    Severe Acute Respiratory Syndrome: Established Infectious Disease
    Control Measures Helped Contain Spread, But a Large-Scale
    Resurgence May Pose Challenges (30-JUL-03, GAO-03-1058T).

    SARS is a highly contagious respiratory disease that infected
    more than 8,000 individuals in 29 countries principally
    throughout Asia, Europe, and North America and led to more than
    800 deaths as of July 11, 2003. Due to the speed and volume of
    international travel and trade, emerging infectious diseases such
    as SARS are difficult to contain within geographic borders,
    placing numerous countries and regions at risk with a single
    outbreak. While SARS did not infect large numbers of individuals
    in the United States, the possibility that it may reemerge raises
    concerns about the ability of public health officials and health
    care workers to prevent the spread of the disease in the United
    States. GAO was asked to assist the Subcommittee in identifying
    ways in which the United States can prepare for the possibility
    of another SARS outbreak. Specifically, GAO was asked to
    determine 1) infectious disease control measures practiced within
    health care and community settings that helped contain the spread
    of SARS and 2) the initiatives and challenges in preparing for a
    possible SARS resurgence.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-03-1058T
        ACCNO:   A07806
      TITLE:     Severe Acute Respiratory Syndrome: Established Infectious
    Disease Control Measures Helped Contain Spread, But a Large-Scale
    Resurgence May Pose Challenges
         DATE:   07/30/2003
      SUBJECT:   Disease detection or diagnosis
    	     Health care services
    	     Infectious diseases
    	     International travel
    	     National preparedness
    	     Respiratory diseases
    	     Strategic planning
    	     Emergency preparedness
    	     Emergency medical services
    	     Severe Acute Respiratory Syndrome

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    GAO-03-1058T

    Testimony Before the Permanent Subcommittee on Investigations, Committee
    on Governmental Affairs, U. S. Senate

    United States General Accounting Office

    GAO For Release on Delivery Expected at 9: 00 a. m. Wednesday, July 30,
    2003 SEVERE ACUTE

    RESPIRATORY SYNDROME

    Established Infectious Disease Control Measures Helped Contain Spread, But
    a Large- Scale Resurgence May Pose Challenges

    Statement of Marjorie E. Kanof Director, Health Care* Clinical

    and Military Health Care Issues

    GAO- 03- 1058T

    Infectious disease experts emphasized that no new infectious disease
    control measures were introduced to contain SARS in the United States.
    Instead, strict compliance with and additional vigilance to enforce the
    use of current measures was sufficient. These measures* case
    identification and contact tracing, transmission control, and exposure
    management* are wellestablished infectious disease control measures that
    proved effective in both health care and community settings. The
    combinations of measures that were used depended on either the prevalence
    of the disease in the community or the number of SARS patients served in a
    health care facility. For SARS, case identification within health care
    settings included screening individuals for fever, cough, and recent
    travel to a country with active cases

    of SARS. Contact tracing, the identification and tracking of individuals
    who had close contact with someone who was infected or suspected of being
    infected, was important for the identification and tracking of individuals
    at risk for SARS. Transmission control measures for SARS included contact
    precautions, especially hand washing after contact with someone who was
    ill, and protection against respiratory spread, including spread by large
    droplets and by smaller airborne particles. The use of isolation rooms
    with controlled airflow and the use of respiratory masks by health care
    workers were key elements of this approach. Exposure management practices*
    isolation and quarantine* occurred in both health care and home settings.
    Effective communication among health care professionals and the general
    public reinforced the need to adhere to infectious disease control
    measures.

    While no one knows whether there will be a resurgence of SARS, federal,
    state, and local health care officials agree that it is necessary to
    prepare for the possibility. As part of these preparations, CDC, along
    with national associations representing state and local health officials,
    and others, is involved in developing both SARS- specific guidelines for
    using infectious disease control measures and contingency response plans.
    In addition, these associations have collaborated with CDC to develop a
    checklist of preparedness activities for state and local health officials.
    Such preparation efforts also improve the health care system*s capacity to
    respond to other infectious disease outbreaks, including those
    precipitated by bioterrorism. However, implementing these plans during a
    large- scale outbreak may prove difficult due to limitations in both
    hospital and workforce capacity that could result in overcrowding, as well
    as potential shortages in health care workers and medical equipment*
    particularly respirators. SARS is a highly contagious respiratory disease
    that infected

    more than 8, 000 individuals in 29 countries principally throughout Asia,
    Europe, and North America and led to more than 800 deaths as of July 11,
    2003. Due to the speed and volume of international travel and trade,
    emerging infectious diseases such as SARS are difficult to contain within
    geographic borders, placing numerous

    countries and regions at risk with a single outbreak. While SARS did not
    infect large numbers of individuals in the United States, the possibility
    that it may reemerge raises concerns about the ability of

    public health officials and health care workers to prevent the spread of
    the disease in the United States. GAO was asked to assist the

    Subcommittee in identifying ways in which the United States can prepare
    for the possibility of another SARS outbreak. Specifically, GAO was asked
    to determine 1) infectious disease

    control measures practiced within health care and community settings that
    helped contain the spread of SARS and 2) the initiatives and challenges in
    preparing for a possible SARS resurgence. www. gao. gov/ cgi- bin/ getrpt?
    GAO- 03- 1058T.

    To view the full product, including the scope and methodology, click on
    the link above. For more information, contact Marjorie E. Kanof at (202)
    512- 7101. Highlights of GAO- 03- 1058T, a report to

    the Permanent Subcommittee on Investigations, Committee on Governmental
    Affairs, U. S. Senate

    July 30, 2003

    SEVERE ACUTE RESPIRATORY SYNDROME

    Established Infectious Disease Control Measures Helped Contain Spread, But
    a Large- Scale Resurgence May Pose Challenges

    Page 1 GAO- 03- 1058T

    Mr. Chairman and Members of the Subcommittee: I am pleased to be here
    today as you consider effective infectious disease control measures to
    help contain the spread of Severe Acute Respiratory Syndrome (SARS) should
    future outbreaks occur. SARS is a highly contagious respiratory disease
    that infected more than 8,000 individuals in 29 countries principally
    throughout Asia, Europe, and North America and led to more than 800 deaths
    as of July 11, 2003. Due to the speed and volume of international travel
    and trade, emerging infectious diseases such

    as SARS are difficult to contain within geographic borders, placing
    numerous countries and regions at risk with a single outbreak. SARS
    quickly became a worldwide health problem, prompting the World Health
    Organization (WHO) to issue a global alert for the first time in more than
    a decade* an alert that was cancelled on July 5, 2003. Although the
    outbreak is currently believed to be contained, the fact that SARS is a
    type of coronavirus* the source of some common colds* leads many to
    suggest that SARS could be seasonal and as such could recur in the fall
    and winter months.

