GAO-12-55, Biosurveillance: Nonfederal Capabilities Should Be Considered in Creating a National Biosurveillance Strategy


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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

October 2011: 

Biosurveillance: 

Nonfederal Capabilities Should Be Considered in Creating a National 
Biosurveillance Strategy: 

GAO-12-55: 

GAO Highlights: 

Highlights of GAO-12-55, a report to congressional committees. 

Why GAO Did This Study: 

The nation is at risk for a catastrophic biological event. The 
Implementing Recommendations of the 9/11 Commission Act directed GAO 
to report on biosurveillance-—to help detect and respond to such 
events—-at multiple jurisdictional levels. In June 2010, GAO 
recommended that the National Security Staff lead the development of a 
national biosurveillance strategy, which is now under development. 
This report focuses on nonfederal jurisdictions, which own many of the 
resources that support a national capability. It discusses (1) federal 
support for state and local biosurveillance; (2) state and local 
challenges; (3) federal support and challenges for tribal and insular 
areas and (4) federal assessments of nonfederal capabilities. To 
conduct this work, GAO interviewed select federal-agency, 
jurisdiction, and association officials and reviewed relevant 
documents. To collect information on federal efforts and challenges, 
we also sent standardized questionnaires to seven states and two 
cities. 

What GAO Found: 

The federal government has efforts to support health preparedness that 
state and city officials identified as critical to their 
biosurveillance capabilities. The efforts these officials identified 
fell into four categories: (1) grants and cooperative agreements, (2) 
nonfinancial technical and material assistance, (3) guidance, and (4) 
information sharing. Within each of the categories, the officials 
identified specific federal efforts that were essential to their 
biosurveillance activities. For example, public-health officials 
described cooperative agreements from the Centers for Disease Control 
and Prevention that provided resources for disease investigation, as 
well as guidance on federal priorities. However, as with our June 2010 
findings about federal biosurveillance, in the absence of a national 
strategy, these efforts are not coordinated or targeted at ensuring 
effective and efficient national biosurveillance capabilities. Because 
the resources that constitute a national biosurveillance capability 
are largely owned by nonfederal entities, a national strategy that 
considers how to leverage nonfederal efforts could improve efforts to 
build and maintain a national biosurveillance capability. 

State and city officials identified common challenges to developing 
and maintaining their biosurveillance capabilities: (1) state policies 
that restrict hiring, travel, and training in response to budget 
constraints; (2) ensuring adequate workforce, training, and systems; 
and (3) the lack of strategic planning and leadership to support long- 
term investment in cross-cutting core capabilities, integrated 
biosurveillance, and effective partnerships. A national 
biosurveillance strategy that considers planning and leadership 
challenges at all levels of the biosurveillance enterprise may help 
partners across the enterprise find shared solutions for an effective 
national biosurveillance capability. 

The federal government provides some resources to help control disease 
in humans and animals in tribal and insular areas, but there are no 
specific efforts to ensure these areas can contribute to a national 
biosurveillance capability. Resources include cooperative agreements, 
disease-specific funding, training, and technical assistance. 
Surveillance capacity varies among tribes and insular areas, but 
common challenges include limited health infrastructure including 
human- and animal-health professionals and systems. 

The federal government has not conducted a comprehensive assessment of 
state and local jurisdictions’ ability to contribute to a national 
biosurveillance capability, as called for in presidential directive. 
According to federal, state, and local officials, the magnitude and 
complexity of such an assessment is a challenge. Until it conducts 
such an assessment, the federal government will lack key information 
to support a national biosurveillance capability. A national strategy 
like the one we previously recommended—one capable of guiding federal 
agencies and its key stakeholders to systematically identify gaps, 
resources to address those gaps, and investment priorities—would 
benefit from an assessment of jurisdictions’ baseline capabilities and 
critical gaps across the entire biosurveillance enterprise. 

What GAO Recommends: 

GAO recommends that the National Security Staff ensure the strategy 
considers (1) existing federal efforts, (2) challenges, and (3) 
assessment of nonfederal capabilities. 

