Public Health Preparedness: Response Capacity Improving, but Much
Remains to Be Accomplished (12-FEB-04, GAO-04-458T).		 
                                                                 
The anthrax incidents in the fall of 2001 and the severe acute	 
respiratory syndrome (SARS) outbreak in 2002-2003 have raised	 
concerns about the nation's ability to respond to a major public 
health threat, whether naturally occurring or the result of	 
bioterrorism. The anthrax incidents strained the public health	 
system, including laboratory and workforce capacities, at the	 
state and local levels. The SARS outbreak highlighted the	 
challenges of responding to new and emerging infectious disease. 
The current influenza season has heightened concerns about the	 
nation's ability to handle a pandemic. GAO was asked to examine  
improvements in state and local preparedness for responding to	 
major public health threats and federal and state efforts to	 
prepare for an influenza pandemic. This testimony is based on	 
GAO's recent report, HHS Bioterrorism Preparedness Programs:	 
States Reported Progress but Fell Short of Program Goals for	 
2002, GAO-04- 360R (Feb. 10, 2004). This testimony also updates  
information contained in GAO's report on federal and state	 
planning for an influenza pandemic, Influenza Pandemic: Plan	 
Needed for Federal and State Response, GAO- 01-4 (Oct. 27, 2000).
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-458T					        
    ACCNO:   A09272						        
  TITLE:     Public Health Preparedness: Response Capacity Improving, 
but Much Remains to Be Accomplished				 
     DATE:   02/12/2004 
  SUBJECT:   Biological warfare 				 
	     Chemical and biological agents			 
	     Emergency medical services 			 
	     Emergency preparedness				 
	     Health services administration			 
	     Local governments					 
	     National preparedness				 
	     Performance measures				 
	     State governments					 
	     Strategic planning 				 
	     CDC Public Health Preparedness and 		 
	     Response for Bioterrorism Program			 
                                                                 

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GAO-04-458T

United States General Accounting Office

GAO Testimony

Before the Committee on Government Reform, House of Representatives

For Release on Delivery Expected at 10:00 a.m. EST Thursday, February 12,
2004

                                 PUBLIC HEALTH
                                  PREPAREDNESS

        Response Capacity Improving, but Much Remains to Be Accomplished

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

GAO-04-458T

Highlights of GAO-04-458T, a testimony before the Committee on Government
Reform, House of Representatives

The anthrax incidents in the fall of 2001 and the severe acute respiratory
syndrome (SARS) outbreak in 2002-2003 have raised concerns about the
nation's ability to respond to a major public health threat, whether
naturally occurring or the result of bioterrorism. The anthrax incidents
strained the public health system, including laboratory and workforce
capacities, at the state and local levels. The SARS outbreak highlighted
the challenges of responding to new and emerging infectious disease. The
current influenza season has heightened concerns about the nation's
ability to handle a pandemic.

GAO was asked to examine improvements in state and local preparedness for
responding to major public health threats and federal and state efforts to
prepare for an influenza pandemic.

This testimony is based on GAO's recent report, HHS Bioterrorism
Preparedness Programs: States Reported Progress but Fell Short of Program
Goals for 2002, GAO-04360R (Feb. 10, 2004). This testimony also updates
information contained in GAO's report on federal and state planning for an
influenza pandemic, Influenza Pandemic: Plan Needed for Federal and State
Response, GAO01-4 (Oct. 27, 2000).

February 12, 2004

PUBLIC HEALTH PREPAREDNESS

Response Capacity Improving, but Much Remains to Be Accomplished

Although states have further developed many important aspects of public
health preparedness, since April 2003, no state is fully prepared to
respond to a major public health threat. States have improved their
disease surveillance systems, laboratory capacity, communication capacity,
and workforce needed to respond to public health threats, but gaps in each
remain. Moreover, regional planning between states is lacking, and many
states lack surge capacity-the capacity to evaluate, diagnose, and treat
the large numbers of patients that would present during a public health
emergency. Although states are developing plans for receiving and
distributing medical supplies and material for mass vaccinations from the
Strategic National Stockpile in the event of a public health emergency,
most of these plans are not yet finalized.