    Although all the modes of SARS transmission may not have been identified,
    the disease is most likely spread through person- to- person contact.
    Experts agree that infected individuals are contagious when symptomatic* a
    time during which they are more likely to seek medical attention and come
    into contact with health care workers. One unique characteristic of the
    SARS outbreak was the high rate of infection among health care workers,
    who* before the institution of specific protective measures* may have
    become infected while treating patients with SARS. The SARS outbreak in
    Asia demonstrated that the disease can also spread rapidly in the
    community, outside of hospital settings.

    While SARS did not infect large numbers of individuals in the United
    States, the possibility that it may reemerge raises concerns about the
    ability of public health officials and health care workers to prevent the
    spread of the disease in the United States. To assist the Subcommittee in
    identifying ways in which the United States can prepare for the
    possibility of another SARS outbreak, my remarks today will focus on 1)
    infectious disease control measures practiced within health care and
    community settings that helped contain the spread of SARS and 2) the
    initiatives and challenges in preparing for a possible SARS resurgence.

    My testimony today is based on the review of documentation about infection
    control practices and guidelines, as well as descriptions about the origin
    of SARS and its spread. In addition, we spoke with leading

    Page 2 GAO- 03- 1058T

    national and international disease experts* most of whom were involved in
    either the investigation of SARS or in the treatment of patients with
    SARS. Specifically, we spoke with experts in infectious diseases,
    epidemiology, clinical medicine, and occupational safety from the Centers
    for Disease Control and Prevention (CDC) and WHO. We also spoke with
    public health officials of Health Canada and Toronto Public Health because
    Canada had the highest prevalence of SARS cases in North America. We
    interviewed state and local public health officials in California and New
    York* both of which had the greatest number of SARS cases reported in the
    United States. These officials represented the California Department of
    Health Services, the New York State Department of Health, and the New York
    City Department of Health and Mental Hygiene. We also spoke with hospital
    infectious disease experts in each of these states. In addition, we spoke
    with national infectious disease experts, hospital epidemiologists, and
    representatives from the National Association of County and City Health
    Officials (NACCHO) and the Association of State and Territorial Health
    Officials (ASTHO). We also used our previous work on the capacity of the
    public health system to respond to both bioterrorism and emerging
    infectious diseases. 1 We conducted our work in July 2003 in accordance
    with generally accepted government auditing standards.

    In summary, infectious disease experts emphasized that no new infectious
    disease control measures were introduced to contain SARS in the United
    States. Instead, strict compliance with and additional vigilance to
    enforce the use of current measures was sufficient. These measures* case
    identification and contact tracing, transmission control, and exposure
    management* are well- established infectious disease control measures that
    proved effective in both health care and community settings. The
    combinations of measures that were used depended on either the prevalence
    of the disease in the community or the number of SARS patients served in a
    health care facility. For SARS, case identification within health care
    settings included screening individuals for fever, cough, and recent
    travel to a country with active cases of SARS. Contact tracing, the
    identification and tracking of individuals who had close contact with
    someone who was infected or suspected of being infected, was important for
    the identification and tracking of individuals at risk for SARS.

    1 U. S. General Accounting Office, SARS Outbreak: Improvements to Public
    Health Capacity Are Needed for Responding to Bioterrorism and Emerging
    Infectious Diseases,

    GAO- 03- 769T (Washington, D. C.: May 7, 2003).

    Page 3 GAO- 03- 1058T

    Transmission control measures for SARS included contact precautions,
    especially hand washing after contact with someone who was ill, and
    protection against respiratory spread, including spread by large droplets
    and by smaller airborne particles. The use of isolation rooms with
    controlled airflow and the use of respiratory masks by health care workers
    were key elements of this approach. Exposure management practices*
    isolation and quarantine* occurred in both health care and home settings.
    Effective communication among health care professionals and the general
    public reinforced the need to adhere to infectious disease control
    measures.

    While no one knows whether there will be a resurgence of SARS, federal,
    state, and local health care officials we interviewed agree that it is
    necessary to prepare for the possibility. As part of these preparations,
    CDC, along with national associations that represent state and local
    health officials, and others, is involved in developing both SARS-
    specific

    guidelines for using infectious disease control measures and contingency
    response plans. In addition, these associations have collaborated with CDC
    to develop a checklist of preparedness activities for state and local
    health officials. Such preparation efforts also improve the health care
    system*s capacity to respond to other infectious disease outbreaks,
    including those precipitated by bioterrorism. However, implementing these
    plans may prove difficult due to limitations in both hospital and
    workforce capacity. A large- scale SARS outbreak could create
    overcrowding, as well as shortages in health care workers and in medical

    equipment* particularly respirators. SARS is an emerging respiratory
    disease that has been reported principally in Asia, Europe, and North
    America. SARS is believed to have originated in Guangdong Province, China
    in mid- November 2002. However, early cases

    of the disease went unreported, which then delayed identification and
    treatment of the disease allowing it to spread. On February 11, 2003, WHO
    received its first official report of an atypical pneumonia outbreak in
    China. This report stated that 305 individuals were affected by atypical
    pneumonia and that 5 deaths had been attributed to the disease. SARS was
    transmitted out of the Guangdong Province on February 21, 2003, by a
    physician who became infected after treating patients in the province.
    Subsequently, the physician traveled to a hotel in Hong Kong and began
    suffering from flu- like symptoms. Days later, other guests and visitors
    at the hotel contracted SARS. As infected hotel patrons traveled to other
    countries, such as Vietnam and Singapore, and sought medical attention for
    their symptoms, they spread the disease throughout each country*s
    Background

    Page 4 GAO- 03- 1058T

    hospitals as well as in some communities. Simultaneously, the disease
    began spreading around the world along international air travel routes as
    guests from the hotel flew homeward to Toronto and elsewhere.

    Scientific evidence indicates that SARS is caused by a previously
    unrecognized coronavirus. 2 Transmission of SARS appears to result
    primarily from close person- to- person contact 3 and contact with large
    respiratory droplets emitted by an infected person who coughs or sneezes.
    After contact, the incubation period for SARS* the time it takes for
    symptoms to appear after an individual is infected* is generally within a
    10- day period. Clinical evidence to date also suggests that people are
    most likely to be contagious at the height of their symptoms. However, it
    is not known how long after symptoms begin that patients with SARS are
    capable of transmitting the virus to others. There is no evidence that
    SARS can be transmitted from asymptomatic individuals.

