A Review of federal Bioterrorism Preparedness Programs from a Public Health Perspective.

Subcommittee on Oversight and Investigations
October 10, 2001
10:00 AM
2322 Rayburn House Office Building 

Ms. Jan Heinrich
U.S. General Accounting Office

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Testimony

Before the Subcommittee on Oversight and

Investigations, Committee on Energy and Commerce,

House of Representatives

GAO

For Release on Delivery

Expected at 10:00 a.m.

Wednesday, October 10, 2001 BIOTERRORISM

Review of Public Health

Preparedness Programs

Statement of Janet Heinrich

Director, Health Care-Public Health Issues

Mr. Chairman and Members of the Subcommittee:

I appreciate the opportunity to be here today to discuss our work on the

activities of federal agencies to prepare the nation to respond to the public

health and medical consequences of a bioterrorist attack.

1

Preparing to

respond to the public health and medical consequences of a bioterrorist

attack poses some challenges that are different from those in other types

of terrorist attacks, such as bombings. On September 28, 2001, we released

a report

2

that describes (1) the research and preparedness activities being

undertaken by federal departments and agencies to manage the

consequences of a bioterrorist attack,

3

(2) the coordination of these

activities, and (3) the findings of reports on the preparedness of state and

local jurisdictions to respond to a bioterrorist attack. My testimony will

summarize the detailed findings included in our report, highlighting

weaknesses in the public health infrastructure that we have identified in

our ongoing work and which we believe warrant special attention.

In summary, we identified more than 20 federal departments and agencies

as having a role in preparing for or responding to the public health and

medical consequences of a bioterrorist attack. These agencies are

participating in a variety of activities, from improving the detection of

biological agents to developing a national stockpile of pharmaceuticals to

treat victims of disasters. Federal departments and agencies have engaged

in a number of efforts to coordinate these activities on a formal and

informal basis, such as interagency work groups. Despite these efforts, we

found evidence that coordination between departments and agencies is

fragmented. We did, however, find recent actions to improve coordination

across federal departments and agencies. In addition, we found emerging

concerns about the preparedness of state and local jurisdictions, including

insufficient state and local planning for response to terrorist events, a lack

of hospital participation in training on terrorism and emergency response

1

Bioterrorism is the threat or intentional release of biological agents (viruses, bacteria, or

their toxins) for the purposes of influencing the conduct of government or intimidating or

coercing a civilian population.

2

See Bioterrorism: Federal Research and Preparedness Activities (GAO-01-915, Sept. 28,

2001). This report was mandated by the Public Health Improvement Act of 2000 (P.L. 106-

505, sec. 102). Also, see the list of related GAO products at the end of this statement.

3

We conducted interviews with and obtained information from the Departments of

Agriculture, Commerce, Defense, Energy, Health and Human Services, Justice,

Transportation, the Treasury, and Veterans Affairs; the Environmental Protection Agency;

and the Federal Emergency Management Agency..Page 2 GAO-02-149T

planning, the timely availability of medical teams and resources in an

emergency, and inadequacies in the public health infrastructure. The last

includes weaknesses in the training of health care providers,

communication among responsible parties, and capacity of laboratories

and hospitals, including the ability to treat mass casualties.

A domestic bioterrorist attack is considered to be a low-probability event,

in part because of the various difficulties involved in successfully

delivering biological agents to achieve large-scale casualties.

4

However, a

number of cases involving biological agents, including at least one

completed bioterrorist act and numerous threats and hoaxes,

5

have

occurred domestically. In 1984, a group intentionally contaminated salad

bars in restaurants in Oregon with salmonella bacteria. Although no one

died, 751 people were diagnosed with foodborne illness. Some experts

predict that more domestic bioterrorist attacks are likely to occur.

The burden of responding to such an attack would fall initially on

personnel in state and local emergency response agencies. These "first

responders" include firefighters, emergency medical service personnel,

law enforcement officers, public health officials, health care workers

(including doctors, nurses, and other medical professionals), and public

works personnel. If the emergency were to require federal disaster

assistance, federal departments and agencies would respond according to

responsibilities outlined in the Federal Response Plan.

6

Several groups,

including the Advisory Panel to Assess Domestic Response Capabilities for

Terrorism Involving Weapons of Mass Destruction (known as the Gilmore

Panel), have assessed the capabilities at the federal, state, and local levels

4

See Combating Terrorism: Need for Comprehensive Threat and Risk Assessments of

Chemical and Biological Attacks (GAO/NSIAD-99-163, Sept. 14, 1999), pp. 10-15, for a

discussion of the ease or difficulty for a terrorist to create mass casualties by making or

using chemical or biological agents without the assistance of a state-sponsored program.

5

For example, in January 2000, threatening letters were sent to a variety of recipients,

including the Planned Parenthood office in Naples, Florida, warning of the release of

anthrax. Federal authorities found no signs of anthrax or any other traces of harmful

substances and determined these incidences to be hoaxes.

6

The Federal Response Plan, originally drafted in 1992 and updated in 1999, is authorized

under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act;

P.L. 93-288, as amended). The plan outlines the planning assumptions, policies, concept of

operations, organizational structures, and specific assignment of responsibilities to lead

departments and agencies in providing federal assistance once the President has declared

an emergency requiring federal assistance.

