HHS Bioterrorism Preparedness Programs: States Reported Progress 
but Fell Short of Program Goals for 2002 (10-FEB-04,		 
GAO-04-360R).							 
                                                                 
The anthrax incidents during the fall of 2001 raised concerns	 
about the nation's ability to respond to bioterrorist events and 
other public health threats. The incidents strained the public	 
health system, including surveillance and laboratory workforce	 
capacities, at the state and local levels. Several months after  
the incidents, the Congress appropriated funds to strengthen	 
state and local bioterrorism preparedness. The Department of	 
Health and Human Services' (HHS) Centers for Disease Control and 
Prevention (CDC) and Health Resources and Services Administration
(HRSA) distributed the funds in 2002 through two cooperative	 
agreement programs with state, municipal, and territorial	 
governments. To strengthen preparedness, the two cooperative	 
agreement programs--CDC's Public Health Preparedness and Response
for Bioterrorism Program and HRSA's National Bioterrorism	 
Hospital Preparedness Program--require participants to complete  
specific activities designed to build public health and health	 
care capacities. The 2002 cooperative agreements for both	 
programs ended on August 30, 2003. For the 2002 cooperative	 
agreements, CDC's and HRSA's programs distributed approximately  
$918 million and approximately $125 million, respectively. The	 
Public Health Security and Bioterrorism Preparedness and Response
Act of 2002 directs us to report on federal programs that support
preparedness efforts at the state and local levels. We have	 
previously reported on state and local efforts and hospital	 
preparedness. As agreed with the committees of jurisdiction, for 
this report, we examined the extent to which states completed	 
2002 cooperative agreement requirements and whether states	 
identified any factors that hindered implementation of CDC's	 
program and HRSA's program.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-360R					        
    ACCNO:   A09245						        
  TITLE:     HHS Bioterrorism Preparedness Programs: States Reported  
Progress but Fell Short of Program Goals for 2002		 
     DATE:   02/10/2004 
  SUBJECT:   Biological warfare 				 
	     Chemical and biological agents			 
	     Emergency preparedness				 
	     Health services administration			 
	     Strategic planning 				 
	     Terrorism						 
	     National preparedness				 
	     Federal/state relations				 
	     Performance measures				 
	     Emergency medical services 			 
	     CDC Public Health Preparedness and 		 
	     Response for Bioterrorism Program			 
                                                                 
	     HRSA Bioterrorism Hospital Preparedness		 
	     Program						 
                                                                 

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GAO-04-360R

United States General Accounting Office Washington, DC 20548

February 10, 2004

Congressional Committees

Subject: HHS Bioterrorism Preparedness Programs: States Reported Progress
but Fell Short of Program Goals for 2002

The anthrax incidents during the fall of 2001 raised concerns about the
nation's ability to respond to bioterrorist events and other public health
threats. The incidents strained the public health system, including
surveillance1 and laboratory workforce capacities, at the state and local
levels.2 Several months after the incidents, the Congress appropriated
funds to strengthen state and local bioterrorism preparedness.3 The
Department of Health and Human Services' (HHS) Centers for Disease Control
and Prevention (CDC) and Health Resources and Services Administration
(HRSA) distributed the funds in 2002 through two cooperative agreement
programs with state, municipal, and territorial governments.4

To strengthen preparedness, the two cooperative agreement programs-CDC's
Public Health Preparedness and Response for Bioterrorism Program and
HRSA's National Bioterrorism Hospital Preparedness Program-require
participants to complete specific activities designed to build public
health and health care capacities. The 2002 cooperative agreements for
both programs ended on August 30, 2003. For the 2002

1Public health surveillance uses systems that provide for the ongoing
collection, analysis, and dissemination of health-related data to
identify, prevent, and control disease.

2See U.S. General Accounting Office, Bioterrorism: Public Health Response
to Anthrax Incidents of 2001, GAO-04-152 (Washington, D.C.: Oct. 15,
2003).

3Department of Defense and Emergency Supplemental Appropriations for
Recovery from and Response to Terrorist Attacks on the United States Act,
Pub. L. No. 107-117, 115 Stat. 2230, 2314 (2002), and the Departments of
Labor, Health and Human Services and Education, and Related Agencies
Appropriations Act of Fiscal Year 2002, Pub. L. No. 107-116, 115 Stat.
2186, 2198.

