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GAO Finds National Plans to Combat Bioterrorism Need Improvement

Kate Traynor

Three reports released in September by the General Accounting Office (GAO) describe problems in the nation’s framework for combating bioterrorism and other terrorist threats.1-3

The reports, which were in the works before the terrorist attacks on September 11, focused mainly on problems known to exist before that date.

Overall, the federal coordination of programs to combat bioterrorism is fragmented, GAO found. The existence of duplicative efforts, accountability problems, and an unclear chain of authority make it difficult for agencies to set clear policies for dealing with bioterrorism and other terrorist acts.

Risk identification. The Justice Department and the Federal Bureau of Investigation identify potential terrorist threats and assess the risk of these threats. According to GAO, a "five-year plan" on counterterrorism developed by these agencies includes goals but lacks measurable outcomes and fails to identify the roles to be played by state and local governments in combating terrorism.

Lack of coordination. GAO estimated that more than 40 federal agencies are involved in combating terrorism. The responsibilities of the various agencies include risk assessment, policymaking, development of specific programs, and funding of antiterrorist activities.

But not every agency knows what is expected of it during a crisis. The Department of Transportation, for example, told GAO auditors that it did not understand the extent of its role in responding to bioterrorism until it participated in a national training exercise last May.

According to GAO, the executive branch of the government should be responsible for coordinating federal antiterrorist activities and assigning responsibilities. GAO suggested that the executive branch create "a single focal point, with all critical functions and responsibilities…to lead and coordinate these programs." The newly created Office of Homeland Security, headed by former Pennsylvania Governor Tom Ridge, seems to be an attempt to address this concern.

Duplication of efforts. GAO found that federal agencies have been pursuing counterterrorism programs that may overlap those of other agencies. For example, at least seven groups—the Secret Service, Environmental Protection Agency, and the Defense, Justice, Energy, Agriculture, and Health and Human Services (HHS) departments—are developing ways to detect biological agents that might be used by terrorists. Of high interest are anthrax, plague, salmonellosis, smallpox, tularemia, and West Nile virus, although not all agencies are studying detection methods for all of these pathogens.

Duplication of efforts also exists for government-initiated responses to bioterrorism, GAO determined. The Federal Emergency Management Agency (FEMA) and the Defense, Justice, and HHS departments each have separate plans to assist state and local authorities during a bioterrorist attack or other public health emergency. GAO recommended consolidating some of the Justice Department assistance programs under FEMA.

 The American Hospital Association has issued a four-part "Disaster Readiness Advisory" to help hospitals plan their responses to disasters. Included in the material is a "Chemical and Bioterrorism Preparedness Checklist," containing a section on pharmaceuticals and equipment and a list of chemical and biological agents, with corresponding first-aid measures, that would most likely be used in a terrorist attack.

Hospitals are a weak point. According to GAO, hospitals are ill-equipped to deal with "mass casualties" resulting from a bioterrorist attack. Hospitals often lack basic tools, such as Internet access, that could help in the preparation for and response to a bioterrorist attack. And people who work in hospitals, GAO noted, have been reluctant to participate in local "training, planning, and exercises" to improve their ability to respond to an attack.

Hospitals are not the only groups to fall short in GAO’s assessment. State and local public health authorities—even those in cities that have received federal emergency-preparedness grants—also apparently lack the ability to respond adequately to a terrorist attack.

Some cooperation exists. GAO noted that some federal agencies have started working together to increase the efficiency of their bioterrorism response and preparedness programs. The Agriculture Department, for example, is reportedly negotiating with the Defense Department to set up a way to track diseases that animals may transmit to humans. Also, some agencies have formed "interagency work groups" on bioterrorism that are designed to minimize duplicative efforts and funding.

FDA is reportedly working with the National Security Council to compile a list of drugs and drug information that could aid the country if a bioterrorist attack occurs. FDA is also looking at ways to expand the labeling of drugs that might be effective for treating victims of bioterrorist attacks but for which insufficient clinical study data from humans exists to make that determination.