Background.Page 3 GAO-02-149T

to respond to a domestic terrorist incident involving a weapon of mass

destruction (WMD), that is, a chemical, biological, radiological, or nuclear

agent or weapon.

7

While many aspects of an effective response to bioterrorism are the same

as those for any disaster, there are some unique features. For example, if a

biological agent is released covertly, it may not be recognized for a week

or more because symptoms may not appear for several days after the

initial exposure and may be misdiagnosed at first. In addition, some

biological agents, such as smallpox, are communicable and can spread to

others who were not initially exposed. These differences require a type of

response that is unique to bioterrorism, including infectious disease

surveillance,

8

epidemiologic investigation,

9

laboratory identification of

biological agents, and distribution of antibiotics to large segments of the

population to prevent the spread of an infectious disease. However, some

aspects of an effective response to bioterrorism are also important in

responding to any type of large-scale disaster, such as providing

emergency medical services, continuing health care services delivery, and

managing mass fatalities.

7

Some agencies define WMDs to include large conventional explosives as well.

8

Disease surveillance systems provide for the ongoing collection, analysis, and

dissemination of data to prevent and control disease.

9

Epidemiological investigation is the study of patterns of health or disease and the factors

that influence these patterns..Page 4 GAO-02-149T

Federal spending on domestic preparedness for terrorist attacks involving

WMDs has risen 310 percent since fiscal year 1998, to approximately $1.7

billion in fiscal year 2001, and may increase significantly after the events of

September 11, 2001. However, only a portion of these funds were used to

conduct a variety of activities related to research on and preparedness for

the public health and medical consequences of a bioterrorist attack. We

cannot measure the total investment in such activities because

departments and agencies provided funding information in various

forms-as appropriations, obligations, or expenditures. Because the

funding information provided is not equivalent,

10

we summarized funding

by department or agency, but not across the federal government (see apps.

I and II).

11

Reported funding generally shows increases from fiscal year

1998 to fiscal year 2001. Several agencies received little or no funding in

fiscal year 1998. For example, within the Department of Health and Human

Services (HHS), the Centers for Disease Control and Prevention's (CDC)

Bioterrorism Preparedness and Response Program was established and

first received funding in fiscal year 1999 (see app. I and app. II). Its funding

has increased from approximately $121 million at that time to

approximately $194 million in fiscal year 2001.

Research is currently being done to enable the rapid identification of

biological agents in a variety of settings; develop new or improved

vaccines, antibiotics, and antivirals to improve treatment and vaccination

for infectious diseases caused by biological agents; and develop and test

emergency response equipment such as respiratory and other personal

protective equipment. Appendix I provides information on the total

10

For example, an agency providing appropriations is not necessarily indicating the level of

its commitments (that is, obligations) or expenditures for that year-only the amount of

budget authority made available to it by the Congress, some of which may be unspent.

Similarly, an agency that provided expenditure information for fiscal year 2000 may have

obligated the funds in fiscal year 1999 based on an appropriation for fiscal year 1998. To

simplify presentation, we generally refer to all the budget data we received from agencies

as "reported funding."

11

Although there are generally no specific appropriations for activities on bioterrorism,

some departments and agencies did provide estimates of the funds they were devoting to

activities on bioterrorism. Other departments and agencies provided estimates for overall

terrorism activities, but were unable to provide funding amounts for activities on

bioterrorism specifically. Still others stated that their activities were relevant for

bioterrorism, but they were unable to specify the funding amounts. Funding levels for

activities on terrorism, including bioterrorism, were reported for activities prior to the 2001

Emergency Supplemental Appropriations Act for Recovery From and Response to Terrorist

Attacks on the United States (P.L. 107-38).

Federal Departments

and Agencies

Reported a Variety of

Research and

Preparedness

Activities

Research Activities Focus

on Detection, Treatment,

Vaccination, and

Equipment.Page 5 GAO-02-149T

reported funding for all the departments and agencies carrying out

research, along with examples of this research.

The Department of Agriculture (USDA), Department of Defense (DOD),

Department of Energy, HHS, Department of Justice (DOJ), Department of

the Treasury, and the Environmental Protection Agency (EPA) have all

sponsored or conducted projects to improve the detection and

characterization of biological agents in a variety of different settings, from

water to clinical samples (such as blood). For example, EPA is sponsoring

research to improve its ability to detect biological agents in the water

supply. Some of these projects, such as those conducted or sponsored by

DOD and DOJ, are not primarily for the public health and medical

consequences of a bioterrorist attack against the civilian population, but

could eventually benefit research for those purposes.

Departments and agencies are also conducting or sponsoring studies to

improve treatment and vaccination for diseases caused by biological

agents. For example, HHS' projects include basic research sponsored by

the National Institutes of Health to develop drugs and diagnostics and

applied research sponsored by the Agency for Healthcare Research and

Quality to improve health care delivery systems by studying the use of

information systems and decision support systems to enhance

preparedness for the delivery of medical care in an emergency.

In addition, several agencies, including the Department of Commerce's

National Institute of Standards and Technology and DOJ's National

Institute of Justice are conducting research that focuses on developing

performance standards and methods for testing the performance of

emergency response equipment, such as respirators and personal

protective equipment.