HHS has not published the federal influenza pandemic plan, and most of the
state plans have not been finalized. In 2000, GAO recommended that HHS
complete the national plan for responding to an influenza pandemic, but
according to HHS, the plan is still under review. Absent a federal plan,
key questions about the federal role in the purchase, distribution, and
administration of vaccines and antiviral drugs during a pandemic remain
unanswered. HHS reports that most states continue to develop their state
plans despite the lack of a federal plan.

www.gao.gov/cgi-bin/getrpt?GAO-04-458T.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Janet Heinrich at (202)
512-7119.

Mr. Chairman and Members of the Committee:

I appreciate the opportunity to be here today to discuss the work we have
done pertaining to the nation's preparedness to manage major public health
threats. The anthrax incidents in the fall of 2001, the SARS1 outbreak in
2002-2003, and the recent incidents involving ricin have raised concerns
about the nation's ability to respond to a major public health threat,
whether naturally occurring or the result of bioterrorism. The anthrax
incidents strained the public health system, including surveillance2 and
laboratory capacities as well as the workforce, at the state and local
levels.3 The SARS outbreak highlighted the challenges in responding to new
and emerging infectious disease-especially when the ability to identify
the disease and a vaccine for preventing it are lacking.4 The current
influenza season has heightened concerns about our nation's ability to
handle a pandemic.5 The Congress has recognized the need to strengthen the
nation's ability to respond to such threats and has increased
appropriations for federal, state, and local public health preparedness
efforts. The Department of Health and Human Services (HHS) has been
developing a national plan for responding to an influenza pandemic.

As you requested, to assist the Committee in its consideration of our
nation's ability to respond to a major public health threat, whether
naturally occurring or the result of bioterrorism, my remarks today will
focus on (1) state and local preparedness for responding to major public
health threats and (2) federal and state efforts to prepare for an
influenza pandemic.

1SARS is the abbreviation for severe acute respiratory syndrome.

2Public health surveillance uses systems that provide for the ongoing
collection, analysis, and dissemination of health-related data to
identify, prevent, and control disease.

3See U.S. General Accounting Office, Bioterrorism: Public Health Response
to Anthrax Incidents of 2001, GAO-04-152 (Washington, D.C.: Oct. 15,
2003).

4See 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).

5Pandemics are worldwide epidemics. Influenza pandemics can have
successive "waves" of disease and last for up to 3 years. Three pandemics
occurred in the 20th century: the "Spanish flu" of 1918, which killed at
least 20 million people worldwide; the "Asian flu" of 1957; and the "Hong
Kong flu" of 1968.

My testimony today updates testimony that we provided to you in April
20036 and is based largely on work we conducted for our recently released
report on HHS's programs that support state and local preparedness for
bioterrorism and other public health threats.7 For that report, we
reviewed each state's progress report8 on the use of bioterrorism
preparedness funding distributed in 2002 by HHS's Centers for Disease
Control and Prevention (CDC) and Health Resources and Services
Administration (HRSA). The progress reports covered the period through
August 30, 2003, for CDC's program and through July 1, 2003, for HRSA's
program. For that report 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. My testimony today
also updates information provided in our October 2000 report on federal
and state planning for an influenza pandemic.9 To update that information,
in February 2004, we spoke with officials from CDC and HHS's National
Vaccine Program Office. We conducted our work in accordance with generally
accepted government auditing standards.

In summary, although states have further developed many important aspects
of public health preparedness, since I testified before you in April 2003,
no state is fully prepared to respond to a major public health threat.
States have improved their disease surveillance systems, laboratory
capacity, communication capacity, and workforce needed to respond to
public health threats, but gaps in each remain. Moreover, regional
planning between states is lacking, and many states lack surge
capacity-the capacity to evaluate, diagnose, and treat the large numbers
of patients that would present during a public health emergency. Although
states are developing plans for receiving and distributing medical
supplies and material for mass vaccinations from the Strategic National
Stockpile in the event of a public, most of these plans are not yet
finalized.