4A cooperative agreement is used as a mechanism to provide financial
support when substantial interaction is expected between the executive
agency and a state, local government, or other recipient carrying out the
funded activity. Under their programs, CDC and HRSA made funding available
to the following: all 50 states; the District of Columbia; the country's
three largest municipalities (New York City, Chicago, and Los Angeles
County); the territories of American Samoa, Guam, and the U.S. Virgin
Islands; and the commonwealths of the Northern Mariana Islands and Puerto
Rico. CDC also made funding available to the republics of Palau and the
Marshall Islands and the Federated States of Micronesia.

cooperative agreements, CDC's and HRSA's programs distributed
approximately $918 million and approximately $125 million, respectively.5

The Public Health Security and Bioterrorism Preparedness and Response Act
of 2002 directs us to report on federal programs that support preparedness
efforts at the state and local levels.6 We have previously reported on
state and local efforts and hospital preparedness.7 As agreed with the
committees of jurisdiction, for this report, we examined the extent to
which states completed 2002 cooperative agreement requirements and whether
states identified any factors that hindered implementation of CDC's
program and HRSA's program. In this report, we use the term "state" to
refer to the 50 states, the District of Columbia, New York City, Chicago,
and Los Angeles County. Enclosure I contains the information we provided
during our January 14, 2004 briefing of your staff.

To determine the extent to which states had completed program
requirements, we relied primarily on the cooperative agreement progress
reports that CDC and HRSA required the states to submit. We checked the
data for internal consistency as well as consistency with other sources
and determined that they were adequate for our purposes. We reviewed
semi-annual progress reports submitted by the states, covering the period
through August 30, 2003, for CDC's program and through July 1, 2003, for
HRSA's program.8 For a number of reasons, we use broad categories to
describe the degree of progress states have made in completing
requirements. These reasons include: CDC and HRSA changed the reporting
formats over the course of the agreements, states had varying
interpretations of what constituted completion of the requirements, and
the final reports do not reflect follow-up by CDC and HRSA to clarify
states' responses. We also interviewed officials and reviewed relevant
documents from CDC, HRSA, and HHS's Office of the Assistant Secretary for
Public Health Emergency Preparedness. We also interviewed officials from
10 states, 1 local health department within each of these states, and 2
major metropolitan areas directly funded by CDC and HRSA.9 The program
participants are not identified in this report because of the sensitive
nature of the issue. In addition, we interviewed representatives and
reviewed documents from the Association of State and

5In 2003, the Congress appropriated additional funds for bioterrorism
preparedness. Consolidated Appropriations Resolution, 2003, Pub. L. No.
108-7, Division G, Title II, 117 Stat. 11, 322. HHS renewed the
cooperative agreements for the period of August 31, 2003 through August
30, 2004. CDC's and HRSA's programs distributed about $870 million and
about $498 million, respectively.

6Pub. L. No. 107-188, S: 157, 116 Stat. 594, 633 (2002).

7U.S. General Accounting Office, Bioterrorism: Preparedness Varied across
State and Local Jurisdictions, GAO-03-373 (Washington, D.C.: Apr. 7,
2003), and Hospital Preparedness: Most Urban Hospitals Have Emergency
Plans but Lack Certain Capacities for Bioterrorism Response, GAO-03-924
(Washington, D.C.: Aug. 6, 2003).

8The final progress report for one state was missing for the CDC program.
HRSA did not require states to complete some of the requirements until
March 31, 2004.

9

We selected these program participants in order to provide a range of
population sizes, geographic locations, and experience with responding to
disasters and conducting large drills and exercises. Each of the 10 local
health departments in our sample serves a major metropolitan area within a
state.

Territorial Health Officials and the American Hospital Association and its
affiliates. We reviewed documents from the National Association of County
and City Health Officials, the Council of State and Territorial
Epidemiologists, and the Association of Public Health Laboratories. We
performed our work from June 2003 through February 2004 in accordance with
generally accepted government auditing standards.