Federal departments' and agencies' preparedness efforts have included

efforts to increase federal, state, and local response capabilities, develop

response teams of medical professionals, increase availability of medical

treatments, participate in and sponsor terrorism response exercises, plan

to aid victims, and provide support during special events such as

presidential inaugurations, major political party conventions, and the

Preparedness Efforts

Include Multiple Actions.Page 6 GAO-02-149T

Superbowl.

12

Appendix II contains information on total reported funding

for all the departments and agencies with bioterrorism preparedness

activities, along with examples of these activities.

Several federal departments and agencies, such as the Federal Emergency

Management Agency (FEMA) and CDC, have programs to increase the

ability of state and local authorities to successfully respond to an

emergency, including a bioterrorist attack. These departments and

agencies contribute to state and local jurisdictions by helping them pay for

equipment and develop emergency response plans, providing technical

assistance, increasing communications capabilities, and conducting

training courses.

Federal departments and agencies have also been increasing their own

capacity to identify and deal with a bioterrorist incident. For example,

CDC, USDA, and the Food and Drug Administration (FDA) are improving

surveillance methods for detecting disease outbreaks in humans and

animals. They have also established laboratory response networks to

maintain state-of-the-art capabilities for biological agent identification and

the characterization of human clinical samples.

Some federal departments and agencies have developed teams to directly

respond to terrorist events and other emergencies. For example, HHS'

Office of Emergency Preparedness (OEP) created Disaster Medical

Assistance Teams to provide medical treatment and assistance in the event

of an emergency. Four of these teams, known as National Medical

Response Teams, are specially trained and equipped to provide medical

care to victims of WMD events, such as bioterrorist attacks.

Several agencies are involved in increasing the availability of medical

supplies that could be used in an emergency, including a bioterrorist

attack. CDC's National Pharmaceutical Stockpile contains

pharmaceuticals, antidotes, and medical supplies that can be delivered

anywhere in the United States within 12 hours of the decision to deploy.

The stockpile was deployed for the first time on September 11, 2001, in

response to the terrorist attacks on New York City.

12

Presidential Decision Directive 62, issued May 22, 1998, created a category of special

events called National Security Special Events, which are events of such significance that

they warrant greater federal planning and protection than other special events..Page 7 GAO-02-149T

Federally initiated bioterrorism response exercises have been conducted

across the country. For example, in May 2000, many departments and

agencies took part in the Top Officials 2000 exercise (TOPOFF 2000) in

Denver, Colorado, which featured the simulated release of a biological

agent.

13

Participants included local fire departments, police, hospitals, the

Colorado Department of Public Health and the Environment, the Colorado

Office of Emergency Management, the Colorado National Guard, the

American Red Cross, the Salvation Army, HHS, DOD, FEMA, the Federal

Bureau of Investigation (FBI), and EPA.

Several agencies also provide assistance to victims of terrorism. FEMA

can provide supplemental funds to state and local mental health agencies

for crisis counseling to eligible survivors of presidentially declared

emergencies. In the aftermath of the recent terrorist attacks, HHS released

$1 million in funding to New York State to support mental health services

and strategic planning for comprehensive and long-term support to

address the mental health needs of the community. DOJ's Office of Justice

Programs (OJP) also manages a program that provides funds for victims of

terrorist attacks that can be used to provide a variety of services, including

mental health treatment and financial assistance to attend related criminal

proceedings.

Federal departments and agencies also provide support at special events

to improve response in case of an emergency. For example, CDC has

deployed a system to provide increased surveillance and epidemiological

capacity before, during, and after special events. Besides improving

emergency response at the events, participation by departments and

agencies gives them valuable experience working together to develop and

practice plans to combat terrorism.

13

In addition to simulating a bioterrorism attack in Denver, the exercise also simulated a

chemical weapons incident in Portsmouth, New Hampshire. A concurrent exercise,

referred to as National Capital Region 2000, simulated a radiological event in the greater

Washington, D.C., area..Page 8 GAO-02-149T

Federal departments and agencies are using a variety of interagency plans,

work groups, and agreements to coordinate their activities to combat

terrorism. However, we found evidence that coordination remains

fragmented. For example, several different agencies are responsible for

various coordination functions, which limits accountability and hinders

unity of effort; several key agencies have not been included in

bioterrorism-related policy and response planning; and the programs that

agencies have developed to provide assistance to state and local

governments are similar and potentially duplicative. The President

recently took steps to improve oversight and coordination, including the

creation of the Office of Homeland Security.

Over 40 federal departments and agencies have some role in combating

terrorism, and coordinating their activities is a significant challenge. We

identified over 20 departments and agencies as having a role in preparing

for or responding to the public health and medical consequences of a

bioterrorist attack. Appendix III, which is based on the framework given in

the Terrorism Incident Annex of the Federal Response Plan, shows a

sample of the coordination efforts by federal departments and agencies

with responsibilities for the public health and medical consequences of a

bioterrorist attack, as they existed prior to the recent creation of the

Office of Homeland Security. This figure illustrates the complex

relationships among the many federal departments and agencies involved.

Departments and agencies use several approaches to coordinate their

activities on terrorism, including interagency response plans, work groups,

and formal agreements. Interagency plans for responding to a terrorist

incident help outline agency responsibilities and identify resources that

could be used during a response. For example, the Federal Response Plan

provides a broad framework for coordinating the delivery of federal

disaster assistance to state and local governments when an emergency

overwhelms their ability to respond effectively. The Federal Response

Plan also designates primary and supporting federal agencies for a variety

of emergency support operations. For example, HHS is the primary agency

for coordinating federal assistance in response to public health and

medical care needs in an emergency. HHS could receive support from

other agencies and organizations, such as DOD, USDA, and FEMA, to

assist state and local jurisdictions.

