Infectious Diseases: Gaps Remain in Surveillance Capabilities of 
State and Local Agencies (24-SEP-03, GAO-03-1176T).		 
                                                                 
Recent challenges, such as the SARS outbreak and the anthrax	 
incidents in the fall of 2001, have raised concerns about the	 
nation's preparedness for a large-scale infectious disease	 
outbreak or bioterrorism event. In order to be adequately	 
prepared for such a major public health threat, state and local  
public health agencies need to have several basic	 capabilities, 
including disease surveillance systems, laboratory facilities,	 
communication systems and a sufficient workforce. GAO was asked  
to examine the capacity of state and local public health agencies
and hospitals to detect and report illnesses or conditions that  
may result from a large-scale infectious disease outbreak or	 
bioterrorism event. This testimony is based largely on recent	 
work, including a report on state and local preparedness for a	 
bioterrorist attack; preliminary findings from current work on	 
updates of bioterrorism preparedness at the state and local	 
levels; and findings from a survey GAO conducted on hospital	 
emergency department capacity and emergency preparedness.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-1176T					        
    ACCNO:   A08562						        
  TITLE:     Infectious Diseases: Gaps Remain in Surveillance	      
Capabilities of State and Local Agencies			 
     DATE:   09/24/2003 
  SUBJECT:   Disease detection or diagnosis			 
	     Health care facilities				 
	     Hospitals						 
	     Infectious diseases				 
	     Emergency preparedness				 
	     National preparedness				 
	     Biological warfare 				 
	     Federal/state relations				 
	     CDC Bioterrorism Preparedness and			 
	     Reponse Program					 
                                                                 
	     HRSA Bioterrorism Hospital Preparedness		 
	     Program						 
                                                                 

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GAO-03-1176T

Testimony Before the Subcommittee on Emergency Preparedness and Response,
Select Committee on Homeland Security, House of Representatives

United States General Accounting Office

GAO For Release on Delivery Expected at 2: 30 p. m. Wednesday, September
24, 2003 INFECTIOUS DISEASES

Gaps Remain in Surveillance Capabilities of State and Local Agencies

Statement of Janet Heinrich Director, Health Care* Public Health Issues

GAO- 03- 1176T

The efforts of public health agencies and health care organizations to
increase their preparedness for infectious disease outbreaks and
bioterrorism have improved the nation*s ability to recognize such events.
However, gaps remain in state and local disease surveillance systems,
which are essential to public health efforts to respond to disease
outbreaks or

bioterrorist attacks. Other essential elements of preparedness include
laboratory facilities, workforce, and communication systems. State and
local officials report that they are addressing gaps in communication
systems. However, there are still significant workforce shortages in state
and local

health departments. GAO also found that while contingency plans are being
developed at the state and local levels, planning for regional
coordination for disease outbreaks or bioterrorist events was lacking
between states. The disease surveillance capacities of many state and
local pubic health

systems depend, in part, on the surveillance capabilities of hospitals.
Whether a disease outbreak occurs naturally or due to the intentional
release of a harmful biological agent by a terrorist, much of the initial
response would occur at the local level, particularly at hospitals and
their emergency departments. Therefore, hospital personnel would be some
of the first

healthcare workers with the opportunity to identify an infectious disease
outbreak or a bioterrorist event. Most hospitals reported training their
staff on biological agents and planning coordination efforts with public
health entities; however, preparedness limitations may impact hospitals*
ability to conduct disease surveillance. In addition, hospitals still lack
the capacity to respond to large- scale infectious disease outbreaks.
Also, most emergency departments across the country have experienced some
degree of overcrowding, which could be exacerbated during a disease
outbreak or bioterrorist event if persons with symptoms go to emergency
departments for treatment. Recent challenges, such as the

SARS outbreak and the anthrax incidents in the fall of 2001, have raised
concerns about the nation*s

preparedness for a large- scale infectious disease outbreak or
bioterrorism event. In order to be adequately prepared for such a

major public health threat, state and local public health agencies need to
have several basic

capabilities, including disease surveillance systems, laboratory
facilities, communication systems and a sufficient workforce. GAO was
asked to examine the

capacity of state and local public health agencies and hospitals to detect
and report illnesses or conditions that may result from a large- scale
infectious disease

outbreak or bioterrorism event. This testimony is based largely on recent
work, including a report on state and local preparedness for a

bioterrorist attack; preliminary findings from current work on updates of
bioterrorism preparedness at the state and local levels; and findings from
a survey GAO conducted on hospital

emergency department capacity and emergency preparedness.