Results

States reported progress toward the CDC program's goal of strengthening
public health preparedness, but identified factors that hindered them from
meeting all of CDC's 2002 cooperative agreement requirements. All states
reported progress in developing the capacities CDC considers critical for
public health preparedness, but no state completed all program
requirements. Some of the 14 requirements that CDC considers critical
benchmarks of preparedness were more likely to be completed than others.
Four critical benchmarks were met by most of the states. These benchmarks
included the establishment of a bioterrorism advisory committee and
coverage of 90 percent of the state's population by the Health Alert
Network-a nationwide program designed to ensure communication capacity at
all state and local health departments. Two critical benchmarks were met
by few of the states: development of a statewide response plan and
development of a regional response plan. The remaining eight critical
benchmarks were met by around half the states. These benchmarks included
assessment of emergency preparedness and response capabilities,
development of a system that can receive and evaluate urgent disease
reports at all times, and development of an interim Strategic National
Stockpile10 plan. In addition, state and local officials reported three
main factors that hindered their ability to complete all of CDC's
requirements: (1) redirection of resources to the National Smallpox
Vaccination Program,11 (2) difficulties in increasing personnel as a
result of state and local budget deficits, and (3) delays caused by state
and local management practices, such as contracting and hiring procedures.

Similarly, states reported progress toward the HRSA program's goal of
strengthening hospital preparedness but identified factors that have
hindered their efforts to complete all of HRSA's 2002 program
requirements. While no state has completed all of HRSA's requirements-to
conduct needs assessments, to meet three critical benchmarks of hospital
preparedness, and to address priority issues-states have until March 31,
2004, to complete most of them. No state reported completing all
components of its needs assessment. Almost all states reported that they
had met two of the three critical benchmarks: designation of a coordinator
for hospital preparedness planning and establishment of a hospital
preparedness planning

10The Strategic National Stockpile, formerly the National Pharmaceutical
Stockpile, is a repository of pharmaceuticals and medical supplies that
can be delivered to the site of a biological or other attack.

11In December 2002, HHS directed states to offer smallpox vaccination to
public health and health care workers; however, additional funds ($100
million) were not made available to carry out the vaccinations until May
2003. For more information on the National Smallpox Vaccination Program,
see U.S. General Accounting Office, Smallpox Vaccination: Implementation
of National Program Faces Challenges, GAO-03-578 (Washington, D.C.: Apr.
30, 2003).

committee. No state reported meeting the third benchmark-development of a
plan for the hospitals in the state to respond to an epidemic involving at
least 500 patients. States reported varying degrees of progress in
addressing the priority issues that HRSA required them to address, such as
receipt and distribution of medications and vaccines, personal protection
of health care workers, quarantine capacity, and communications. State
officials expressed concern that HRSA funding was insufficient for states
to meet the requirements of the 2002 program. Similarly, hospital
representatives reported that redirection of resources to the National
Smallpox Vaccination Program and delays caused by lengthy contracting
processes for distributing funds from the state to the hospitals hindered
efforts to implement the program.

In summary, although the states' progress fell short of 2002 program
goals, CDC's and HRSA's cooperative agreement programs have enabled states
to make much needed improvements in the public health and health care
capacities critical for preparedness. States are more prepared now than
they were prior to these programs, but much remains to be accomplished.

Agency Comments

We provided a draft of this report to HHS. HHS informed us that it had no
comment on the draft report but provided technical comments, which we
incorporated where appropriate.

We are sending copies of this report to the Secretary of HHS, the Director
of CDC, the
Administrator of HRSA, and other interested officials. We will also
provide copies to
others upon request. In addition, the report will be available at no
charge on the GAO
Web site at http://www.gao.gov.

If you or your staff have any questions or need additional information,
please contact
me at (202) 512-7119. Another contact and key contributors are listed in
enclosure III.