Interagency work groups are being used to minimize duplication of

funding and effort in federal activities to combat terrorism. For example,

the Technical Support Working Group is chartered to coordinate

Fragmentation

Remains Despite

Efforts to Coordinate

Federal Programs

Departments and Agencies

Use a Variety of Methods

to Coordinate Activities.Page 9 GAO-02-149T

interagency research and development requirements across the federal

government in order to prevent duplication of effort between agencies.

The Technical Support Working Group, among other projects, helped to

identify research needs and fund a project to detect biological agents in

food that can be used by both DOD and USDA.

Formal agreements between departments and agencies are being used to

share resources and knowledge. For example, CDC contracts with the

Department of Veterans Affairs (VA) to purchase drugs and medical

supplies for the National Pharmaceutical Stockpile because of VA's

purchasing power and ability to negotiate large discounts.

Overall coordination of federal programs to combat terrorism is

fragmented.

14

For example, several agencies have coordination functions,

including DOJ, the FBI, FEMA, and the Office of Management and Budget.

Officials from a number of the agencies that combat terrorism told us that

the coordination roles of these various agencies are not always clear and

sometimes overlap, leading to a fragmented approach. We have found that

the overall coordination of federal research and development efforts to

combat terrorism is still limited by several factors, including the

compartmentalization or security classification of some research efforts.

15

The Gilmore Panel also concluded that the current coordination structure

does not provide for the requisite authority or accountability to impose the

discipline necessary among the federal agencies involved.

16

The multiplicity of federal assistance programs requires focus and

attention to minimize redundancy of effort.

17

Table 1 shows some of the

federal programs providing assistance to state and local governments for

emergency planning that would be relevant to responding to a bioterrorist

attack. While the programs vary somewhat in their target audiences, the

14

See also Combating Terrorism: Comments on Counterterrorism Leadership and National

Strategy (GAO-01-556T, Mar. 27, 2001), p. 1.

15

See Combating Terrorism: Selected Challenges and Related Recommendations

(GAO-01-822, Sept. 20, 2001), pp. 79, 84.

16

Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving

Weapons of Mass Destruction (Gilmore Panel), Toward a National Strategy for Combating

Terrorism, Second Annual Report (Arlington, Va.: RAND, Dec. 15, 2000), p. 7.

17

See also Combating Terrorism: Issues in Managing Counterterrorist Programs

(GAO/T-NSIAD-00-145, Apr. 6, 2000), p. 8.

Coordination Remains

Fragmented Within the

Federal Government.Page 10 GAO-02-149T

potential redundancy of these federal efforts highlights the need for

scrutiny. In our report on combating terrorism, issued on September 20,

2001, we recommended that the President, working closely with the

Congress, consolidate some of the activities of DOJ's OJP under FEMA.

18

HHS-CDC Provides grants, technical support, and

performance standards to support

bioterrorism preparedness and response

planning.

State and local health

agencies

HHS-OEP Enters into contracts to enhance medical

response capability. The program includes a

focus on response to bioterrorism, including

early recognition, mass postexposure

treatment, mass casualty care, and mass

fatality management.

Local jurisdictions (for

fire, police, and

emergency medical

services; hospitals;

public health agencies;

and other services)

DOJ-OJP Assists states in developing strategic plans.

Includes funding for training, equipment

acquisition, technical assistance, and

exercise planning and execution to enhance

state and local capabilities to respond to

terrorist incidents.

States (for fire, law

enforcement,

emergency medical,

and hazardous

materials response

services; hospitals;

public health

departments; and other

services)

FEMA Provides grant assistance to support state

and local consequence management

planning, training, and exercises for all types

of terrorism, including bioterrorism.

State emergency

management agencies

Source: Information obtained from departments and agencies.

We have also recommended that the federal government conduct

multidisciplinary and analytically sound threat and risk assessments to

define and prioritize requirements and properly focus programs and

investments in combating terrorism.

19

Such assessments would be useful in

addressing the fragmentation that is evident in the different threat lists of

biological agents developed by federal departments and agencies.

18

See GAO-01-822, Sept. 20, 2001, pp. 104-106.

19

See Combating Terrorism: Threat and Risk Assessments Can Help Prioritize and Target

Program Investments (GAO/NSIAD-98-74, Apr. 9, 1998) and GAO/NSIAD-99-163, Sept. 14,

1999..Page 11 GAO-02-149T

Understanding which biological agents are considered most likely to be

used in an act of domestic terrorism is necessary to focus the investment

in new technologies, equipment, training, and planning. Several different

agencies have or are in the process of developing biological agent threat

lists, which differ based on the agencies' focus. For example, CDC

collaborated with law enforcement, intelligence, and defense agencies to

develop a critical agent list that focuses on the biological agents that

would have the greatest impact on public health. The FBI, the National

Institute of Justice, and the Technical Support Working Group are

completing a report that lists biological agents that may be more likely to

be used by a terrorist group working in the United States that is not

sponsored by a foreign government. In addition, an official at USDA's

Animal and Plant Health Inspection Service told us that it uses two lists of

agents of concern for a potential bioterrorist attack. These lists of agents,

only some of which are capable of making both animals and humans sick,

were developed through an international process. According to agency

officials, separate threat lists are appropriate because of the different

focuses of these agencies. In our view, the existence of competing lists

makes the assignment of priorities difficult for state and local officials.