6U.S. General Accounting Office, Infectious Disease Outbreaks:
Bioterrorism Preparedness Efforts Have Improved Public Health Response
Capacity, but Gaps Remain, GAO-03-654T (Washington, D.C.: Apr. 9, 2003).

7U.S. General Accounting Office, HHS Bioterrorism Preparedness Programs:
States Reported Progress but Fell Short of Program Goals for 2002,
GAO-04-360R (Washington, D.C.: Feb. 10, 2004).

8The progress reports were for the 50 states, the District of Columbia,
and the nation's three largest municipalities (New York City, Chicago, and
Los Angeles County).

9U.S. General Accounting Office, Influenza Pandemic: Plan Needed for
Federal and State Response, GAO-01-4 (Washington, D.C.: Oct. 27, 2000).

Background

HHS has not published the federal influenza pandemic plan, and most of the
state plans for influenza have not been finalized. In 2000, we recommended
that HHS complete the national plan for responding to an influenza
pandemic, but according to HHS, the plan is still under review. Absent a
federal plan, key questions about the federal role in the purchase,
distribution, and administration of vaccines and antiviral drugs during a
pandemic remain unanswered. HHS reports that most states continue to
develop their state plans despite the lack of a federal plan.

The initial response to a public health emergency-for instance an outbreak
of an infectious disease-generally occurs at the local and state levels
and could involve disease surveillance, laboratory testing, epidemiologic
investigation,10 communication, and health care treatment. As a public
health emergency develops, each plays a critical role in an effective
response. Local and state health departments collect and monitor data,
such as reports from clinicians, for disease trends and evidence of an
outbreak. Laboratory personnel test clinical and environmental samples for
possible exposures and identification of illnesses. Epidemiologists in the
health departments use disease surveillance systems to detect clusters of
suspicious symptoms or diseases in order to facilitate early detection of
disease and treatment of victims. Public health officials provide needed
information to the clinical community, other responders, and the public
and implement control measures to prevent additional cases from occurring.
Health care providers treat patients and limit the spread of infectious
disease. All these response activities require a workforce that is
sufficiently skilled and adequate in number.

The federal government provides funding and resources to state and local
entities to support preparedness and response efforts. For example, in
fiscal year 2002 CDC's Public Health Preparedness and Response for
Bioterrorism cooperative agreement11 program provided approximately $918
million to states to improve bioterrorism preparedness and response as
well as other public health emergency preparedness capacities. Similarly,
HRSA's Bioterrorism Hospital Preparedness cooperative

10Epidemiology is the study of how disease is distributed in populations
and the factors that influence or determine this distribution.

11A cooperative agreement is used as a mechanism to provide financial
support for a particular activity when substantial interaction is expected
between the executive agency and a state, local government, or other
recipient carrying out the funded activity.

agreement program provided approximately $125 million to states in fiscal
year 2002 to enhance the capacity of hospitals and associated health care
entities to respond to bioterrorist attacks. HHS renewed these cooperative
agreements for the period of August 31, 2003 through August 30, 2004. For
these renewed agreements, CDC's program and HRSA's program distributed
about $870 million and about $498 million, respectively. Among the other
resources that the federal government provides is the Strategic National
Stockpile, which contains pharmaceuticals and medical supplies that can be
delivered to the site of a public health emergency anywhere in the United
States within 12 hours of the decision to deploy them.

The federal government also supports preparedness efforts for an influenza
pandemic. HHS's National Vaccine Program Office is responsible for the
development of federal plans for vaccine and immunization activities and
coordinating these efforts among federal agencies. To foster state and
local planning, HHS issued interim planning guidance for the states in
1997 that outlined general federal and state responsibilities during an
influenza pandemic. HHS expects that if a pandemic occurs, both the
vaccines that are used to prevent influenza and the antiviral drugs that
are used to treat influenza will be in short supply.12 The guidance
discussed certain key issues related to limited supplies of the influenza
vaccine and antiviral drugs-for instance the amount of vaccine and
antiviral drugs that will be purchased at the federal level; the division
of responsibility between the public and private sectors for the purchase,
distribution, and administration of these supplies during a pandemic; and
priorities for vaccinating population groups, such as health workers and
public health personnel involved in the pandemic response, and persons
traditionally considered to be at increased risk of severe influenza
illness and mortality.