Janet Heinrich
Director, Health Care-Public Health Issues

Enclosures - 3

List of Committees

The Honorable Judd Gregg
Chairman
The Honorable Edward M. Kennedy
Ranking Minority Member
Committee on Health, Education, Labor, and Pensions
United States Senate

The Honorable Ted Stevens
Chairman
The Honorable Robert C. Byrd
Ranking Minority Member
Committee on Appropriations
United States Senate

The Honorable W.J. "Billy" Tauzin
Chairman
The Honorable John D. Dingell
Ranking Minority Member
Committee on Energy and Commerce
House of Representatives

The Honorable C.W. Bill Young
Chairman
The Honorable David R. Obey
Ranking Minority Member
Committee on Appropriations
House of Representatives

HHS Bioterrorism Preparedness Programs: States Reported Progress but Fell Short
                           of Program Goals for 2002

                        Briefing for Congressional Staff

 Senate Committee on Health, Education, Labor, and Pensions Senate Committee on
                                 Appropriations

    House Committee on Energy and Commerce House Committee on Appropriations

                                January 14, 2004

                             Congressional Mandate

The Public Health Security and Bioterrorism Preparedness and Response Act
of 2002 directs us to report on federal programs that support preparedness
efforts at the state and local levels

We previously reported that although preparedness efforts had improved the
ability of state and local jurisdictions to respond to infectious disease
outbreaks and other major public health threats, gaps in preparedness
remained

We also reported that most urban hospitals lacked certain health care
capacities for bioterrorism response

                                   Objectives

Examine extent to which states completed 2002 cooperative agreement
requirements and whether states identified any factors that hindered
implementation of

o  CDC's program for Public Health Preparedness and Response for
Bioterrorism

o  HRSA's National Bioterrorism Hospital Preparedness Program

                             Scope and Methodology

We reviewed the 2002 cooperative agreement semi-annual progress reports CDC and
                        HRSA required states1 to submit

CDC's progress reports covered the period from February 19, 2002 through
August 30, 2003

HRSA's progress reports covered the period from April 1, 2002 through July
1, 2003

1"State" refers to the 50 states, the District of Columbia, and the three
municipalities that participate in the cooperative agreement programs (New
York City, Chicago, and Los Angeles County).

                         Scope and Methodology (cont.)

We checked the data for internal consistency as well as consistency with
other sources and determined that they were adequate for our purposes

For a number of reasons, we use broad categories to describe the degree of
progress states have made in completing requirements, including

o 	CDC and HRSA introduced new formats for the final progress reports

o 	States had varying interpretations of what constituted completion of
the requirements

o 	The progress reports do not reflect follow-up by CDC and HRSA to
clarify states' responses

                         Scope and Methodology (cont.)

We interviewed officials from 10 states,1 local health department within
each of these states, and 2 metropolitan areas

We interviewed officials and reviewed relevant documents from CDC, HRSA
and HHS's Office of the Assistant Secretary for Public Health Emergency
Preparedness

We interviewed representatives from professional organizations
representing state health officials and hospitals

Goal of CDC and HRSA Cooperative Agreement Programs

The common goal of the CDC and HRSA cooperative agreement programs is to
improve state and local preparedness to respond to bioterrorist events and
other public health emergencies

The focus of CDC's program is public health preparedness

The focus of HRSA's program is hospital preparedness

CDC Funding of Public Health Preparedness and Response for Bioterrorism

In 1999, CDC began funding states as part of HHS's Bioterrorism Initiative
to improve the nation's public health capacity to respond to bioterrorism

                       Fiscal Year Funding (in millions)

                                   1999 $40.7

                                   2000 $41.9

                                   2001 $49.9

                                  2002 $918.0

                                  2003 $870.02

2 Although 2002 funding for CDC's program included support for activities
connected with the Strategic National Stockpile, its 2003 funding did not
because responsibility for funding these activities had been transferred
to the Department of Homeland Security in March 2003.

Note: In May 2003, HHS announced that an additional $100 million would be
available to states for their smallpox vaccination programs.