www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 1176T. To view the full
testimony, including the scope and methodology, click on the link above.
For more information, contact Janet Heinrich at (202) 512- 7119.
Highlights of GAO- 03- 1176T, testimony

before the Subcommittee on Emergency Preparedness and Response, Select
Committee on Homeland Security, House of Representatives

September 24, 2003

INFECTIOUS DISEASES

Gaps Remain in Surveillance Capabilities of State and Local Agencies

Page 1 GAO- 03- 1176T Mr. Chairman and Members of the Subcommittee: I
appreciate the opportunity to be here today to discuss the work we have

done on state and local preparedness to manage outbreaks of infectious
diseases, which may be naturally occurring or the product of bioterrorism.
In order to be adequately prepared for such a major public health threat,
state and local public health agencies need to have several basic
capabilities, including disease surveillance systems. 1 Surveillance is
public health officials* most important tool for detecting and monitoring
both

existing and emerging infections. Effective surveillance can facilitate
timely action to control outbreaks and inform allocation of resources to
meet changing disease conditions. Without adequate surveillance, local,
state, and federal officials cannot know the true scope of existing health
problems and may not recognize new diseases until many people have been
affected.

Recent challenges, such as the SARS 2 outbreak and the anthrax incidents
in the fall of 2001, have raised concerns about the nation*s preparedness
to manage a disease outbreak or a bioterrorist event should it reach
largescale proportions. Existing surveillance systems have weaknesses,
such as chronic underreporting and outdated laboratory facilities, which
raise concerns about the ability of state and local agencies to detect
emerging diseases or a bioterrorist event. As a result, state and local
response agencies and organizations have recognized the need to strengthen
their public health infrastructure and capacity. The improvements they are
making are intended to strengthen their ability to identify and respond to
major public health threats, including naturally occurring infectious
disease outbreaks and acts of bioterrorism.

To assist the Subcommittee in its consideration of our nation*s capacity
to detect and monitor an outbreak of an infectious disease, my remarks
today will focus on (1) the preparedness of state and local public health
agencies for responding to an infectious disease outbreak, and (2) the
contributions of hospitals to preparedness for an infectious disease
outbreak.

1 Disease surveillance uses systems that provide for the ongoing
collection, analysis, and dissemination of health- related data to
identify, prevent, and control disease. 2 SARS is the abbreviation for
severe acute respiratory syndrome.

Page 2 GAO- 03- 1176T My testimony today is based largely on our recent
work, including a report on state and local preparedness for a
bioterrorist attack. 3 For that report,

we conducted site visits in December 2001 through March 2002 to seven
cities and their respective state governments. We also reviewed each
state*s spring 2002 applications for bioterrorism preparedness funding to
the Department of Health and Human Services* (HHS) Centers for Disease
Control and Prevention (CDC) and Health Resources and Services
Administration (HRSA), and each state*s fall 2002 progress report on the
use of that funding. In addition, I will discuss some preliminary findings
from our current work that provides updated information on the
preparedness of state and local public health agencies. For that work, we
are reviewing the summer 2003 applications and progress reports and
interviewing public health officials from 10 states and two major
municipalities. I also will present some findings from a survey we
conducted in 2002 on hospital emergency department capacity and emergency
preparedness. 4 We conducted our work in accordance with generally
accepted government auditing standards.

In summary, state and local officials in the cities we visited reported
varying levels of public health preparedness to respond to outbreaks of
emerging infectious diseases such as SARS. They recognized gaps in
preparedness elements that have been difficult to address, including the
disease surveillance and laboratory systems and the response capacity of
the workforce. They also were beginning to address gaps in preparedness
elements such as communication. We found that planning for regional

coordination was lacking between states. Because those with symptoms of an
infectious disease might go to emergency departments for treatment,
hospital personnel would likely be some of the first healthcare workers
with the opportunity to identify an infectious disease outbreak.
Therefore, the disease surveillance capacities

of many state and local public health systems may depend, in part, on the
3 U. S. General Accounting Office, Bioterrorism: Preparedness Varied
across State and Local Jurisdictions, GAO- 03- 373 (Washington, D. C.:
Apr. 7, 2003). 4 Findings from the survey include those related to
emergency department capacity, which we reported in U. S. General
Accounting Office, Hospital Emergency Departments: Crowded Conditions Vary
among Hospitals and Communities, GAO- 03- 460 (Washington, D. C.: Mar. 14,
2003) and to hospital emergency preparedness for mass casualty incidents,
which we reported in U. S. General Accounting Office, Hospital
Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain
Capacities for Bioterrorism Response, GAO- 03- 924 (Washington, D. C.:
Aug. 6, 2003).