12These shortages are expected because demand would exceed current rates
of production and because manufacturers report that increasing the
production capacity of antiviral drugs can take at least 6 to 9 months.

  States Have Further Developed Important Aspects of Public Health Preparedness,
  but Additional Work Is Needed

States reported that as of the summer of 2003 they have made improvements
in their preparedness to respond to major public health threats, but no
aspect of preparedness has been fully addressed by all of the states.13
Specifically, although states have strengthened their disease surveillance
systems, laboratory capacity, communications, workforce, surge capacity,
regional coordination across state borders, and readiness to utilize the
Strategic National Stockpile, all of these important aspects of
preparedness require additional work.

Disease Surveillance Systems

Although some states have made improvements to their disease surveillance
systems, the nation's ability to detect and report a disease outbreak is
not uniformly strong across all states. For example, about half of the
states reported that their health departments are capable of receiving and
evaluating urgent disease reports on a 24-hour-per-day, 7-day-per-week
basis; however, few states reported having the ability to rapidly detect
an outbreak of an influenza-like illness in the state. Similarly, few
states reported efforts to strengthen links between their public health
and animal surveillance systems14 and the veterinary community in order to
monitor diseases in animals that may be spread to humans, such as the West
Nile virus.15

                              Laboratory Capacity

States have increased their capacity to test and identify specimens and
improve laboratory security, although laboratory capacity is not uniformly
robust in all states. All states participate in CDC's Laboratory Response
Network, a network of local, state, federal, and international
laboratories that are equipped to respond to biological and chemical
terrorism, emerging infectious diseases and other public health threats.
However, only about half of the states reported that they have at least
one public health laboratory within the state that has the appropriate
instrumentation and appropriately trained staff to conduct certain tests
for rapidly

13In this section, "state" refers to the 50 states, the District of
Columbia, New York City, Chicago and Los Angeles County.

14Animal health surveillance involves the collection, evaluation, and
interpretation of data to provide timely and accurate detection,
diagnosis, prevention, and control of diseases in animals.

15For more information, see U.S. General Accounting Office, West Nile
Virus Outbreak: Lessons for Public Health Preparedness, GAO/HEHS-00-180
(Washington, D.C.: Sept. 11, 2000).

detecting and correctly identifying biological agents. About half of the
states reported that they had a facility with a biosafety level sufficient
to handle such agents as anthrax.16 About half the states also reported
that laboratory security within the state is consistent with HHS
guidelines, which include recommendations for protecting laboratory
personnel and preventing the unauthorized removal of dangerous biologic
agents from the laboratory.

                                 Communication

Although improving, communication, both among those involved in responding
to a major public health threat-such as public health officials, health
care providers, and emergency management agencies-and with the public,
remains a challenge. CDC's Health Alert Network has been expanded-most of
the states reported that the local health departments that cover at least
90 percent of their populations are involved in this network.17 However,
many states reported that they were still in the process of assessing
their communication needs. Although about half the states have a plan for
educating the public about the risks posed by bioterrorism and other
public health threats, few states have mechanisms in place for
communicating with the general public during an incident about such issues
as when it is necessary to go to the hospital.

                                   Workforce

States have increased the number of personnel essential to public health
preparedness, but concerns about workforce shortages remain. Most of the
states reported that the bioterrorism preparedness funding from CDC
allowed each to appoint an executive director of its bioterrorism
preparedness and response program, to designate a response coordinator,
and to hire at least one epidemiologist for each metropolitan area with a
population greater than 500,000. However, most states continue to have
staffing concerns. As we have reported previously,18 some state and local
health officials have had difficulty finding and hiring epidemiologists
and

16Biosafety measures the degree of protection a laboratory offers to
personnel, the environment, and the community.