Distribution of CDC's 2002 Funding

CDC distributed $5 million plus a per capita amount to each state

States had flexibility on how to distribute CDC funds to local health
agencies; allocation formulas used by states included

o  Base amounts plus per capita amounts

o 	Larger amounts to designated local health agencies with regional
coordination responsibilities

o  Larger amounts to selected local health agencies for specific projects

The proportion of total funds that states reported distributing directly
to local health agencies varied

CDC Identified Focus Areas to Improve Public Health Capacity

o  Preparedness Planning and Readiness Assessment

o  Surveillance and Epidemiology3

o  Laboratories (Biologic Agents)

o  Health Alert Network/Communications and Information Technology

o  Risk Communication and Health Information Dissemination

o  Education and Training

3Epidemiology is the study of the distribution and causes of disease or
injury in a population. 10

CDC Identified Capacities That Are Critical for States to Be Prepared

Within the focus areas, CDC identified a total of 16 critical capacities
for preparedness

Under the critical capacities, CDC specified a total of 74 requirements,
and allowed states to determine what specific activities to undertake to
complete the requirements

CDC required states to complete the requirements by the end of the 2002
cooperative agreement

CDC designated 14 of these requirements as critical benchmarks for
tracking progress4

4See enclosure II. 11

Example of CDC Requirements for States

                                       12

                           How CDC Monitors Progress

To monitor states' implementation of 2002 cooperative agreements, CDC

o 	Required states to submit semi-annual progress reports that track
states' progress toward completion of requirements

o  Conducted site visits

o  Assigned project officers (who also provided technical assistance)

                                       13

HRSA Funding of National Bioterrorism Hospital Preparedness Program

HRSA's program was established in 2002 to facilitate state and regional
planning with local hospitals, emergency medical services systems, and
other health care facilities to improve the capacity to respond to
bioterrorist attacks and other public health emergencies

                       Fiscal Year Funding (in millions)

                                   2002 $125

                                   2003 $498

                                       14

Distribution of HRSA's 2002 Funding

HRSA distributed $250,000 plus a per capita amount to each state5 and
required that at least 74 percent of the funds be allocated to hospitals
or other health care entities

The remaining amount supported states' administrative costs and needs
assessments

States distributed most of the funds to hospitals; a small portion went to
other entities, such as community health centers, emergency medical
services, and poison control centers

5The base allocation was $500,000 for the District of Columbia. 15

Distribution of HRSA's 2002 Funding (cont.)

Some states administered HRSA funds themselves; others
through hospital associations
Allocation formulas used by states included

o  Equal allotment to each hospital

o  Amounts based on emergency department admissions

o  Higher levels of funding to larger hospitals

State officials we interviewed reported that the funds allocated to
individual hospitals ranged from $1,000 to $80,000

                                       16

                               HRSA Requirements

HRSA required states to

o  Conduct needs assessments

o  Meet critical benchmarks

o  Address priority issues

HRSA required states to complete requirements by March 31, 2004

                                       17

                           HRSA Requirements (cont.)

HRSA required states to meet the following three critical benchmarks

o 	Designation of a coordinator for bioterrorism hospital preparedness
planning6

o  Establishment of a hospital preparedness planning committee6

o 	Development of a plan for the hospitals in the state to respond to a
potential epidemic involving at least 500 patients

6HRSA required these critical benchmarks to be met within the first few
months of the program. 18

                           HRSA Requirements (cont.)

HRSA identified priority issues for states to address

o  Medications and Vaccines (stockpile receipt and distribution)

o 	Personal Protection (for heath care workers and patients), quarantine,
and decontamination

o  Communications

o  Biological Disaster Drills

o  Personnel (i.e., hospital and emergency medical services)  o Training

o  Patient Transfer

         Note: HRSA put a higher priority on the first four issues. 19

How HRSA Monitors Progress

To monitor states' implementation of 2002 cooperative agreements, HRSA

o  Required states to submit semi-annual progress reports

o  Conducted site visits

o  Assigned project officers (who also provided technical assistance)

                                       20

Progress on CDC Requirements

States reported progress in completing CDC's 2002 cooperative agreement
requirements

However, states identified factors that hindered them from completing all
requirements by August 30, 2003

                                       21

Progress Reported but No State Completed All of CDC's 2002 Requirements

All states reported progress in developing the capacities CDC considers
critical for public health preparedness

However, no state completed all requirements Some of the 14 requirements
that CDC designated as critical benchmarks were more likely to be
completed than others