Page 3 GAO- 03- 1176T surveillance capabilities of hospitals. Most
hospitals reported training their staff and planning coordination efforts
with other public health entities.

However, even with these preparations in place, hospitals lacked the
capacity to respond to large- scale infectious disease outbreaks.

Infectious diseases include naturally occurring outbreaks, such as SARS,
as well as diseases from biological agents that are intentionally released
by a terrorist, such as smallpox. 5 An infectious disease outbreak, either

naturally occurring or from an intentional release, may not be recognized
for a week or more because symptoms may not appear for several days after
the initial exposure, during which time a communicable disease could be
spread to those who were not initially exposed.

The initial response to an infectious disease of any type, including a
bioterrorist attack, is generally a local responsibility that could
involve multiple jurisdictions in a region, with states providing
additional support when needed. Figure 1 presents the probable series of
responses to a covert release of a biological agent. Just as in a
naturally occurring outbreak, exposed individuals would seek out local
health care providers, such as private physicians or medical staff in
hospital emergency departments or public clinics. Health care providers
would report any illness patterns or diagnostic clues that might indicate
an unusual infectious disease outbreak associated with the intentional
release of a biologic agent to their state or local health departments.

5 CDC developed a critical agent list that focuses on the biological
agents that would have the greatest impact on public health. This list
includes a category of agents identified by CDC as most likely to be used
in a bioterrorist attack and includes communicable diseases such as
smallpox and pneumonic plague. Background

Page 4 GAO- 03- 1176T Figure 1: Local, State, and Federal Entities
Involved in Response to the Covert Release of a Biological Agent

Page 5 GAO- 03- 1176T a Health care providers can also contact state
entities directly. b Federal departments and agencies can also respond
directly to local and state entities.

c The Strategic National Stockpile, formerly the National Pharmaceutical
Stockpile, is a repository of pharmaceuticals, antidotes, and medical
supplies that can be delivered to the site of a biological (or other)
attack.

In order to be adequately prepared for emerging infectious diseases in the
United States, state and local public health agencies need to have several
basic capabilities, whether they possess them directly or have access to
them through regional agreements. Public health departments need to have
disease surveillance systems and epidemiologists to detect clusters of
suspicious symptoms or diseases in order to facilitate early detection of
disease and treatment of victims. Laboratories need to have adequate
capacity and necessary staff to test clinical and environmental samples in

order to identify an agent promptly so that proper treatment can be
started

Page 6 GAO- 03- 1176T and infectious diseases prevented from spreading.
All organizations involved in the response must be able to communicate
easily with one

another as events unfold and critical information is acquired, especially
in a large- scale infectious disease outbreak. In the event of an
outbreak, hospitals and their emergency departments would be on the front
line, and their personnel would take on the role of first responders.
Because hospital emergency departments are open 24 hours a day, 7 days a
week, exposed individuals would be likely to seek treatment from the
medical staff on duty. Staff would need to be able to recognize and report
any illness patterns or diagnostic clues that might indicate an unusual
infectious disease outbreak to their state or local health department.
Hospitals would need to have the capacity and staff necessary to treat
severely ill patients and limit the spread of infectious disease.

The federal government also has a role in preparedness for and response to
major public health threats. It becomes involved in investigating the
cause of a disease, as it did with SARS. In addition, the federal
government provides funding and resources to state and local entities to
support preparedness and response efforts. CDC*s Public Health
Preparedness and Response for Bioterrorism program provided funding
through cooperative agreements in fiscal year 2002 totaling $918 million
to states and municipalities to improve bioterrorism preparedness and
response, as well as other public health emergency preparedness
activities. The funding supported development and improvements in a number
of areas CDC considers critical to preparedness and response, including
surveillance capacity to rapidly detect outbreaks of illness that may be
the result of bioterrorism or other public health threats.