Fragmentation is also apparent in the composition of groups of federal

agencies involved in bioterrorism-related planning and policy. Officials at

the Department of Transportation (DOT) told us that that even though the

nation's transportation centers account for a significant percentage of the

nation's potential terrorist targets, the department was not part of the

founding group of agencies that worked on bioterrorism issues and has

not been included in bioterrorism response plans. DOT officials also told

us that the department is supposed to deliver supplies for FEMA under the

Federal Response Plan, but it was not brought into the planning early

enough to understand the extentof its responsibilities in the

transportation process. The department learned what its responsibilities

would be during the TOPOFF 2000 exercise, which simulated a release of

a biological agent..Page 12 GAO-02-149T

In May 2001, the President asked the Vice President to oversee the

development of a coordinated national effort dealing with WMDs.

20

At the

same time, the President asked the Director of FEMA to establish an

Office of National Preparedness to implement the results of the Vice

President's effort that relate to programs within federal agencies that

address consequence management resulting from the use of WMDs. The

purpose of this effort is to better focus policies and ensure that programs

and activities are fully coordinated in support of building the needed

preparedness and response capabilities. In addition, on September 20,

2001, the President announced the creation of the Office of Homeland

Security to lead, oversee, and coordinate a comprehensive national

strategy to protect the country from terrorism and respond to any attacks

that may occur. These actions represent potentially significant steps

toward improved coordination of federal activities. Our recent report

highlighted a number of important characteristics and responsibilities

necessary for a single focal point, such as the proposed Office of

Homeland Security, to improve coordination and accountability.

21

Nonprofit research organizations, congressionally chartered advisory

panels, government documents, and articles in peer-reviewed literature

have identified concerns about the preparedness of states and local areas

to respond to a bioterrorist attack. These concerns include insufficient

state and local planning for response to terrorist events, a lack of hospital

participation in training on terrorism and emergency response planning,

questions regarding the timely availability of medical teams and resources

in an emergency, and inadequacies in the public health infrastructure. In

our view, there are weaknesses in three key areas of the public health

infrastructure: training of health care providers, communication among

responsible parties, and capacity of laboratories and hospitals, including

the ability to treat mass casualties.

Questions exist regarding how effectively federal programs have prepared

state and local governments to respond to terrorism. All 50 states and

approximately 255 local jurisdictions have received or are scheduled to

receive at least some federal assistance, including training and equipment

grants, to help them prepare for a terrorist WMD incident. In 1997, FEMA

20

According to the Office of the Vice President, as of June 2001, details on the Vice

President's efforts had not yet been determined.

21

See GAO-01-822, Sept. 20, 2001, pp. 41-42.

Recent Actions Seek to

Improve Coordination

Across Federal

Departments and Agencies

Despite Federal

Efforts, Concerns

Exist Regarding

Preparedness at State

and Local Levels.Page 13 GAO-02-149T

identified planning and equipment for response to nuclear, biological, and

chemical incidents as areas in need of significant improvement at the state

level. However, an October 2000 research report concluded that even

those cities receiving federal aid are still not adequately prepared to

respond to a bioterrorist attack.

22

Inadequate training and planning for bioterrorism response by hospitals is

a major problem. The Gilmore Panel concluded that the level of expertise

in recognizing and dealing with a terrorist attack involving a biological or

chemical agent is problematic in many hospitals.

23

A recent research report

concluded that hospitals need to improve their preparedness for mass

casualty incidents.

24

Local officials told us that it has been difficult to get

hospitals and medical personnel to participate in local training, planning,

and exercises to improve their preparedness.

Local officials are also concerned about whether the federal government

could quickly deliver enough medical teams and resources to help after a

biological attack.

25

Agency officials say that federal response teams, such

as Disaster Medical Assistance Teams, could be on site within 12 to 24

hours. However, local officials who have deployed with such teams say

that the federal assistance probably would not arrive for 24 to 72 hours.

Local officials also told us that they were concerned about the time and

resources required to prepare and distribute drugs from the National

Pharmaceutical Stockpile during an emergency. Partially in response to

these concerns, CDC has developed training for state and local officials in

using the stockpile and will deploy a small staff with the supplies to assist

the local jurisdiction with distribution.

Components of the nation's public health system are also not well

prepared to detect or respond to a bioterrorist attack. In particular,

weaknesses exist in the key areas of training, communication, and hospital

and laboratory capacity. It has been reported that physicians and nurses in

22

A.E. Smithson and L.-A. Levy, Ataxia: The Chemical and Biological Terrorism Threat and

the U.S. Response (Washington, D.C.: The Henry L. Stimson Center, Oct. 2000), p. 271.

23

Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving

Weapons of Mass Destruction, p. 32.

24

D.C. Wetter, W.E. Daniell, and C.D. Treser, "Hospital Preparedness for Victims of

Chemical or Biological Terrorism," American Journal of Public Health, Vol. 91, No. 5 (May

2001), pp. 710-16.