                                       22

CDC Critical Benchmarks: 4 of 14 Reported Met by Most States

Each of the following four critical benchmarks was reported met by most
states by August 30, 2003

o 	Designation of an executive director of the bioterrorism preparedness
and response program

o  Establishment of a bioterrorism advisory committee

o 	Assessment of epidemiologic capacity and achievement of the goal of at
least one epidemiologist for each Metropolitan Statistical Area

o  Coverage of 90 percent of the population by the Health Alert Network

                                       23

CDC Critical Benchmarks: 2 of 14 Reported Met by Few States

Each of the following two critical benchmarks was reported met by few
states

o 	Development of statewide response plan for incidents of bioterrorism
and other public health threats and emergencies and provisions for
exercising the plan

o 	Development of regional response plan across state borders for
incidents of bioterrorism and other public health threats and emergencies

                                       24

CDC Critical Benchmarks: 8 of 14 Reported Met by Around Half the States

Each of the remaining eight critical benchmarks was reported met by around
half the states

o  Assessment of emergency preparedness and response capabilities

o 	Assessment of statutes, regulations, and ordinances that provide for
credentialing, licensure, and delegation of authority for executing
emergency public health measures

o 	Development of interim plan to receive and manage items from the
Strategic National Stockpile

o  Development of a system to receive and evaluate urgent disease reports
at all times

o 	Development of a plan to improve working relationships and
communication between clinical and public health laboratories

o 	Development of a communications system that provides for flow of
critical health information at all times

o  Development of an interim plan for risk communication

o  Preparation of a timeline to assess training needs

                                       25

Factors Cited as Hindering Completion of CDC's 2002 Requirements

State and local officials identified three main factors that hindered
their ability to complete program requirements

o 	Redirection of resources to the National Smallpox Vaccination Program

o 	Difficulties in increasing personnel as a result of state and local
budget deficits

o  Delays caused by state and local management practices

                                       26

National Smallpox Vaccination Program

CDC directed states to offer vaccinations to public health and health care
workers beginning January 24, 2003, and expected vaccinations to be
completed within 30 days;however, no additional funds were provided until
May 20037

Many states reported that the smallpox vaccination program disrupted their
general bioterrorism preparedness activities because personnel and
resources were redirected to implement the program

7CDC instructed states to redirect funds previously distributed under the
2002 cooperative agreement 27 program.

Budget Deficits and Management Practices

         State and local officials reported that budget deficits led to

o  Hiring freezes

o  Reductions in public health personnel

State and local officials also reported that management practices delayed
hiring and distribution of funds

o  Salary levels led to difficulties in attracting and retaining personnel

o 	Lengthy contracting procedures delayed distribution of funds to local
health agencies

                                       28

Progress on HRSA Requirements

States reported progress in completing HRSA's 2002 cooperative agreement
requirements

However, states identified factors that have hindered their efforts to
complete HRSA requirements

While no state reported completing all HRSA requirements, states have
until March 31, 2004, to complete them

                                       29

Progress Reported on Needs Assessments Required by HRSA

No state reported completing all components of its needs assessment

For example, most states reported that they had not yet identified

o 	Which hospitals in the state to target for capital improvements (e.g.,
for quarantine and decontamination)

o 	The need for bioterrorism-related diagnostic and treatment protocols
and mechanisms to bring clinicians up to speed on these protocols

                                       30

                          Progress on HRSA Benchmarks

Almost all states reported meeting two of the three critical benchmarks of
preparedness required by HRSA

o  Designation of a coordinator for hospital preparedness planning

o  Establishment of a hospital preparedness planning committee

No state reported meeting the third benchmark-a plan for the hospitals in
the state to respond to an epidemic involving at least 500 patients

                                       31

Progress on Third HRSA Benchmark

Components of a hospital response plan not reported as complete by most
states included

o 	Mechanism to ensure the movement of equipment maintained by hospitals
or emergency medical services systems to the scene of a bioterrorist event

o 	System that allows for the delivery of essential goods and services to
patients and hospitals during an incident

o 	System to ensure access to medically appropriate care to children,
pregnant women, the elderly and those with disabilities during a terrorist
incident