HRSA*s Bioterrorism Hospital Preparedness Program provided funding through
cooperative agreements in fiscal year 2002 of approximately $125 million
to states and municipalities to enhance the capacity of hospitals and
associated health care entities to respond to bioterrorist attacks.
Earlier this month, HHS announced that approximately $870 million and $498
million have been provided for fiscal year 2003 through the CDC and HRSA
programs, respectively, to states and municipalities to continue these
efforts.

Page 7 GAO- 03- 1176T In the cities we visited, state and local officials
reported varying levels of public health preparedness to respond to
outbreaks of emerging infectious

diseases such as SARS. They recognized gaps in preparedness elements that
have been difficult to address, including the disease surveillance and
laboratory systems and the response capacity of the workforce. They also
were beginning to address gaps in preparedness elements such as
communication. We found that planning for regional coordination was
lacking between states.

States and local areas had weaknesses in some public health preparedness
elements, including the disease surveillance and laboratory systems and
the response capacity of the workforce. Gaps in capacity often are not
amenable to solution in the short term because either they require
additional resources or the solution takes time to implement. States and
local areas were addressing gaps in communication.

State and local officials for the cities we visited in early 2002
recognized and were attempting to address inadequacies in their
surveillance systems. Local officials were concerned that their
surveillance systems were inadequate to detect a bioterrorist event, and
all of the states we visited were making efforts to improve their disease
surveillance systems. Six of the cities we visited used a passive
surveillance system 6 to detect infectious disease outbreaks. 7 However,
passive systems may be inadequate to identify a rapidly spreading outbreak
in its earliest and most manageable stage because, as officials in three
states noted, there is chronic underreporting and a time lag between
diagnosis of a condition and the health department*s receipt of the
report. To improve disease surveillance, six of the states and two of the
cities we visited were developing surveillance systems using electronic
databases. Several cities

6 Passive surveillance systems rely on laboratory and hospital staff,
physicians, and other relevant sources to take the initiative to provide
data on illnesses to the health department, where officials analyze and
interpret the information as it arrives. In contrast, in an active disease
surveillance system, public health officials contact sources, such as
laboratories,

hospitals, and physicians, to obtain information on conditions or diseases
in order to identify cases. Active surveillance can provide more complete
detection of disease patterns than a system that is wholly dependent on
voluntary reporting. 7 Officials in one city told us that although it had
no local disease surveillance, its state maintained a passive disease
surveillance system. Despite Improvements, Gaps

Remain in Disease Surveillance Capabilities of State and Local Public
Health Agencies

Progress Has Been Made in Elements of Public Health Preparedness, but Gaps
Remain

Surveillance Systems

Page 8 GAO- 03- 1176T were also evaluating the use of nontraditional data
sources, such as pharmacy sales, to conduct surveillance. 8 Three of the
cities we visited

were attempting to improve their surveillance capabilities by
incorporating active surveillance components into their systems. For our
ongoing work, state and local officials told us that their surveillance
systems had improved somewhat. The officials reported that CDC funds have
enabled them make some of these improvements in their surveillance
systems, including the development of Web- based disease reporting and
active surveillance systems.

Officials from all of the states we visited in early 2002 reported
problems with their public health laboratory systems and said that they
needed to be upgraded. All states were planning to purchase the equipment
necessary for rapidly identifying a biological agent. State and local
officials in most of the areas that we visited told us that the public
health laboratory systems in their states were stressed, in some cases
severely, by the sudden and significant increases in workload during the
anthrax incidents in the fall of 2001. During these incidents, the demand
for laboratory testing was significant even in states where no anthrax was
found and affected the ability of the laboratories to perform their
routine public health functions. Following the incidents, over 70, 000
suspected anthrax samples were tested in laboratories across the country.
According to preliminary data from our interviews and review of 2003
progress reports, officials reported that CDC funds enabled them to make
improvements to their laboratory infrastructure, including upgrading their
laboratory facilities, purchasing reagents and equipment, and improving
their capability to test for select biologic agents.