    Currently, there is no definitive test to identify SARS during the early
    phase of the illness, which complicates diagnosing infected individuals.
    As a result, the early diagnosis of SARS relies more on interpreting
    individuals* symptoms and identification of travel to locations with SARS
    transmission. SARS symptoms include fever, chills, headaches, body

    aches, and respiratory symptoms such as shortness of breath and dry cough*
    making SARS difficult to distinguish from other respiratory illnesses,
    such as the flu and pneumonia. The initial symptoms can be quite mild, and
    gradually increase in severity, often peaking in the second week of
    illness. In some individuals, the disease might progress to the point
    where insufficient oxygen is getting to the blood. CDC has established for
    health care providers criteria used for the

    identification of individuals with SARS, called case definitions. 4 In the
    absence of a definitive diagnostic test for the disease in its early
    phase,

    2 The coronavirus is one of a group of viruses that are responsible for
    some but not all common colds. They are so named because their microscopic
    appearance is that of a virus particle surrounded by a crown.

    3 Close contact is usually defined as having cared for, lived with, or
    having direct contact with bodily secretions of an infected individual. 4
    See Centers for Disease Control and Prevention, Department of Health and
    Human Services, Updated Interim U. S. Case Definition for Severe Acute
    Respiratory Syndrome (SARS) (Atlanta, Ga.: July 16, 2003). Description of
    Severe

    Acute Respiratory Syndrome

    Page 5 GAO- 03- 1058T

    reported cases of SARS are classified into two categories based on
    clinical and epidemiologic criteria** suspect* and *probable.* These case
    definitions continue to be refined as more is learned about this disease.
    A *suspect* case of SARS includes the following criteria:

     high fever,  respiratory illness, and  recent travel to an area with
    current or previously documented suspected transmission of SARS, 5 and/ or

     close contact within 10 days of the onset of symptoms with a person
    known or suspected to have SARS.

    A *probable* case of SARS includes the following criteria:  all the
    criteria for *suspect* cases and  evidence in the form of chest x- ray
    findings of pneumonia, acute

    respiratory distress syndrome (ARDS), or an unexplained respiratory
    illness resulting in death with autopsy findings of ARDS.

    The final determination of whether cases meeting the definitions for
    *suspect* and *probable* SARS are due to infection with the SARS virus is
    based on results of testing a blood specimen obtained 28 days after the
    onset of illness.

    Furthermore, there is no specific treatment for SARS. In the absence of a
    rapid diagnostic test, it can be very difficult to distinguish clinically
    between individuals with SARS and individuals with atypical pneumonia.
    Therefore, CDC currently recommends that individuals suspected of having
    SARS be managed using the same diagnostic and therapeutic strategies that
    would be used for any patient with serious atypical pneumonia. In mild
    cases of SARS, management at home may be appropriate, while more severe
    cases may require treatment, such as intravenous medication and oxygen
    supplementation, that necessitates hospitalization. In 10 to 20 percent of
    SARS cases, patients require mechanical ventilation. 6 As of July 11,
    2003, the mortality rate for SARS

    5 The last date for illness onset is 10 days (i. e., one incubation
    period) after removal of a CDC travel alert. To be considered a suspect
    case, an individual*s travel would have occurred on or before the last
    date the travel alert was in place.

    6 Mechanical ventilation involves artificial ventilation of the lung using
    means external to the body. A mechanical ventilator is a machine that
    generates a controlled flow of gas (a mixture of oxygen and air) into a
    patient*s airways.

    Page 6 GAO- 03- 1058T

    was approximately 10 percent, but the mortality rates in individuals over
    60 years of age approached 50 percent.

    As of July 11, 2003, WHO reported that there were an estimated 8,427
    *probable* cases from 29 countries, with 813 deaths from SARS. China, Hong
    Kong, Singapore, Taiwan, and Canada reported the highest number of cases.
    As of July 15, 2003, the United States identified 211 SARS cases in 39
    states (including Puerto Rico), with no related deaths. Of these cases,
    175 are classified as *suspect* cases, while 36 are classified as
    *probable.* 7 In the United States, 34 of the 36 *probable* cases
    contracted SARS

    through international travel. However, in the other affected countries,
    SARS spread extensively among health care workers. For example, of the 138
    diagnosed cases in Hong Kong as of March 25, 2003, that were not due to
    travel, 85 (62 percent) occurred among health care workers; among the 144
    cases in Canada as of April 10, 2003, 73 (51 percent) were health care

    workers. In the United States, the Healthcare Infection Control Practices
    Advisory Committee (HICPAC), a federal advisory committee made up of 14
    infection control experts, develops recommendations and guidelines
    regarding general infectious disease control measures for CDC. Important
    components of these infectious disease control measures are the following:
    case identification and contact tracing, transmission control, and
    exposure management.

    Case Identification and Contact Tracing. Case identification and contact
    tracing are considered by health care providers to be important first
    steps in the containment of infectious diseases in both the community and
    health care settings. Case identification is the process of determining
    whether or not a person meets the specific definitions for a given
    disease. Generally, health care providers interview patients in order to
    obtain the

    history, signs, and symptoms of the patient*s complaint and perform a
    physical examination. Tests, such as blood tests or x- rays, can be
    performed to provide additional information to help determine the
    diagnosis. Public awareness of the symptoms of a disease can help case
    identification to the extent that individuals who believe they exhibit the

    7 Additionally, on July 16, 2003, CDC revised the case definition to
    exclude individuals with negative test results for SARS coronavirus. This
    resulted in 207 previously identified SARS cases (169 suspect cases and 38
    probable cases) being removed from the count of SARS cases in the United
    States. General Infectious Disease

    Control Measures

    Page 7 GAO- 03- 1058T

    symptoms seek medical attention. Contact tracing involves the
    identification and tracking of individuals who may have been exposed to a
    person with a specific disease.

    Transmission Control. Transmission control measures decrease the risk for
    transmission of microorganisms through proper hand hygiene and the use of
    personal protective equipment, such as masks, gowns, and gloves. These
    measures also include the decontamination of objects and rooms. The types
    of transmission control measures used are based on how an illness is
    transmitted. For example, some categories of transmission are as follows:

     Direct contact: person- to- person contact (e. g., two people shaking
    hands) and physical transfer of the microorganism between an infected
    person and an uninfected person.  Indirect contact: contact with a
    contaminated object, such as secretions

    from an infected person on a doorknob or telephone receiver.  Droplet:
    eye, nose, or mouth of an uninfected person coming into contact with
    droplets (larger than 5 micrometers) containing the microorganism from an
    infected person, for example an infected person sneezing without

    covering his/ her mouth with a tissue.  Airborne: contact with small
    droplets (5 micrometers or smaller) or dust

    particles containing the microorganism, which are suspended in the air.