                                       32

Progress on HRSA Priority Issues

States reported varying degrees of progress in addressing priority issues,
for example, the extent to which they had developed mechanisms

o 	To stage prophylaxis and immunization clinics for large numbers of
patients

o  That provide redundancy in communication systems

                                       33

States Reported Factors Hindering Implementation of HRSA's Program

State officials expressed concern that HRSA funding was insufficient to
accomplish the 2002 goals of the cooperative agreement program; some
reported that HRSA funds were spread thinly across many hospitals and
other health care entities

                                       34

Hospital Representatives Reported Factors Hindering Implementation of
HRSA's Program

Hospital representatives reported two factors that hindered efforts to
implement the cooperative agreements

o 	Redirection of resources to the National Smallpox Vaccination Program

o 	Delays caused by lengthy contracting processes for distributing funds
from the states to hospitals

                                       35

                            Concluding Observations

Although states' progress fell short of 2002 program goals, CDC's and
HRSA's cooperative agreement programs have enabled states to make much
needed improvements in the public health and health care capacities
critical for preparedness

States are more prepared now than they were prior to these programs, but
much remains to be accomplished

                                       36

      CDC Focus Areas, Critical Capacities, and Critical Benchmarks (2002)

To strengthen public health preparedness, CDC identified focus areas for
states to improve their public health capacity. Within each focus area,
CDC identified the specific capacities that are critical for states to be
prepared to respond to a bioterrorist event or other public health
emergency. To guide states in building these critical capacities, CDC
specified a number of requirements for the 2002 cooperative agreements,
and designated some of them as critical benchmarks. Table 1 lists the
focus areas and their associated critical capacities and critical
benchmarks.

Table 1: CDC Focus Areas, Critical Capacities, and Critical Benchmarks for
the 2002 Cooperative Agreements

Focus area Critical capacity Critical benchmark

Focus area A: Preparedness Planning and Readiness Assessment

Critical capacity #1: To establish a process for Critical benchmark #1:
Designate strategic leadership, direction, coordination, and an executive
director of the assessment of activities to ensure state and local
bioterrorism preparedness and readiness, interagency collaboration, and
preparedness response program. for bioterrorism, other outbreaks of
infectious disease, Critical benchmark #2: Establishand other public
health threats and emergencies. a bioterrorism advisory committee.

Critical capacity #2: To conduct integrated assessments of public health
system capacities related to bioterrorism, other infectious disease
outbreaks, and other public health threats and emergencies to aid and
improve planning, coordination, and implementation.

Critical benchmark #3:

Assessment of emergency preparedness and response capabilities.

Critical benchmark #4:

Assessment of statutes, regulations, and ordinances that provide for
credentialing, licensure, and delegation of authority for executing
emergency public health measures.

Critical capacity #3: To respond to emergencies Critical benchmark #5:
caused by bioterrorism, other infectious disease Development of a
statewide outbreaks, and other public health threats and response plan and
provisions for emergencies through the development and exercise of
exercising the plan. a comprehensive public health emergency Critical
benchmark #6:

preparedness and response plan.	Development of regional response plans.

Critical capacity #4: To ensure that state, local, and Critical benchmark
#7: Develop regional preparedness for and response to bioterrorism, an
interim plan to receive and other infectious outbreaks, and other public
health manage items from the Strategic threats and emergencies are
effectively coordinated National Stockpile (SNS). with federal response
assets.

Critical capacity #5: To effectively manage the CDC No critical benchmarks
were
SNS, should it be deployed-translating SNS plans into identified for 2002
cooperative
firm preparations, periodic testing of SNS agreements.
preparedness, and periodic training for entities and
individuals that are part of SNS preparedness.

Focus area Critical capacity Critical benchmark

              Focus area B: Surveillance and Epidemiology Capacity

Critical capacity #6: To rapidly detect a terrorist event through a highly
functioning, mandatory reportable disease surveillance system, as
evidenced by ongoing timely and complete reporting by providers and
laboratories, especially of illnesses and conditions possibly resulting
from bioterrorism, other infectious disease outbreaks, and other public
health threats and emergencies.

Critical capacity #7: To rapidly and effectively investigate and respond
to a potential terrorist event as evidenced by a comprehensive and
exercised epidemiologic response plan that addresses surge capacity,
delivery of mass prophylaxis and immunizations, and pre-event development
of specific epidemiologic investigation and response needs.