Officials in the states we visited in 2002 were working on other solutions
to their laboratory problems. States were examining various ways to manage
peak loads, including entering into agreements with other states to
provide surge capacity, incorporating clinical laboratories into
cooperative laboratory systems, and purchasing new equipment. One state
was working to alleviate its laboratory problems by upgrading two local

8 This type of active surveillance system in which the public health
department obtains information from such sources as hospitals and
pharmacies and conducts ongoing analysis of the data to search for certain
combinations of signs and symptoms, is sometimes

referred to as a syndromic surveillance system. A senior HHS official
stated that research examining the usefulness of syndromic surveillance
needs to continue. See S. Lillibridge,

Disease Surveillance, Bioterrorism, and Homeland Security, Conference
Summary and Proceedings Prepared by the Annapolis Center for Science-
Based Public Policy (Annapolis, Md.: U. S. Medicine Institute for Health
Studies, Dec. 4, 2001). Laboratory Facilities

Page 9 GAO- 03- 1176T public health laboratories to enable them to process
samples of more dangerous pathogens and by establishing agreements with
other states to

provide backup capacity. Another state reported that it was using the
funding from CDC to increase the number of pathogens the state laboratory
could diagnose. The state also reported that it has worked to identify
laboratories in adjacent states that are capable of being reached within 3
hours over surface roads. In addition, all of the states reported that
their laboratory response plans had been revised to cover reporting and
sharing laboratory results with local public health and law enforcement
agencies.

At the time of our early 2002 site visits, shortages in personnel existed
in state and local public health departments and laboratories and were
difficult to remedy. Officials from state and local health departments
told us that staffing shortages were a major concern. Two of the states
and cities that we visited were particularly concerned that they did not
have enough epidemiologists to do the appropriate investigations in an
emergency. Officials at one state department of public health we visited
said that the department had lost approximately one- third of its staff
because of budget cuts over the past decade. This department had been
attempting to hire more epidemiologists. Barriers to finding and hiring

epidemiologists included noncompetitive salaries and a general shortage of
people with the necessary skills.

Workforce capacity issues may also hinder implementation of infectious
disease control measures. For example, the shortage of epidemiologists
could grow worse if, in the event of a severe outbreak, existing health
care workers became infected as a result of their more frequent exposure
to a contaminated environment or became exhausted working longer hours.
Workforce shortages could be further exacerbated because of the need to
conduct contact tracing. 9 According to World Health Organization
officials, an individual infected with SARS came in contact with, on
average, 30 to 40 people in Asian countries* all of whom had to be
contacted and

informed of their possible exposure. During our site visits in early 2002,
shortages in laboratory personnel were also cited. Officials in one city
noted that they had difficulty filling and maintaining laboratory
positions and that people that accepted the

9 Contact tracing is the identification and tracking of individuals who
may have been exposed to a person with a specific disease. Workforce

Page 10 GAO- 03- 1176T positions often left the health department for
better- paying positions. Increased funding for hiring staff cannot
necessarily solve these shortages

in the near term because for many types of laboratory positions there are
not enough trained individuals in the workforce. According to the
Association of Public Health Laboratories, training laboratory personnel
to provide them with the necessary skills will take time and require a
strategy for building the needed workforce. 10 For our current work
updating these findings, many of the state and local officials we
interviewed cited shortages in trained epidemiologists or laboratory
personnel as persistent.

In 2002, state and local officials told us that sustained funding would be
necessary to address one important need* hiring and retaining needed
staff. They told us they would be reluctant to hire additional staff
unless they were confident that the funding would be sustained and staff
could be retained. These statements are consistent with the findings of
the Advisory

Panel to Assess Domestic Response Capabilities for Terrorism Involving
Weapons of Mass Destruction, which recommended that federal support for
state and local public health preparedness and infrastructure building be
sustained at an annual rate of $1 billion for the next 5 years to have a
material impact on state and local governments* preparedness for a
bioterrorist event. 11 We have noted previously that federal, state, and
local governments have a shared responsibility in preparing for terrorist
attacks and other disasters. 12 However, prior to the infusion of federal
funds, few states were investing in their public health infrastructure.

10 Association of Public Health Laboratories, *State Public Health
Laboratory Bioterrorism Capacity,* Public Health Laboratory Issues in
Brief: Bioterrorism Capacity (Washington, D. C.: October 2002). 11
Advisory Panel to Assess Domestic Response Capabilities for Terrorism
Involving Weapons of Mass Destruction, Fourth Annual Report to the
President and the Congress of the Advisory Panel to Assess Domestic
Response Capabilities for Terrorism Involving

Weapons of Mass Destruction (Arlington, Va.: RAND, Dec. 15, 2002). The
Advisory Panel was established to assess federal agency efforts to enhance
domestic preparedness, the progress of federal training programs for local
emergency responses, and deficiencies in federal programs for response to
incidents involving weapons of mass destruction; to recommend strategies
for ensuring effective coordination of federal agency response efforts and
for ensuring fully effective local response capabilities for weapons of
mass

destruction incidents; and to assess appropriate state and local roles in
funding effective local response capabilities. The Advisory Panel issues
annual reports to the President and to the Congress and has submitted four
annuals reports to date.