Management of the National Pharmaceutical Stockpile. GAO described the Centers for Disease Control and Prevention (CDC) as another agency that has enlisted outside federal help to combat bioterrorism. CDC contracts with the Department of Veterans Affairs to purchase materials for the National Pharmaceutical Stockpile, which is controlled by CDC. The stockpile, which was created in 1999, is described by CDC as "a national repository of antibiotics, chemical antidotes, antitoxins, life-support medications, IV administration and airway maintenance supplies, and medical/surgical items."

The first-ever emergency use of the stockpile was authorized September 11, when supplies were sent to New York City to aid victims of the terrorist attacks on the World Trade Center. A few weeks later, supplies from the stockpile were sent to Florida in response to a case of anthrax identified in the state.

Problems with the stockpile were the focus of a 1999 GAO report,4 which found that supplies in the stockpile were not being properly tracked and rotated. GAO reported in May 2001 that management of the stockpile had improved but said that additional quality assurance and better oversight are needed.5

Many of the issues recently raised by GAO echo the findings of other reports the agency has generated since 1999, when it began producing congressionally mandated annual reports on combating terrorism. In general, GAO determined, little evidence exists that these reports have prompted the federal government to set priorities and minimize the duplication of efforts to combat terrorism.

GAO acknowledged, however, that federal plans to combat terrorism have changed since September 11 and that the issue is now "at the top of the national agenda."

1. Combating terrorism: actions needed to improve DOD antiterrorism program implementation and management. Washington, DC: U.S. General Accounting Office, 2001 Sept 19; GAO-01-909.

2. Combating terrorism: selected challenges and related recommendations. Washington, DC: U.S. General Accounting Office, 2001 Sept 20; GAO-01-822.

3. Bioterrorism: federal research and preparedness activities. Washington, DC: U.S. General Accounting Office, 2001 Sept 28; GAO-01-915.

4. Combating terrorism: chemical and biological medical supplies are poorly managed. Washington, DC: U.S. General Accounting Office, 1999 Oct 29; GAO/HEHS/AIMD-00-36.

5. Combating terrorism: accountability over medical supplies needs further improvement. Washington, DC: U.S. General Accounting Office, 2001 May 1; GAO-01-666T.

 Pharmacies are on Bioterrorism Frontline

Pharmacists could be the first health professionals to see signs of a covert bioterrorist attack.

"I believe that the local pharmacies are where people are going to show up first," said Rex Archer, who chairs the Bioterrorism and Emergency Preparedness Committee of the National Association of County and City Health Officials.

"People self-medicate first, before they even go to an outpatient setting or to the emergency room," he said. This means that community pharmacies could notice unusual increases in sales of nonprescription products to treat the early symptoms of a bioterrorism-related illness.

In addition to paying attention to unusual drug-sale trends, Archer said pharmacists need to be alert to the signs of diseases that could be spread through bioterrorism. "If [pharmacies] have people coming in that have rashes, and [the rash] is smallpox, they need to be able to recognize it," he said.

Archer pointed out that the ability to recognize the signs of infectious diseases is more than a public health duty for pharmacists—it protects the health of the pharmacy staff members who are exposed to the diseases on the job.

"When people are coming in, and they’re coughing, and they’re getting over-the-counter cough medicine, who are they coughing on?" he asked.

Archer, who is also the director of the Kansas City, Missouri, health department, wants pharmacies to be electronically connected to the public health network. When the Centers for Disease Control and Prevention sends out an electronic public health alert, he said, "we should be sending this to the local pharmacies and the pharmacists to keep them aware of what’s happening, what to be looking for."

Most of the biological agents thought to be available to bioterrorists are naturally occurring organisms that public health agencies have dealt with in the past. But Archer cautioned that the time course of a bioterrorist attack would be different than that of a naturally occurring disease outbreak.

"Natural outbreaks tend to occur…over weeks and, with some illnesses, months," Archer said. In contrast, a deliberate release of a biological agent by terrorists would compress the time available to respond and save lives.

"We have to start thinking in a matter of minutes and hours, and, at most, a day, of doing some things that we used to think, in natural outbreaks, that we could do over weeks," Archer said. "It’s a different ball game."