Critical benchmark #8: Develop a system to receive and evaluate urgent
disease reports on a 24hour-per-day, 7-day-per-week basis.

Critical benchmark #9: Assess current epidemiologic capacity and achieve
the goal of at least one epidemiologist for each metropolitan statistical
area.

Critical capacity #8: To rapidly and effectively No critical benchmarks
were
investigate and respond to a potential terrorist event, as identified for
2002 cooperative
evidenced by ongoing effective state and local agreements.
response to naturally occurring individual cases of
urgent public health importance, outbreaks of disease,
and emergency public health interventions such as
emergency chemoprophylaxis or immunization
activities.

               Focus area C: Laboratory Capacity-Biologic Agents

Critical capacity #9: To develop and implement a Critical benchmark #10:
Develop statewide program to provide rapid and effective a plan to improve
working laboratory services in support of the response to relationships
and communication bioterrorism, other infectious disease outbreaks, and
between clinical labs and higher other public health threats and
emergencies. level Laboratory Response

Network (LRN)a labs.

Critical capacity #10: As an LRN member, to ensure No critical benchmarks
were
adequate and secure laboratory facilities, reagents, and identified for
2002 cooperative
equipment to rapidly detect and correctly identify agreements.
biological agents likely to be used in a bioterrorist
incident.

               Focus area D: Laboratory Capacity-Chemical Agents

No critical capacities/benchmarks were identified for 2002 cooperative
agreements.

Focus area E: Health Alert Network/Communications and Information
Technology

Critical capacity #11: To ensure effective Critical benchmark #11: Ensure
communications connectivity among public health that 90 percent of the
population is
departments, health care organizations, law covered by the Health Alert
enforcement organizations, public officials, and others Network.
by: (a) continuous, high-speed connectivity to the Critical benchmark #12:
Develop
Internet; (b) routine use of e-mail for notification of a communications
system that
alerts and other critical communication; and (c) a provides a
24-hour-per-day, 7-day
directory of public health participants (including primary per-week flow
of critical health
clinical personnel), their roles, and contact information information.
covering all jurisdictions.

Critical capacity #12: To ensure a method of No critical benchmarks were
emergency communication for participants in public identified for 2002
cooperative
health emergency response that is fully redundant with agreements.
e-mail.

Critical capacity #13: To ensure the ongoing protection of critical data
and information systems and identified for 2002 cooperative capabilities
for continuity of operations. agreements.

No critical benchmarks were

Focus area Critical capacity Critical benchmark

Critical capacity #14: To ensure secure electronic No critical benchmarks
were
exchange of clinical, laboratory, environmental, and identified for 2002
cooperative
other public health information in standard formats agreements.
between the computer systems of public health
partners.

     Focus area F: Risk Communication and Health Information Dissemination

Critical capacity #15: To provide needed health/risk Critical benchmark
#13: Develop
information to the public and key partners during a an interim plan for
risk
terrorism event by establishing critical baseline communication and
information
information about the current communication needs and dissemination.
barriers within individual communities, and identifying
effective channels of communication for reaching the
general public and special populations during public
health threats and emergencies.

                      Focus area G: Education and Training

Critical capacity #16: To ensure the delivery of Critical benchmark #14:
Prepare
appropriate education and training to key public health a timeline to
assess training needs.
professionals, infectious disease specialists, emergency
department personnel, and other health care providers
in preparedness for and response to bioterrorism, other
infectious disease outbreaks, and other public health
threats and emergencies, either directly or through the
use (where possible) of existing curricula and other
sources, including schools of public health and
medicine, academic health centers, CDC training
networks, and other providers.

Source: CDC.

aCDC established the LRN to maintain state-of-the-art capabilities for
biological agent identification and characterization. The LRN is a
multilevel system designed to link state and local public health
laboratories with advanced capacity clinical, military, veterinary,
agricultural, water, and food-testing laboratories.

                     GAO Contact and Staff Acknowledgments

GAO Contact

Michele Orza, (202) 512-6970

Acknowledgments

The following staff members made important contributions to this work:
Angela Choy, Chad Davenport, Maria Hewitt, Krister Friday, and Nkeruka
Okonmah.

(290293)

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