    Exposure Management. Exposure management is the separation of infected
    individuals from noninfected individuals through isolation or quarantine.
    Isolation refers to the separation of individuals who have a specific
    infectious illness from healthy individuals and the restriction of their
    movement to contain the spread of that illness. Quarantine refers to the
    separation and restriction of movement of individuals who are not yet ill,
    but who have been exposed to an infectious agent and are potentially
    infectious.

    The success of these infectious disease control measures* case
    identification and contact tracing, transmission control, and exposure
    management* depends, in part, on the frequent and timely exchange of
    information. Public health officials and health care providers need to be
    informed about any modifications of existing infectious disease control

    measures, the geographic progression of an outbreak, and reports of
    disease occurrence. Likewise, elevating public knowledge about an
    infectious disease and its symptoms will enable infected individuals to
    seek medical attention as soon as possible to contain the spread.

    Page 8 GAO- 03- 1058T

    Infectious disease experts emphasized that existing infectious disease
    control measures played a pivotal role in containing the spread of SARS in
    both health care and community settings. The combinations of measures that
    were used depended on either the prevalence of the disease in the
    community or the number of SARS patients served in a health care facility.

    No new measures were introduced to contain the SARS outbreak in the United
    States; instead, experts said strict compliance with and additional
    vigilance to enforce the use of current measures was sufficient. The
    successful implementation of all of the infectious disease control
    measures depended, in part, on effective communication among health care
    professionals and the general public.

    To prevent the spread of SARS, public health authorities worked to
    identify every individual who might have been infected with the disease.
    Rapid identification of these individuals was critical, but the lack of an
    effective and timely diagnostic test that could be used during the early

    stages of the disease to identify those who actually had SARS was an
    obstacle in halting its spread. Experts acknowledged that identification
    of individuals who might have been infected with the SARS virus was likely
    to include many people who did not have SARS because the case definition
    of an individual with SARS is not highly specific and the disease
    resembles other respiratory illnesses, such as pneumonia and the flu. The
    long incubation period for SARS provided health care workers the
    opportunity to identify cases and close contacts of infected individuals
    before those who actually had the SARS virus could spread the disease to
    others.

    An important part of case identification is screening individuals for
    symptoms of a disease. CDC recommended that when individuals called for
    appointments and as soon as possible after the individual arrived in a

    health care setting, all individuals should be screened with targeted
    questions concerning SARS- related symptoms, close contact with a SARS
    suspect case patient, and recent travel. For SARS, public health and
    hospital officials in California and New York said hospital emergency room
    or other waiting room staff routinely used questionnaires to screen
    incoming patients for fever, cough, and travel to a country with active
    cases of SARS. They said that hospitals* signs in various locations
    generally used by incoming patients and visitors also included these
    criteria and asked individuals to identify themselves to hospital staff if
    they met them. According to these officials, an individual identified as a
    potential SARS case generally was given a surgical mask and moved into a
    separate area for further medical evaluation. CDC officials said that
    these Experts Recommend

    Case Identification and Contact Tracing, Transmission Control, and
    Exposure Management Measures To Prevent the Spread of SARS

    Timely Case Identification and Contact Tracing of SARS Cases Was Critical
    But Difficult

    Page 9 GAO- 03- 1058T

    measures were also important for physicians in private practice. The New
    York City and California health departments used e- mail health alert
    notices to inform private physicians, such as family practitioners and
    pediatricians, about these case identification procedures. These notices
    directed physicians to information posted on the health departments* Web
    sites. In addition, officials from these health departments provided
    information about SARS case identification, among other topics, during
    local meetings for members of the medical community, including physicians
    in private practice.

    Toronto, which experienced a much greater prevalence of SARS than the
    United States, used somewhat different case identification practices. At
    the height of the outbreak in Toronto, everyone entering a hospital was
    required to answer screening questions and to have their temperature
    checked before they were allowed to enter. Toronto public health
    department officials said this heightened screening was useful for case
    identification and had an added benefit of educating staff and visitors
    about SARS symptoms. As a further measure, Toronto health officials
    established SARS assessment clinics, also known as fever clinics; persons
    suspecting they might have SARS were asked to go to the clinics rather
    than directly to hospital emergency rooms to avoid infecting other
    individuals. However, officials acknowledged several limitations to using
    these assessment clinics. Because there was no follow- up to an initial
    assessment, some SARS cases that were in the early stages were not
    identified, but later these individuals went to hospital emergency rooms.
    Other difficulties included finding physicians to staff the clinics and
    implementing hospital- level infectious disease control measures at these
    separate clinics. For example, some clinics were set up in non- hospital
    locations* one assessment clinic was set up in a tent near a hospital
    emergency room entrance, while another was situated in a hospital
    ambulance bay where emergency personnel transfer patients into the
    hospital.

    Contact tracing* the identification and tracking of individuals who had
    close contact with a *suspect* or *probable* case* is an important
    component of case identification. Contact tracing to identify individuals
    at significant risk for SARS required significant local health department
    resources. In New York City, four teams from the communicable disease
    bureau, comprised of either a physician or nurse and several field
    workers, interviewed each suspect or probable case in order to identify
    contacts. They then called each contact to advise them of their exposure
    and provided information on monitoring for symptoms of SARS and receiving
    treatment if necessary. The calls were also to ensure that the contacts

    Page 10 GAO- 03- 1058T

    were following infection control measures in the home. Each contact
    received routine calls during a 10- day period* an average of four calls
    each from a team member. A New York City health department official
    characterized the process of contact tracing as labor and time intensive.
    Standardized forms and electronic contact and case databases helped the
    teams manage contact tracing. Additionally, routine weekly meetings with
    other health department divisions ensured that if assistance was needed
    from these departments, they would be up- to- date. Furthermore, New

    York City developed procedure manuals that would allow staff from other
    departments to be trained quickly if needed to assist members of the
    communicable disease bureau. The health department official emphasized
    that the electronic database created to log information about SARS
    contacts was an important tool to facilitate contact tracing. Toronto
    officials agreed that daily contact tracing required a large amount of
    resources. Adding to Toronto*s difficulties, its health department did not
    have an electronic case or contact database, but had to rely on separate
    paper files for each individual.