17The Health Alert Network is a nationwide program designed to ensure
communication capacity at all state and local health departments. This
network enables local health departments to receive health alerts and
other information from CDC and state health departments.

18U.S. General Accounting Office, Bioterrorism: Preparedness Varied across
State and Local Jurisdictions, GAO-03-373 (Washington, D.C.: Apr. 7,
2003); GAO-04-360R; GAO-03-654T.

laboratory personnel. The ability to hire and retain personnel in these
areas is still a concern for state and local health officials, who
identify workforce shortages as a long-term challenge to their
preparedness efforts.

                                 Surge Capacity

Most states lack surge capacity-that is, the capacity to respond to the
large influx of patients that could occur during a public health
emergency. For example, few states reported that they had the capacity to
evaluate, diagnose, and treat 500 or more patients involved in a single
incident. Furthermore, no state reported having protocols in place for
augmenting personnel in response to large influxes of patients, and few
states reported having plans for sharing clinical personnel among
hospitals. In addition, few states reported having the capacity to rapidly
establish clinics to immunize or provide treatment to large numbers of
patients.

Regional Planning 	Few states have regional plans in place that would
coordinate the response among states during a public health emergency, and
state officials remain concerned about a lack of regional planning across
state borders. Few states have completed regional response plans for
incidents of bioterrorism and other public health threats and emergencies.
Most of the states that do have such plans have not established training
programs to support their plans or mechanisms to test their plans.

Strategic National Most state plans for using the Strategic National
Stockpile in the event of a

Stockpile 	public health emergency have not been fully developed. All
states have prepared preliminary plans for the receipt and management of
stockpile materials, but only about a third of the states have plans that
outline how they would distribute antibiotics, chemical/nerve agent
antidotes, and other materials to areas within the state.

  The Federal Influenza Plan Has Not Been Finalized, but State Planning and
  Other Efforts Continue

Concluding Observations

Federal officials have not finalized plans for responding to an influenza
pandemic, and state influenza pandemic response plans are in various
stages of completion.

As we have reported previously,19 federal officials have drafted but not
finalized the federal influenza pandemic plan. In 2000, we recommended
that HHS complete the national plan for responding to an influenza
pandemic, but HHS reported recently that the plan was still under review
within HHS. However, HHS is taking other steps to prepare for an influenza
pandemic. For example, CDC has increased the supply of ventilators and
added an antiviral drug to the Strategic National Stockpile. HHS is also
coordinating with other federal partners, such as the Department of
Agriculture, to improve the nation's ability to respond to public health
emergencies involving the veterinary and agricultural sectors.

Despite the absence of a finalized, federal response plan for an influenza
pandemic, states are developing their own response plans. According to HHS
officials, as of February 2004, 15 states have final or draft plans, and
34 states are actively working on plans. In these plans, states have had
to make assumptions about what the federal role during an influenza
pandemic will be. It is still unclear whether the private sector, the
public sector, or both will have responsibility for purchasing and
distributing vaccines and antiviral drugs. Some states have assumed that
vaccine supply will be under the control of the federal government, while
others have assumed that it will not. States have also made different
assumptions about who will pay for vaccines, antiviral medications, and
related supplies.

States have taken many actions to improve their ability to respond to a
major public health threat, but no state has reported being fully
prepared. Federal plans for the purchase, distribution, and administration
of vaccines and drugs in response to an influenza pandemic still have not
been finalized, complicating the efforts of states to develop their state
plans and heightening concern about our nation's ability to respond
effectively to an influenza pandemic. States are more prepared now, but
much remains to be accomplished.

19GAO-01-4; GAO-03-654T.

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

Contact and 	For further information about this testimony, please contact
Janet Heinrich at (202) 512-7119. Angela Choy, Maria Hewitt, Krister
Friday,

Acknowledgments 	Nkeruka Okonmah, and Michele Orza also made key
contributions to this statement.

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