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			 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
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)

This is a work of the U. S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.

The General Accounting Office, the audit, evaluation and investigative arm
of Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability of
the federal government for the American people. GAO examines the use of
public funds; evaluates federal programs and policies; and provides
analyses, recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO*s commitment to
good government is reflected in its core values of accountability,
integrity, and reliability.

The fastest and easiest way to obtain copies of GAO documents at no cost
is through the Internet. GAO*s Web site (www. gao. gov) contains abstracts
and fulltext files of current reports and testimony and an expanding
archive of older products. The Web site features a search engine to help
you locate documents using key words and phrases. You can print these
documents in their entirety, including charts and other graphics.

Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as *Today*s Reports,* on its
Web site daily. The list contains links to the full- text document files.
To have GAO e- mail

this list to you every afternoon, go to www. gao. gov and select
*Subscribe to e- mail alerts* under the *Order GAO Products* heading.

The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent of
Documents. GAO also accepts VISA and Mastercard. Orders for 100 or more
copies mailed to a single address are discounted 25 percent. Orders should
be sent to: U. S. General Accounting Office 441 G Street NW, Room LM
Washington, D. C. 20548 To order by Phone: Voice: (202) 512- 6000

TDD: (202) 512- 2537 Fax: (202) 512- 6061

Contact: Web site: www. gao. gov/ fraudnet/ fraudnet. htm E- mail:
fraudnet@ gao. gov Automated answering system: (800) 424- 5454 or (202)
512- 7470 Jeff Nelligan, Managing Director, NelliganJ@ gao. gov (202) 512-
4800

U. S. General Accounting Office, 441 G Street NW, Room 7149 Washington, D.
C. 20548 GAO*s Mission Obtaining Copies of

GAO Reports and Testimony

Order by Mail or Phone To Report Fraud, Waste, and Abuse in Federal
Programs Public Affairs
*** End of document. ***