GAO provided a draft of this report to the National Security Staff, 
and the federal, state and city officials who contributed information. 
The National Security Staff acknowledged the accuracy of the report, 
but did not comment on the recommendation. 

View [hyperlink, http://www.gao.gov/products/GAO-12-55]. For more 
information, contact Bill Jenkins at (202) 512-8777 or 
jenkinswo@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Absent a Strategy and Biosurveillance-Specific Capability Efforts, 
Existing Federal Activities Help Support State and Local Capabilities: 

State and Local Officials Reported Challenges Related to State 
Policies, Core Capability Resources, and Planning and Leadership to 
Support Biosurveillance Capabilities: 

Federal Agencies Provide Some Support, but Biosurveillance 
Capabilities in Tribal and Insular Areas Are Limited by Resources and 
Infrastructure: 

The Federal Government Has Not Comprehensively Assessed Nonfederal 
Biosurveillance Capabilities: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Laboratories, Laboratory Networks, and Their Roles in 
Biosurveillance: 

Appendix III: Responses to Follow-Up Questionnaire Concerning Federal 
Programs and Initiatives That May Support Nonfederal Biosurveillance 
Capabilities: 

Appendix IV: Responses to Follow-Up Questionnaire Concerning 
Challenges State and Local Officials May Face in Building and 
Maintaining Biosurveillance Capabilities: 

Appendix V: Comments from the Department of Homeland Security: 

Appendix VI: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Selected Biosurveillance Roles and Responsibilities: 

Table 2: Grants and Cooperative Agreements Most Commonly Identified by 
City and State Questionnaire Respondents as Essential for Supporting 
Their Core Biosurveillance Capabilities: 

Table 3: Types of Nonfinancial Assistance Most Commonly Identified by 
City and State Questionnaire Respondents as Essential for Supporting 
Their Core Biosurveillance Capabilities: 

Table 4: Types of Federal Guidance Most Commonly Identified by City 
and State Questionnaire Respondents as Being Very Useful for 
Supporting Their Core Biosurveillance Capabilities: 

Table 5: Types of Information-Sharing Tools and Analytical Products 
Most Commonly Identified by City and State Questionnaire Respondents 
as Essential to Supporting Their Core Biosurveillance Capabilities: 

Table 6: Factors Identified and Their Application to Our Site 
Selection: 

Table 7: Laboratories and Laboratory Networks: 

Table 8: Responses from the Epidemiology and Laboratory Groups 
Concerning Information Sharing and Analytical Products: 

Table 9: Responses from the Agriculture and Wildlife Groups Concerning 
Information Sharing and Analytical Products: 

Table 10: Responses from the Epidemiology and Laboratory Groups 
Concerning Nonfinancial Assistance: 

Table 11: Responses from the Agriculture and Wildlife Groups 
Concerning Nonfinancial Assistance: 

Table 12: Responses from the Epidemiology and Laboratory Groups 
Concerning Grants and Cooperative Agreements: 

Table 13: Responses from the Agriculture and Wildlife Groups 
Concerning Grants and Cooperative Agreements: 

Table14: Responses from the Epidemiology and Laboratory Groups 
Concerning Guidance: 

Table15: Responses from the Agriculture and Wildlife Groups Concerning 
Guidance: 

Table 16: Results of Responses to Questions Concerning Challenges: 

Figures: 

Figure 1: Biosurveillance in Brief: 

Figure 2: State and Local Public Health Structure: 

Figure 3: Examples of Zoonotic Diseases and Their Affected Populations: 

Figure 4: Tribal Epidemiology Centers: 

Abbreviations: 

Arbo: Net Arboviral Surveillance System: 

BSL-3: Biological Security Level - Three laboratory: 

CDC: Centers for Disease Control and Prevention: 

DHS: Department of Homeland Security: 

DOI: Department of the Interior: 

ELC: Epidemiology and Laboratory Capacity for Infectious Diseases 
Cooperative Agreement: 

eLEXNET: Electronic Laboratory Exchange Network: 

Epi-X: Epidemic Information Exchange: 