25

Smithson and Levy, p. 227..Page 14 GAO-02-149T

emergency rooms and private offices, who will most likely be the first

health care workers to see patients following a bioterrorist attack, lack the

needed training to ensure their ability to make observations of unusual

symptoms and patterns.

26

Most physicians and nurses have never seen

cases of certain diseases, such as smallpox or plague, and some biological

agents initially produce symptoms that can be easily confused with

influenza or other, less virulent illnesses, leading to a delay in diagnosis or

identification. Medical laboratory personnel require training because they

also lack experience in identifying biological agents such as anthrax.

Because it could take days to weeks to identify the pathogen used in a

biological attack, good channels of communication among the parties

involved in the response are essential to ensure that the response

proceeds as rapidly as possible. Physicians will need to report their

observations to the infectious disease surveillance system. Once the

disease outbreak has been recognized, local health departments will need

to collaborate closely with personnel across a variety of agencies to bring

in the needed expertise and resources. They will need to obtain the

information necessary to conduct epidemiological investigations to

establish the likely site and time of exposure, the size and location of the

exposed population, and the prospects for secondary transmission.

However, past experiences with infectious disease response have revealed

a lack of sufficient and secure channels for sharing information. Our

report last year on the initial West Nile virus outbreak in New York City

found that as the public health investigation grew, lines of communication

were often unclear, and efforts to keep everyone informed were awkward,

such as conference calls that lasted for hours and involved dozens of

people.

27

Adequate laboratory and hospital capacity is also a concern. Reductions in

public health laboratory staffing and training have affected the ability of

state and local authorities to identify biological agents. Even the initial

West Nile virus outbreak in 1999, which was relatively small and occurred

in an area with one of the nation's largest local public health agencies,

taxed the federal, state, and local laboratory resources. Both the New York

State and the CDC laboratories were inundated with requests for tests, and

the CDC laboratory handled the bulk of the testing because of the limited

26

Smithson and Levy, p. 248.

27

See West Nile Virus Outbreak: Lessons for Public Health Preparedness

(GAO/HEHS-00-180, Sept. 11, 2000), pp. 21-22..Page 15 GAO-02-149T

capacity at the New York laboratories. Officials indicated that the CDC

laboratory would have been unable to respond to another outbreak, had

one occurred at the same time. In fiscal year 2000, CDC awarded

approximately $11 million to 48 states and four major urban health

departments to improve and upgrade their surveillance and

epidemiological capabilities. With regard to hospitals, several federal and

local officials reported that there is little excess capacity in the health care

system in most communities for accepting and treating mass casualty

patients. Research reports have concluded that the patient load of a

regular influenza season in the late 1990s overtaxed primary care facilities

and that emergency rooms in major metropolitan areas are routinely filled

and unable to accept patients in need of urgent care.

28

We found that federal departments and agencies are participating in a

variety of research and preparedness activities that are important steps in

improving our readiness. Although federal departments and agencies have

engaged in a number of efforts to coordinate these activities on a formal

and informal basis, we found that coordination between departments and

agencies is fragmented. In addition, we remain concerned about

weaknesses in public health preparedness at the state and local levels, a

lack of hospital participation in training on terrorism and emergency

response planning, the timely availability of medical teams and resources

in an emergency, and, in particular, inadequacies in the public health

infrastructure. The latter include weaknesses in the training of health care

providers, communication among responsible parties, and capacity of

laboratories and hospitals, including the ability to treat mass casualties.

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.

28

J.R. Richards, M.L. Navarro, and R.W. Derlet, "Survey of Directors of Emergency

Departments in California on Overcrowding," Western Journal of Medicine, Vol. 172 (June

2000), pp. 385-88. R. Derlet, J. Richards, and R. Kravitz, "Frequent Overcrowding in U.S.

Emergency Departments," Academic Emergency Medicine, Vol. 8, No. 2 (2001), pp.151-55.

Smithson and Levy, p. 262.

Concluding

Observations.Page 16 GAO-02-149T

For further information about this testimony, please contact me at (202)

512-7118. Barbara Chapman, Robert Copeland, Marcia Crosse, Greg

Ferrante, Deborah Miller, and Roseanne Price also made key contributions

to this statement.

Contact and

Acknowledgments.Page 17 GAO-02-149T

U.S. Department of Agriculture

(USDA)-Agricultural Research

Service

0 $0.5 Improving detection of biological agents

Department of Energy $35.5 $39.6 Developing technologies for detecting and responding to a

bioterrorist attack

Developing models of the spread of and exposure to a

biological agent after release

Department of Health and Human

Services (HHS)-Agency for

Healthcare Research and Quality

$5.0 0 Examining clinical training and ability of frontline medical staff

to detect and respond to a bioterrorist threat

Studying use of information systems and decision support

systems to enhance preparedness for medical care in the

event of a bioterrorist event

HHS-Centers for Disease

Control and Prevention (CDC)

$48.2 $46.6 Developing equipment performance standards

Conducting research on smallpox and anthrax viruses and

therapeutics

HHS-Food and Drug

Administration (FDA)

$8.8 $9.1 Licensing of vaccines for anthrax and smallpox

Determining procedures for allowing use of not-yet-approved

drugs and specifying data needed for approval and labeling

HHS-National Institutes of

Health

$43.0 $49.7 Developing new therapies for smallpox virus

Developing smallpox and bacterial antigen detection system

HHS-Office of Emergency

Preparedness (OEP)