    Experts recommended a combination of transmission control measures because
    not all modes of SARS transmission are known. The primary mode of
    transmission is direct person- to- person contact, although contact with
    body fluids and contaminated objects, and possibly airborne spread, may
    play a role. Therefore, multiple infection control practices that are

    used for each type of transmission are included in SARS infection control
    guidelines. Some combination of practices was recommended for both health
    care settings and in the community, with more intensive infection control
    procedures recommended for health care settings. According to several
    experts, the simple *things your mother taught you,* such as washing your
    hands and covering your mouth and nose with a tissue when sneezing or
    coughing were effective in reducing the spread of SARS.

    CDC prepared SARS guidelines for transmission control measures for both
    inpatient (such as hospitals) and outpatient (such as physician offices)
    health care settings. 8 These recommendations combined what the CDC calls
    *standard* hospital transmission control measures with transmission

    8 See Centers for Disease Control and Prevention, Department and Health
    and Human Services, Updated Interim Domestic Infection Control Guidance in
    the Health- Care and Community Setting for Patients with Suspected SARS
    (Atlanta, Ga.: May 1, 2003). Multiple Transmission

    Control Measures Used to Contain Spread

    Page 11 GAO- 03- 1058T

    control measures specific to contact and airborne transmission. For the
    inpatient setting, the guidelines included:

     Routine standard precautions, including hand washing. In addition to
    standard precautions, CDC recommended eye protection* such as goggles or a
    face shield.  Contact precautions, such as the use of a gown and gloves
    for encounters

    with the patient or his/ her environment.  Airborne precautions, such as
    an isolation room with negative pressure

    relative to the surrounding area, 9 and the use of an N- 95 filtering
    disposable respirator for persons entering the room. The CDC guidelines
    suggested that if an isolation room was not available, patients should be

    placed in a private room, and all persons entering the room should wear
    N95 respirators (or respirators offering comparable protection) to protect
    the wearer from particles expelled by a sick person, such as in coughing
    or sneezing. CDC recommended that, where possible, a test to ensure that
    the N- 95 respirators fit properly should be conducted. If N- 95
    respirators were not available for health care personnel, then surgical
    masks should be worn. Generally, the material of N- 95 respirators is
    designed to filter smaller particles than a surgical mask, and they also
    are designed to seal more tightly to the face.

    The health department and hospital officials we spoke with said they
    generally adopted these CDC guidelines for transmission control in
    inpatient settings. Officials said one of the most effective practices to
    contain SARS was frequent hand washing with soap and water. CDC guidelines
    also allow the use of waterless alcohol- based hand rubs after coming in
    contact with *suspect* or *probable* SARS patients or their environments.
    Additionally, a hospital and a health department official said careful
    cleaning of SARS patient rooms was an important hygiene measure.

    Inpatient facilities in the United States generally saw few SARS patients.
    In New York and California, the hospital officials stated that because of
    the small number of cases that were seen in each hospital, usually only
    one or two at a time, the hospitals were able to manage SARS patients in
    available isolation rooms. Because of the greater prevalence of SARS in
    Toronto, all 22 acute care hospitals were directed to have a SARS unit
    with negative pressure to the rest of the hospital, individual rooms, and
    specific staff

    9 Negative pressure rooms generally are private rooms in which air flow is
    from the hallway into the room, and then outdoors.

    Page 12 GAO- 03- 1058T

    who only cared for SARS patients. Toronto health department officials
    later were able to designate four hospitals as SARS hospitals and direct
    all SARS patients to these four facilities. The use of face masks or N- 95
    respirators was highly recommended by

    experts as an effective means of transmission control for SARS in
    inpatient settings. In one study of health care workers who had extensive
    contact with SARS patients in five Hong Kong hospitals, researchers found
    that no health care worker who consistently used either type of face
    covering became infected. 10 Experts also noted that the use of N- 95
    respirators and isolation rooms was especially important for high- risk
    medical procedures, such as intubation, where a patient*s secretions are
    likely to be transformed into a fine spray and spread for a longer
    distance than large droplets. 11 Officials cautioned, however, that there
    can be difficulties in the use of N- 95 respirators. One public health
    official said that compliance may be limited in hospitals in several ways*
    either staff has never been properly fitted for the respirators, or some
    staff who were fitted many years ago should have a more recent fitting. In
    Canada, Ontario*s health ministry directed health care workers in the
    province (which includes Toronto) to employ an additional level of
    protective equipment when conducting high- risk medical procedures that
    was not recommended in the United States. For example, health care workers
    used a protective system that included a hood, a full- face respirator,
    and a complete body covering such as long- sleeved floor- length gowns and
    gloves.

    The CDC guidelines for outpatient settings included the same standard and
    contact precautions outlined for inpatient settings. Reflecting the
    different types of facilities likely available in a physician office
    compared to a hospital, for example, outpatient guidelines did not
    advocate the use of specialized isolation rooms. Instead, for outpatient
    settings, the guidelines advised health care personnel to separate the
    potential SARS patient from others in a reception area as soon as
    possible, preferably in a private room with negative pressure relative to
    the surrounding area. At the same time, the guidelines said that a
    surgical mask should be placed

    10 See W. H. Seto, et. al., Effectiveness of precautions against droplets
    and contact in prevention of nosocomial transmission of severe acute
    respiratory syndrome (SARS),

    The Lancet (Vol. 361, May 3, 2003), pp. 1519- 20. 11 Generally, intubation
    is the introduction of a tube into an individual*s airway to facilitate
    breathing.

    Page 13 GAO- 03- 1058T

    over the patient*s nose and mouth* if this was not feasible, the patient
    should be asked to cover his or her mouth with a disposable tissue when
    coughing, talking, or sneezing.

    Transmission control guidelines for community settings incorporated many
    of the same types of measures for containing the spread of SARS as
    recommended for health care settings. 12 CDC published SARS transmission
    control guidelines for two community settings* the workplace and
    households. The workplace guidelines recommended frequent hand washing
    with soap and water or waterless alcohol- based hand rubs. Along with
    handwashing, guidelines for household transmission control included the
    following:

     Infection control precautions should be continued for SARS patients for
    10 days after respiratory symptoms and fever are gone. SARS patients
    should limit interactions outside the home and should not go to work,
    school, outof- home day care, or other public areas during the 10- day
    period.  During this 10- day period, each patient with SARS should cover
    his or her

    mouth and nose with a tissue before sneezing or coughing. If possible, a
    person recovering from SARS should wear a surgical mask during close
    contact with uninfected persons. If the patient is unable to wear a
    surgical mask, other people in the home should wear one when in close
    contact with the patient.  Disposable gloves should be considered for any
    contact with body fluids

    from a SARS patient. Immediately after activities involving contact with
    body fluids, gloves should be removed and discarded, and hands should be
    washed. Gloves should not be washed or reused, and were not intended to
    replace proper hand hygiene.