12 See U. S. General Accounting Office, Homeland Security: Effective
Intergovernmental Coordination Is Key to Success, GAO- 02- 1013T
(Washington, D. C.: Aug. 23, 2002).

Page 11 GAO- 03- 1176T We found that officials were beginning to address
communication problems. For example, six of the seven cities we visited in
early 2002

were examining how communication would take place in a public health
emergency. Many cities had purchased communication systems that allow
officials from different organizations to communicate with one another in
real time. In addition, state and local health agencies were working with
CDC to build the Health Alert Network (HAN), an information and
communication system. The nationwide HAN program has provided funding to
establish infrastructure at the local level to improve the collection and
transmission of information related to public health preparedness. Goals
of the HAN program include providing high- speed Internet connectivity,
broadcast capacity for emergency communication, and distance- learning
infrastructure for training. For our current work, our preliminary review
of the 2003 progress reports from 12 jurisdictions shows that 11 reported
that over 90 percent of their population was covered by HAN.

As part of the effort to prepare for a possible outbreak of an infectious
disease, there is contingency planning at the state and local levels.
Health departments, for instance, are in the process of developing
contingency response plans for SARS. The SARS preparations have been
modeled after

a checklist designed for pandemic influenza. To facilitate these
preparations, the Association of State and Territorial Health Officials
and the National Association of County and City Health Officials, in
collaboration with CDC, published a checklist for state and local health

officials to use in the event of a SARS resurgence. 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.

During our 2002 site visits, however, we found that response organization
officials were concerned about a lack of planning for regional
coordination between states during an infectious disease outbreak. As
called for by the guidance for the CDC and HRSA funding, all of the states
we visited in 2002 organized their planning on the basis of regions within
their states, assigning local areas to particular regions for planning
purposes. A concern for response organization officials was the lack of
planning for regional coordination between states. A hospital official in
one city we visited said that state lines presented a *real wall* for
planning purposes. Hospital officials in one state reported that they had
no Communication

Some State and Local Contingency Planning Underway, but Regional
Coordination Is Lacking

Page 12 GAO- 03- 1176T agreements with other states to share physicians.
However, one local official reported that he had been discussing these
issues and had drafted

mutual aid agreements for hospitals and emergency medical services. Public
health officials from several states reported developing working
relationships with officials from other states to provide backup
laboratory capacity.

Because those with symptoms of an infectious disease might go to emergency
departments for treatment, hospital personnel would likely be some of the
first healthcare workers with the opportunity to identify an emerging
infectious disease outbreak. Therefore, the disease surveillance

capacities of many state and local public health systems may depend, in
part, on the surveillance capabilities of hospitals. Most hospitals
reported training their staff and planning coordination efforts with other
public health entities. However, even with these preparations in place,
hospitals lacked the capacity to respond to large- scale infectious
disease outbreaks.

The disease surveillance capacities of many state and local public health
systems may depend, in part, on the surveillance capabilities of
hospitals. During the recent SARS outbreak in North America, for instance,
hospital emergency rooms played an important role in identifying those who
had

the disease. According to hospital officials in California and New York,
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
asked individuals to identify themselves to hospital staff if they met
these criteria. In Toronto, which experienced a much greater prevalence of
SARS than the United States, everyone entering a hospital was required to
answer screening questions and to have their temperature checked before

they were allowed to enter. Hospital

Preparedness Improved, but Limitations in Response Capacity Remain

Hospitals Provide Vital Disease Surveillance Capacity

Page 13 GAO- 03- 1176T In our survey of over 2,000 metropolitan hospitals,
13 most reported that they have provided training to staff on biological
agents, but fewer than

half have participated in drills or exercises related to bioterrorism.
Most hospitals we surveyed reported providing training about identifying
and diagnosing symptoms for the six biological agents identified by the
CDC as

most likely to be used in a bioterrorist attack. At least 90 percent of
hospitals reported providing training for two of these agents* smallpox
and anthrax* and approximately three- fourths of hospitals reported
providing training about the other four* plague, botulism, tularemia, and
hemorrhagic fever viruses.

