2003 through the CDC and HRSA programs, respectively, to states and municipalities to continue these efforts. In the cities we visited, state and local officials reported varying levels of public health preparedness to respond to outbreaks of emerging infectious diseases such as SARS. They recognized gaps in preparedness elements that have been difficult to address, including the disease surveillance and laboratory systems and the response capacity of the workforce. They also were beginning to address gaps in preparedness elements such as communication. We found that planning for regional coordination was lacking between states. States and local areas had weaknesses in some public health preparedness elements, including the disease surveillance and laboratory systems and the response capacity of the workforce. Gaps in capacity often are not amenable to solution in the short term because either they require additional resources or the solution takes time to implement. States and local areas were addressing gaps in communication. State and local officials for the cities we visited in early 2002 recognized and were attempting to address inadequacies in their surveillance systems. 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. For our ongoing work, state and local officials told us that their surveillance systems had improved somewhat. The officials reported that CDC funds have enabled them make some of these improvements in their surveillance systems, including the development of Web-based disease reporting and active surveillance systems. Officials from all of the states we visited in early 2002 reported problems with their public health laboratory systems and said that they needed to be upgraded. All states were planning to purchase the equipment necessary for rapidly identifying a biological agent. State and local officials in most of the areas that we visited told us that the public health laboratory systems in their states were stressed, in some cases severely, by the sudden and significant increases in workload during the anthrax incidents in the fall of 2001. During these incidents, the demand for laboratory testing was significant even in states where no anthrax was found and affected the ability of the laboratories to perform their routine public health functions. Following the incidents, over 70,000 suspected anthrax samples were tested in laboratories across the country. According to preliminary data from our interviews and review of 2003 progress reports, officials reported that CDC funds enabled them to make improvements to their laboratory infrastructure, including upgrading their laboratory facilities, purchasing reagents and equipment, and improving their capability to test for select biologic agents. Officials in the states we visited in 2002 were working on other solutions to their laboratory problems. States were examining various ways to manage peak loads, including entering into agreements with other states to provide surge capacity, incorporating clinical laboratories into cooperative laboratory systems, and purchasing new equipment. One state was working to alleviate its laboratory problems by upgrading two local public health laboratories to enable them to process samples of more dangerous pathogens and by establishing agreements with other states to provide backup capacity. Another state reported that it was using the funding from CDC to increase the number of pathogens the state laboratory could diagnose. The state also reported that it has worked to identify laboratories in adjacent states that are capable of being reached within 3 hours over surface roads. In addition, all of the states reported that their laboratory response plans had been revised to cover reporting and sharing laboratory results with local public health and law enforcement agencies. At the time of our early 2002 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. Officials at one state department of public health we visited said that the department 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. Workforce capacity issues may also hinder implementation of infectious disease control measures. For example, the shortage of epidemiologists could grow worse if, in the event of a severe outbreak, existing health care workers became infected as a result of their more frequent exposure to a contaminated environment or became exhausted working longer hours. Workforce shortages could be further exacerbated because of the need to conduct contact tracing. According to World Health Organization officials, an individual infected with SARS came in contact with, on average, 30 to 40 people in Asian countries—all of whom had to be contacted and informed of their possible exposure. During our site visits in early 2002, shortages in laboratory personnel were also cited. Officials in one city noted that they had difficulty filling and maintaining laboratory positions and that 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. For our current work updating these findings, many of the state and local officials we interviewed cited shortages in trained epidemiologists or laboratory personnel as persistent. In 2002, state and local officials told us that sustained funding would be necessary to address one important need—hiring and retaining needed staff. They told us they would be reluctant to hire additional staff unless they were confident that the funding would be sustained and staff could be retained.