     SARS patients should avoid sharing eating utensils, towels, and bedding
    with other members of the household, although these items could be used by
    others after routine cleaning, such as washing or laundering with soap and
    hot water.  Frequent use should be made of common household cleaners for

    disinfecting toilets, sinks, and other surfaces touched by patients with
    SARS.

    12 See Centers for Disease Control and Prevention, Department of Health
    and Human Services, Interim Guidance on Infection Control Precautions for
    Patients with Suspected Severe Acute Respiratory Syndrome (SARS) and Close
    Contacts in Households (Atlanta,

    Ga.: Apr. 29, 2003).

    Page 14 GAO- 03- 1058T

    Exposure management methods such as isolation and quarantine are important
    infectious disease control measures. These measures were particularly
    effective for SARS because of its long incubation period during which
    infected individuals could be isolated before they become contagious. In
    fact, experts stated that isolation of infected individuals and quarantine
    measures used for exposed individuals were critical for the containment of
    SARS.

    Isolation of SARS infected individuals occurred in both health care and
    home settings. In Toronto, patients were typically isolated in the
    hospital* even in cases where individuals were not ill enough to need
    hospitalization. During the height of Toronto*s outbreak, all 22 acute
    care hospitals were directed to have separate SARS units. On the other
    hand, in the United States, individuals were hospitalized only if they
    needed

    intensive medical treatment. According to an infectious disease expert who
    consulted with the CDC, this practice was prompted by concerns that
    grouping SARS cases together, such as in a hospital ward, could increase
    the likelihood of spread to both health care workers and other hospital
    patients.

    For home isolation in New York City, each patient and contact was given
    detailed information that included instructions on what to do if ill,
    reminders of the importance of calling ahead before going to a physician*s
    office or other health care settings, and information on how to travel to
    a health care setting without coming in contact with others. These
    instructions also included guidelines for transmission control measures to
    be used in the home. For all probable cases, the New York City health
    department conducted a home assessment to ensure that a SARS patient could
    be adequately isolated at home, which included the need for such things as
    adequate ventilation and bathrooms that would not be shared by noninfected
    individuals. Quarantine of exposed individuals was based on different
    parameters,

    depending on the number of *suspect* or *probable* SARS cases in the
    community. CDC officials said the agency*s guidance reflected the fact
    that there was little or no transmission of SARS in the United States, and

    therefore quarantine was less warranted because there were so few cases in
    a community. CDC*s guidance advised individuals who were exposed but not
    symptomatic to monitor themselves for symptoms* such as fever, a cough,
    and difficulty breathing, and further advised home isolation and medical
    evaluation if symptoms began. CDC officials also advised transfer to a
    hospital only if the illness became severe. Exposure Management

    Used to Prevent SARS Spread

    Page 15 GAO- 03- 1058T

    In contrast, Toronto, which experienced a high level of person- to- person
    transmission, used a more conservative quarantine standard. Individuals
    who did not have symptoms but had been in contact with SARS infected
    individuals were ordered to stay in their homes and avoid public
    gatherings for 10 days. Thousands people were asked to undergo quarantine
    in their homes in the Toronto area. During the outbreak, exposed Toronto
    health care workers were restricted to *work quarantine** they were only
    allowed to travel to and from work alone in their vehicles, but they were
    not allowed to have visitors or visit public places. Quarantine efforts in
    Toronto again required a high level of resources. Daily phone calls
    required 60 staff per 1,000 people who were quarantined in the Toronto
    area; these staff worked 7 days a week to follow up with twice- daily
    calls to each individual.

    According to health officials, rapid and frequent communications of
    crucial information about SARS* such as the level of outbreak worldwide
    and recommended infectious disease control measures* were vital

    components of the efforts to contain the spread of SARS. Since March 2003,
    health organizations have shared extensive SARS- related information and
    guidelines with health care workers. For example, WHO scheduled numerous
    press briefings that updated the health community about the status of
    international SARS containment and prevention efforts. WHO, with CDC
    support, sponsored a videoconference broadcast globally to discuss the
    latest findings of the outbreak and prevention of transmission in health
    care settings (which was also available for

    computer download). CDC activated its Emergency Operations Center and
    devoted over 800 medical experts and support personnel worldwide to
    provide round- the- clock coordination and response to the SARS outbreak.
    CDC also had regular conference calls and information- sharing sessions
    with various medical professional associations and state and local health
    departments and laboratories.

    At the state level, the California health department utilized the
    California Health Alert Network to send e- mails with SARS information
    (often based on CDC information) to all local health departments and many
    hospitals and physicians. The New York City health department hosted a
    symposium specifically for health care workers, to share the latest
    available SARS information. Hospital officials we spoke with also offered
    training seminars for their health care personnel on the signs and
    symptoms of SARS, recommended screening questions, and appropriate
    infectious disease control measures. Furthermore, hospitals kept their
    Success in Implementing

    Infectious Disease Control Measures Depended on Rapid and Frequent
    Communication

    Page 16 GAO- 03- 1058T

    patients informed about SARS via posters and flyers throughout their
    facilities, especially in emergency room waiting areas.

    Health organizations maintained open and frequent communications in the
    community setting to facilitate the containment of SARS. For example, in a
    2- week period early in the SARS outbreak, CDC conducted nine telephone
    press conferences with the media to keep the public informed about the

    latest SARS information, including numbers of *suspect* and *probable*
    SARS cases, laboratory and surveillance findings, travel advisories, and
    CDC*s efforts nationally and worldwide. CDC also distributed more than two
    million health alert notices to travelers entering the United States from
    China, Hong Kong, Singapore, Taiwan, Vietnam, or Toronto. These cards,
    printed in eight languages, asked individuals to monitor their health for
    at least 10 days and to contact their health care provider if they

    exhibited SARS symptoms. A state and a local health official also stressed
    the importance of informing and educating the general public in workplaces
    and schools on the signs and symptoms of SARS, an effort which was
    intended to foster self- identification, minimize panic, and assuage fears
    of being infected.

    Public health officials also concurred that collaboration between federal,
    state, and local health agencies as well as the medical community was
    crucial in containing the spread of SARS. Through the collaboration of all
    the appropriate players, coordination of prevention activities could be
    maintained, roles could be identified and assigned, available resources
    could be shared, and subsequent evaluations could be conducted. For
    instance, the Toronto health department maintained active communications
    with its local, provincial, and national governments in regard to
    isolation and quarantine practices, travel jurisdictions, and other SARS-
    related matters. The health department published directives for all
    Toronto area health care providers, outlining their SARS- related roles
    and

    responsibilities. The health department also maintained ongoing contact
    with identified liaisons at Toronto hospitals where SARS patients were
    hospitalized. Furthermore, the city of Toronto activated its local
    emergency operations center, which brought together emergency medical
    services, police, and community neighborhood planners to work together to
    contain SARS. Throughout Toronto*s efforts, numerous briefings and

    teleconferences were organized to keep all players abreast about the
    latest SARS information in the community.