Our hospital survey found that 4 out of 5 hospitals reported having a
written emergency response plan for large- scale infectious disease
outbreaks. Of the hospitals with emergency response plans, most include a
description of how to achieve surge capacity for obtaining additional
pharmaceuticals, other supplies, and staff. In addition, almost all
hospitals reported participating in community interagency disaster
preparedness committees.

At the time of our site visits between December 2001 and March 2002, we
found that hospitals were beginning to coordinate with other local
response organizations and collaborate with each other in local planning
efforts. Hospital officials in one city we visited told us that until
September 11, 2001, hospitals were not seen as part of a response to a
terrorist event but that city officials had come to realize that the first
responders to a bioterrorism incident could be a hospital*s medical staff.
Officials from the state began to emphasize the need for a local approach
to hospital preparedness. They said, however, that it was difficult to
impress the importance of cooperation on hospitals because hospitals had
not seen themselves as part of a local response system. The local
government officials were asking them to create plans that integrated the
city*s hospitals and addressed such issues as off- site triage of patients
and offsite acute care.

13 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. Most Hospitals Reported Planning and Training

Efforts, but Fewer Than Half Have Participated in Drills or Exercises

Page 14 GAO- 03- 1176T Our survey of metropolitan hospitals found that
most emergency departments have experienced some degree of overcrowding.
14 Persons

with symptoms of infectious disease would potentially go to emergency
departments for treatment, further stressing these facilities. The problem
of overcrowding is much more pronounced in some hospitals and areas than
in others. In general, hospitals that reported the most problems with
crowding were in the largest metropolitan statistical areas (MSA) and in

the MSAs with high population growth. For example, in fiscal year 2001,
hospitals in MSAs with populations of 2.5 million or more had about 162
hours of diversion (an indicator of crowding), 15 compared with about 9
hours for hospitals in MSAs with populations of less than 1 million. Also,
the median number of hours of diversion in fiscal year 2001 for hospitals
in MSAs with a high percentage population growth was about five times that
for hospitals in MSAs with lower percentage population growth.

Hospitals in the largest MSAs and in MSAs with high population growth that
have reported crowding in emergency departments may have difficulty
handling a large influx of patients during a potential infectious disease
outbreak, especially if this outbreak occurred in the winter months when
the incidence of influenza is quite high. For example, public health
officials with whom we spoke said that in the event of a large- scale SARS
outbreak, entire hospital wards may need to be used as separate SARS

isolation facilities. Moreover, certain hospitals within a community may
need to be designated as SARS hospitals.

Efforts at the state and local level have improved the ability to identify
and respond to infectious disease outbreaks and bioterrorism. These
improvements have included upgrades to laboratory facilities and
communication systems. Hospitals have also begun planning and training
efforts to respond to large- scale infectious disease outbreaks. Despite
these improvements, gaps in preparedness remain. We found that some
disease surveillance systems may be inadequate, that there are shortages
of key personnel in some localities, and that most hospital emergency
departments across the country have experienced some degree of
overcrowding, which could be exacerbated during a disease outbreak.

14 GAO- 03- 460. 15 Diversions occur when hospitals request that en route
ambulances bypass their emergency departments and transport patients that
would have otherwise been taken to those emergency departments to other
medical facilities. Most Emergency Departments Have

Experienced Some Degree of Crowding

Concluding Observations

Page 15 GAO- 03- 1176T 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 further information about this testimony, please contact Janet
Heinrich at (202) 512- 7119. Angela Choy, Krister Friday, Martin T.
Gahart, Gay Hee Lee, and Deborah Miller also made key contributions to
this statement. Contact and Staff

Acknowledgments

Page 16 GAO- 03- 1176T Hospital Preparedness: Most Urban Hospitals Have
Emergency Plans but Lack Certain Capacities for Bioterrorism Response.
GAO- 03- 924.

Washington, D. C.: August 6, 2003.

Severe Acute Respiratory Syndrome: Established Infectious Disease Control
Measures Helped Contain Spread, But a Large- Scale Resurgence May Pose
Challenges. GAO- 03- 1058T. Washington, D. C.: July 30, 2003.

Bioterrorism: Information Technology Strategy Could Strengthen Federal
Agencies* Abilities to Respond to Public Health Emergencies.

GAO- 03- 139. Washington, D. C.: May 30, 2003.

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. Related GAO Products

Page 17 GAO- 03- 1176T 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.

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.

(290327)

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