0 $4.6 Overseeing a study on response systems

Department of Justice (DOJ)-

Office of Justice Programs (OJP)

$0.7 $4.6 Developing a biological agent detector

DOJ-Federal Bureau of

Investigation

0 $1.1 Conducting work on detection and characterization of

biological materials

Department of the Treasury-

Secret Service

0 $0.5 Developing a biological agent detector

Environmental Protection Agency

(EPA)

0 $0.5 Improving detection of biological agents

Note: Total reported funding refers to budget data we received from agencies. Agencies reported

appropriations, actual or estimated obligations, or actual or estimated expenditures. An agency

providing appropriations is not necessarily indicating the level of its obligations or expenditures for

that year-only the amount of budget authority made available to it by the Congress. Similarly, an

agency that provided expenditure information for fiscal year 2000 may have obligated the funds in

fiscal year 1999 based on an appropriation for fiscal year 1998.

Source: Information obtained from departments and agencies.

Appendix I: Funding for Research.Page 18 GAO-02-149T

USDA-Animal and Plant

Health Inspection Service

0 $0.2 Developing educational materials and training programs

specifically dealing with bioterrorism

Department of Defense

(DOD)-Joint Task Force for

Civil Support

$3.4 $8.7 Planning, and when directed, commanding and controlling DOD's

WMD and high-yield explosive consequence management

capabilities in support of FEMA

DOD-National Guard $70.0 $93.3 Managing response teams that would enter a contaminated area

to gather samples for on-site evaluation

DOD-U.S. Army $29.5 $11.7 Maintaining a repository of information about chemical and

biological weapons and agents, detectors, and protection and

decontamination equipment

HHS-CDC $124.9 $147.3 Awarding planning grants to state and local health departments to

prepare bioterrorism response plans

Improving surveillance methods for detecting disease outbreaks

Increasing communication capabilities in order to improve the

gathering and exchanging of information related to bioterrorist

incidents

HHS-FDA $0.1 $2.1 Improving capabilities to identify and characterize foodborne

pathogens

Identifying biological agents using animal studies and

microbiological surveillance

HHS-OEP $35.3 $46.1 Providing contracts to increase local emergency response

capabilities

Developing and managing response teams that can provide

support at the site of a disaster

DOJ-OJP $7.6 $5.3 Helping prepare state and local emergency responders through

training, exercises, technical assistance, and equipment

programs

Developing a data collection tool to assist states in conducting

their threat, risk, and needs assessments, and in developing their

preparedness strategy for terrorism, including bioterrorism

EPA $0.1 $2.0 Providing technical assistance in identifying biological agents and

decontaminating affected areas

Conducting assessments of water supply vulnerability to

terrorism, including contamination with biological agents

Federal Emergency

Management Agency

$25.1 $30.3 Providing grant assistance and guidance to states for planning

and training

Maintaining databases of safety precautions for biological,

chemical, and nuclear agents

Note: Total reported funding refers to budget data we received from agencies. Agencies reported

appropriations, actual or estimated obligations, or actual or estimated expenditures. An agency

providing appropriations is not necessarily indicating the level of its obligations or expenditures for

that year-only the amount of budget authority made available to it by the Congress. Similarly, an

agency that provided expenditure information for fiscal year 2000 may have obligated the funds in

fiscal year 1999 based on an appropriation for fiscal year 1998.

Source: Information obtained from departments and agencies.

Appendix II: Funding for Preparedness

Activities.Page 19 GAO-02-149T

We identified the following federal departments and agencies as having

responsibilities related to the public health and medical consequences of a

bioterrorist attack:

. USDA - U.S. Department of Agriculture

. APHIS - Animal and Plant Health Inspection Service

. ARS - Agricultural Research Service

. FSIS - Food Safety Inspection Service

. OCPM - Office of Crisis Planning and Management

. DOC - Department of Commerce

. NIST - National Institute of Standards and Technology

. DOD - Department of Defense

. DARPA - Defense Advanced Research Projects Agency

. JTFCS - Joint Task Force for Civil Support

. National Guard

. U.S. Army

. DOE - Department of Energy

. HHS - Department of Health and Human Services

. AHRQ - Agency for Healthcare Research and Quality

. CDC - Centers for Disease Control and Prevention

. FDA - Food and Drug Administration

. NIH - National Institutes of Health

. OEP - Office of Emergency Preparedness

. DOJ - Department of Justice

. FBI - Federal Bureau of Investigation

. OJP - Office of Justice Programs

. DOT - Department of Transportation

. USCG - U.S. Coast Guard

. Treasury - Department of the Treasury

. USSS - U.S. Secret Service

. VA - Department of Veterans Affairs

. EPA - Environmental Protection Agency

. FEMA - Federal Emergency Management Agency

Figure 1, which is based on the framework given in the Terrorism Incident

Annex of the Federal Response Plan, shows a sample of the coordination

activities by these federal departments and agencies, as they existed prior

to the recent creation of the Office of Homeland Security. This figure

illustrates the complex relationships among the many federal departments

and agencies involved. The following coordination activities are

represented on the figure:

Appendix III: Examples of Coordination

Activities on Bioterrorism Among Federal

Departments and Agencies.Page 20 GAO-02-149T

. OMB Oversight of Terrorism Funding. The Office of Management and

Budget established a reporting system on the budgeting and expenditure

of funds to combat terrorism, with goals to reduce overlap and improve

coordination as part of the annual budget cycle.