    Page 17 GAO- 03- 1058T

    While no one knows whether there will be a resurgence of SARS, federal,
    state, and local health care officials we interviewed agree that it is
    necessary to prepare for the possibility. As part of these preparations,
    CDC, along with national associations that represent state and local
    health officials, and others, is involved in developing SARS- specific
    guidelines for

    using infectious disease control measures and contingency response plans.
    In addition, these associations have collaborated with CDC to develop a
    checklist of preparedness activities for state and local health officials.
    Such preparation efforts also improve the health care system*s capacity to
    respond to other infectious disease outbreaks, including those
    precipitated

    by bioterrorism. However, implementing these plans may prove difficult due
    to limitations in both hospital and workforce capacity. A large- scale
    SARS outbreak could create overcrowding, as well as shortages in medical
    equipment (including N- 95 respirators) and in health care personnel, who
    are at higher risk for infection due to their more frequent exposure to a
    contaminated environment.

    At the federal level, CDC has begun contingency planning for a SARS
    outbreak, having convened a task force of infection control experts who
    are responsible for developing SARS- specific guidelines and
    recommendations, which address various infection control measures. The
    task force plans to publish its guidelines and recommendations by
    September 2003. CDC is collaborating with several professional
    associations, such as the Council of State and Territorial
    Epidemiologists, ASTHO, and NACCHO, to develop these response plans that
    vary according to the prevalence of the disease and the type of setting
    (i. e., health care or community) in which control measures need to be
    implemented.

    At the state and local levels, health departments are also in the process
    of developing contingency response plans for SARS. To facilitate this,
    ASTHO and NACCHO, in collaboration with CDC, published a checklist for
    state and local health officials to use in the event of a SARS resurgence.
    The SARS preparations have been modeled after a checklist

    designed for pandemic influenza. The checklist encompasses a broad
    spectrum of preparedness activities, such as legal issues related to
    isolation and quarantine, strategies for communicating information to
    health care providers, and suggestions for ensuring other community
    partners such as law enforcement and school officials are prepared (see
    app. I for a copy of the checklist). Federal, State, and

    Local Health Officials Are Preparing for a Possible SARS Resurgence, But
    Implementing Plans May Pose Challenges if the Resurgence Is Large- Scale

    Federal, State, and Local Health Officials Are Preparing for the
    Possibility of Future Outbreaks

    Page 18 GAO- 03- 1058T

    In specific local preparedness efforts, California and New York, which had
    the highest number of SARS cases in the United States, are also preparing
    for a large- scale SARS outbreak. For example, California health
    department officials said they were developing a plan for surge capacity
    by considering staff rotations or details of health department specialists
    to

    maintain a high level of response during a potential SARS outbreak. 13
    Similarly, officials with the New York City health department said they
    had created a formal procedure manual, which outlines the roles of
    reallocated staff from various teams in the department, to help contain a
    large- scale SARS outbreak.

    While hospital officials we spoke with stated that they are taking steps
    to ensure that they have the necessary preparations to address a large-
    scale SARS outbreak, hospitals may still be limited in their capacity to
    respond.

    Because of the inability to precisely determine if someone has SARS, many
    people may be treated who do not have the virus. In the event of a
    largescale outbreak, this imprecision may result in severe overcrowding in
    health care settings* especially if a SARS resurgence occurs during a peak
    season for another respiratory disease like influenza. This could strain
    the

    available capacity of hospitals. For example, public health officials with
    whom we spoke said that in the event of a large- scale SARS outbreak,
    entire hospital wards (along with their staff) may need to be used as
    separate SARS isolation facilities. Moreover, certain hospitals within a
    community might need to be designated as SARS hospitals.

    We recently reported that most hospitals lack the capacity to respond to
    large- scale infectious disease outbreaks. 14 Most emergency departments
    have experienced some degree of crowding and therefore, in some cases, may
    not be able to handle a large influx of patients during a potential
    outbreak of SARS or another infectious disease. Few hospitals have
    adequate staff, medical resources, and equipment, such as N- 95
    respirators, needed to care for the potentially large numbers of patients

    13 Surge capacity is the ability of the health care system to handle a
    large number of patients. 14 U. S. General Accounting Office, SARS
    Outbreak: Improvements to Public Health Capacity Are Needed for Responding
    to Bioterrorism and Emerging Infectious Diseases,

    GAO- 03- 769T (Washington D. C.: May 7, 2003). Limitations in Hospital and

    Workforce Capacity Make Implementing Infectious Disease Control Measures
    Difficult in the Event of a Large- Scale SARS Outbreak

    Page 19 GAO- 03- 1058T

    that may seek treatment. 15 We reported that in the seven cities we
    visited, hospital, state, and local officials indicated that hospitals
    needed additional equipment and capital improvements* including medical
    stockpiles, personal protective equipment, quarantine and isolation
    facilities, and air handling and filtering equipment* to enhance
    preparedness. According to our survey of over 2,000 hospitals, 16 the
    availability of medical equipment varied greatly among hospitals, and few
    hospitals reported having the equipment and supplies needed to handle a
    large- scale infectious disease outbreak. Half the hospitals we surveyed
    had, for every 100 staffed beds, fewer than 6 ventilators, 3 or fewer
    personal protective equipment suits, and fewer than 4 isolation beds.

    Workforce capacity issues may also hinder implementation of infectious
    disease control measures. Health officials noted that there is a lack of
    qualified and trained personnel, including epidemiologists, who would be
    needed in the event of a SARS resurgence. This shortage 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 WHO officials, an individual infected with SARS came
    into contact with, on average, 30 to 40 people in Asian countries* all of
    whom had to be contacted and informed of their possible exposure. In
    contrast, New York City health department officials said that infected
    individuals came into contact with 4 people on average.

    In addition, the monitoring of individuals placed under isolation and
    quarantine may strain resources if widespread isolations and quarantines
    are needed. For example, follow- up with isolated or quarantined
    individuals requires significant resources. Officials of the New York City

    15 Shortages in N- 95 respirators occurred during the SARS outbreak
    because of the high demand. CDC officials said that shortages in the
    United States may have been due to high demand in other countries,
    particularly when WHO recommended that health care workers

    in all affected countries use N- 95 respirators. 16 Between May and
    September 2002, we surveyed over 2, 000 short- term, nonfederal general
    medical and surgical hospitals with emergency departments located in
    metropolitan statistical areas. (See U. S. General Accounting Office,
    Hospital Emergency Departments: Crowded Conditions Vary among Hospitals
    and Communities, GAO- 03- 460 (Washington, D. C.: Mar. 14, 2003) for
    information on the survey universe and development of the survey.) For the
    part of the survey that specifically addressed hospital preparedness for
    mass casualty incidents, we obtained responses from 1,482 hospitals, a
    response rate of about 73 percent.

    Page 20 GAO- 03- 1058T

    Department of Health and Mental Hygiene said that they made home visits to
    SARS cases when officials became concerned that these individuals were not
    following infection control measures or were not remaining in their homes.
    Similarly, Canadian public health officials said that they, and in some
    cases Canadian police, made home visits to check compliance with
    quarantine orders. These officials also described the difficulty in
    providing necessary resources (food, medicines, masks, and thermometers)
    to individuals under isolation or quarantine. In Canada, police and the
    Red Cross had to help deliver food to those under isolation or quarantine.

    The global spread of SARS was contained through an unprecedented level of
    international scientific collaboration and the use of well- established
    infection control measures that have been used effectively in the past to
    control diseases. Although questions remain about SARS, especially about

    the ways it can be transmitted, many lessons were learned that could be
    helpful to the United States in the event of a resurgence. Lessons to
    carry forward are the importance of early identification of infected
    individuals and their contacts, the effectiveness of safety precautions to
    control transmission and ensure the protection of health care workers, and
    the need to use, in some cases, isolation and quarantine. Swift and
    unfettered communication among heath care workers, public health
    officials,

    government agencies, as well as the public provided the essential backbone
    to support ongoing efforts to contain the disease.

    Although SARS is currently believed to be contained, now is the time to
    prepare for the possibility of a future outbreak. Some preparations are
    already underway and encompass, in large part, approaches similar to those
    for pandemic influenza and are also part of general bioterrorism
    preparedness. Worldwide disease surveillance would facilitate prompt
    identification of a resurgence of SARS, allowing rapid implementation of
    infectious disease control measures that would reduce both the spread of
    SARS and the risk of a large outbreak. Should a large- scale outbreak
    occur in the near term, limitations in the capacity of our nation*s health
    system to undertake effective and rapid implementation of infectious
    disease control measures could prove problematic. A major SARS outbreak
    would necessitate rapid escalation of infectious disease control resources
    including health care workers, emergency room and hospital capacity, and
    the requisite control and support equipment. Concluding

    Observations

    Page 21 GAO- 03- 1058T

    Mr. Chairman, this completes my prepared statement. I would be happy to
    respond to any questions you or other Members of the Subcommittee may have
    at this time.

    For more information regarding this testimony, please contact Marjorie
    Kanof at (202) 512- 7101. Bonnie Anderson, Karen Doran, John Oh, Danielle
    Organek, and Krister Friday also made key contributions to this statement.
    Contact and Staff

    Acknowledgments

    Page 22 GAO- 03- 1058T

    Source: National Association of County and City Health Officials. Appendix
    I: SARS Preparedness Checklist

    Page 23 GAO- 03- 1058T Source: National Association of County and City
    Health Officials.

    Page 24 GAO- 03- 1058T Source: National Association of County and City
    Health Officials.

    Page 25 GAO- 03- 1058T Source: National Association of County and City
    Health Officials.

    Page 26 GAO- 03- 1058T Source: National Association of County and City
    Health Officials.

    Page 27 GAO- 03- 1058T Source: National Association of County and City
    Health Officials.

    Page 28 GAO- 03- 1058T

    SARS Outbreak: Improvements to Public Health Capacity are Needed for
    Responding to Bioterrorism and Emerging Infectious Diseases. GAO- 03-
    769T. Washington, D. C.: May 7, 2003. Smallpox Vaccination: Implementation
    of National Program Faces

    Challenges. GAO- 03- 578. Washington, D. C.: April 30, 2003.

    Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have
    Improved Public Health Response Capacity, but Gaps Remain. GAO- 03- 654T.
    Washington, D. C.: April 9, 2003.

    Bioterrorism: Preparedness Varied across State and Local Jurisdictions.

    GAO- 03- 373. Washington, D. C.: April 7, 2003.

    Hospital Emergency Departments: Crowded Conditions Vary among Hospitals
    and Communities. GAO- 03- 460. Washington, D. C.: March 14, 2003.

    Homeland Security: New Department Could Improve Coordination but
    Transferring Control of Certain Public Health Programs Raises Concerns.
    GAO- 02- 954T. Washington, D. C.: July 16, 2002.

    Homeland Security: New Department Could Improve Biomedical R& D
    Coordination but May Disrupt Dual- Purpose Efforts. GAO- 02- 924T.
    Washington, D. C.: July 9, 2002.

    Homeland Security: New Department Could Improve Coordination but May
    Complicate Priority Setting. GAO- 02- 893T. Washington, D. C.: June 28,
    2002.

    Homeland Security: New Department Could Improve Coordination but May
    Complicate Public Health Priority Setting. GAO- 02- 883T. Washington, D.
    C.: June 25, 2002.

    Bioterrorism: The Centers for Disease Control and Prevention*s Role in
    Public Health Protection. GAO- 02- 235T. Washington, D. C.: November 15,
    2001.

    Bioterrorism: Review of Public Health Preparedness Programs. GAO- 02-
    149T. Washington, D. C.: October 10, 2001.

    Bioterrorism: Public Health and Medical Preparedness. GAO- 02- 141T.
    Washington, D. C.: October 9, 2001. Related GAO Products

    Page 29 GAO- 03- 1058T

    Bioterrorism: Coordination and Preparedness. GAO- 02- 129T. Washington, D.
    C.: October 5, 2001.

    Bioterrorism: Federal Research and Preparedness Activities. GAO- 01- 915.
    Washington, D. C.: September 28, 2001.

    West Nile Virus Outbreak: Lessons for Public Health Preparedness.

    GAO/ HEHS- 00- 180. Washington, D. C.: September 11, 2000.

    Combating Terrorism: Need for Comprehensive Threat and Risk Assessments of
    Chemical and Biological Attacks. GAO/ NSIAD- 99- 163. Washington, D. C.:
    September 14, 1999.

    Combating Terrorism: Observations on Biological Terrorism and Public
    Health Initiatives. GAO/ T- NSIAD- 99- 112. Washington, D. C.: March 16,
    1999.

    (290303)

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