. Federal Response Plan - Health and Medical Services Annex. This annex

to the Federal Response Plan states that HHS is the primary agency for

coordinating federal assistance to supplement state and local resources in

response to public health and medical care needs in an emergency,

including a bioterrorist attack.

. Informal Working Group - Equipment Request Review. This group meets

as necessary to review equipment requests of state and local jurisdictions

to ensure that duplicative funding is not being given for the same

activities.

. Agreement on Tracking Diseases in Animals That Can Be Transmitted to

Humans. This group is negotiating an agreement to share information and

expertise on tracking diseases that can be transmitted from animals to

people and could be used in a bioterrorist attack.

. National Medical Response Team Caches. These caches form a stockpile

of drugs for OEP's National Medical Response Teams.

. Domestic Preparedness Program. This program was formed in response to

the National Defense Authorization Act of Fiscal Year 1997 (P.L. 104-201)

and required DOD to enhance the capability of federal, state, and local

emergency responders regarding terrorist incidents involving WMDs and

high-yield explosives. As of October 1, 2000, DOD and DOJ share

responsibilities under this program.

. Office of National Preparedness - Consequence Management of WMD

Attack. In May 2001, the President asked the Director of FEMA to establish

this office to coordinate activities of the listed agencies that address

consequence management resulting from the use of WMDs.

. Food Safety Surveillance Systems. These systems are FoodNet and

PulseNet, two surveillance systems for identifying and characterizing

contaminated food.

. National Disaster Medical System. This system, a partnership between

federal agencies, state and local governments, and the private sector, is

intended to ensure that resources are available to provide medical services

following a disaster that overwhelms the local health care resources.

. Collaborative Funding of Smallpox Research. These agencies conduct

research on vaccines for smallpox.

. National Pharmaceutical Stockpile Program. This program maintains

repositories of life-saving pharmaceuticals, antidotes, and medical

supplies that can be delivered to the site of a biological (or other) attack..Page 21 GAO-02-149T

. National Response Teams. The teams constitute a national planning,

policy, and coordinating body to provide guidance before and assistance

during an incident.

. Interagency Group for Equipment Standards. This group develops and

maintains a standardized equipment list of essential items for responding

to a terrorist WMD attack. (The complete name for this group is the

Interagency Board for Equipment Standardization and Interoperability.)

. Force Packages Response Team. This is a grouping of military units that

are designated to respond to an incident.

. Cooperative Work on Rapid Detection of Biological Agents in Animals,

Plants, and Food. This cooperative group is developing a system to

improve on-site rapid detection of biological agents in animals, plants, and

food..Page 22 GAO-02-149T

Bioterrorism: Public Health and Medical Preparedness (GAO-02-141T, Oct.

9, 2001).

Bioterrorism: Coordination and Preparedness (GAO-02-129T, Oct. 5, 2001).

Bioterrorism: Federal Research and Preparedness Activities (GAO-01-915,

Sept. 28, 2001).

Combating Terrorism: Selected Challenges and Related Recommendations

(GAO-01-822, Sept. 20, 2001).

Combating Terrorism: Comments on H.R. 525 to Create a President's

Council on Domestic Terrorism Preparedness (GAO-01-555T, May 9, 2001).

Combating Terrorism: Accountability Over Medical Supplies Needs

Further Improvement (GAO-01-666T, May 1, 2001).

Combating Terrorism: Observations on Options to Improve the

FederalResponse (GAO-01-660T, Apr. 24, 2001).

Combating Terrorism: Accountability Over Medical Supplies Needs

Further Improvement (GAO-01-463, Mar. 30, 2001).

Combating Terrorism: Comments on Counterterrorism Leadership and

National Strategy (GAO-01-556T, Mar. 27, 2001).

Combating Terrorism: FEMA Continues to Make Progress in Coordinating

Preparedness and Response (GAO-01-15, Mar. 20, 2001).

Combating Terrorism: Federal Response Teams Provide Varied

Capabilities; Opportunities Remain to Improve Coordination (GAO-01-14,

Nov. 30, 2000).

West Nile Virus Outbreak: Lessons for Public Health Preparedness

(GAO/HEHS-00-180, Sept. 11, 2000).

Combating Terrorism: Linking Threats to Strategies and Resources

(GAO/T-NSIAD-00-218, July 26, 2000).

Chemical and Biological Defense: Observations on Nonmedical Chemical

and Biological R&D Programs (GAO/T-NSIAD-00-130, Mar. 22, 2000).

Related GAO Products.Page 25 GAO-02-149T

Combating Terrorism: Need to Eliminate Duplicate Federal Weapons of

Mass Destruction Training (GAO/NSIAD-00-64, Mar. 21, 2000).

Combating Terrorism: Chemical and Biological Medical Supplies Are

Poorly Managed (GAO/T-HEHS/AIMD-00-59, Mar. 8, 2000).

Combating Terrorism: Chemical and Biological Medical Supplies Are

Poorly Managed (GAO/HEHS/AIMD-00-36, Oct. 29, 1999).

Food Safety: Agencies Should Further Test Plans for Responding to

Deliberate Contamination (GAO/RCED-00-3, Oct. 27, 1999).

(290143)

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