ERLN: Environmental Response Laboratory Network: 

FERN: Food Emergency Response Network: 

FoodNet: Foodborne Disease Active Surveillance Network: 

HHS: Department of Health and Human Services: 

HIPAA: Health Insurance Portability and Accountability Act: 

HSPD: Homeland Security Presidential Directive: 

ICLN: Integrated Consortium of Laboratory Networks: 

HIS: Indian Health Service: 

ILINet: Influenza-like Illness Surveillance Program: 

LRN: Laboratory Response Network: 

MMWR: Morbidity and Mortality Weekly Report: 

NAHRS: National Animal Health Reporting System: 

NAHLN: National Animal Health Laboratory Network: 

NEDSS: National Electronic Disease Surveillance System: 

NIFA: National Institute of Food and Agriculture: 

NVSL: National Veterinary Services Laboratory: 

OIE: World Organization for Animal Health: 

PHEP: Public Health Emergency Preparedness: 

PIHOA: Pacific Island Health Officers Association: 

PPACA: Patient Protection and Affordable Care Act: 

SARS: Severe Acute Respiratory Syndrome: 

SCWDS: Southeastern Cooperative Wildlife Disease Study: 

TB GIMS: TB Genotyping Information Management System: 

USDA: United States Department of Agriculture: 

USGS: United States Geological Survey: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

October 31, 2011: 

The Honorable Joseph I. Lieberman: 
Chairman: 
The Honorable Susan M. Collins: 
Ranking Member: 
Committee on Homeland Security and Governmental Affairs: 
United States Senate: 

The Honorable Peter King: 
Chairman: 
The Honorable Bennie Thompson: 
Ranking Member: 
Committee on Homeland Security: 
House of Representatives: 

A catastrophic biological event, such as a terrorist attack with a 
weapon of mass destruction or a naturally occurring pandemic, could 
cause thousands of casualties or more, weaken the economy, damage 
public morale and confidence, and threaten national security. 
Effective preparation for, detection of, and response to a major 
biological event requires effective pre-and postdisaster coordination 
and cooperation among different federal agencies, levels of 
government, nongovernmental organizations, and the private sector. 
Timely detection of signs of unusual and potentially dangerous disease 
is a first step in an effective response to a natural, accidental, or 
intentional outbreak of a biological event of national concern. 

Although the United States has numerous surveillance programs and 
systems at various levels of government and in the private sector to 
monitor disease, these programs and systems were developed separately 
for a variety of mission objectives, and as such are relatively 
uncoordinated. We reported in June 2010 that federal biosurveillance 
efforts were dispersed across many federal agencies, but no federal 
entity had responsibility and authority for coordinating activities to 
help ensure timely detection and situational awareness for disease 
outbreaks with potentially catastrophic consequences.[Footnote 1] We 
also reported that the responsibility and capacity for collecting most 
information and carrying out most health-monitoring activities resides 
within state and local jurisdictions or with private-sector entities-- 
such as hospitals and other private health-care providers. The federal 
government generally cannot compel state and local jurisdictions or 
private-sector entities to provide information or resources to support 
federal biosurveillance efforts. Instead, individual federal agencies, 
in pursuit of their missions, attempt to build relationships and offer 
incentives--like grants--to encourage voluntary cooperation with 
specific federal efforts. 

In October 2007, Homeland Security Presidential Directive-21 (HSPD-21) 
articulated a vision for protecting the nation from catastrophic 
disease outbreaks in humans that included a call for a national 
biosurveillance capability that enhances the timeliness of detection 
and the quality of situational awareness for response. The national 
biosurveillance capability described in HSPD-21 relies on, among other 
things, (1) strong clinician awareness and laboratory diagnostic 
capacity; (2) a national "common operating picture" that provides a 
comprehensive picture of the health of communities and the associated 
threat environment by incorporating information from human health, 
animal health, agricultural, meteorological, environmental, 
intelligence, and other data; and (3) a nationwide epidemiologic 
surveillance system that is robust enough to identify specific disease 
incidence and prevalence and flexible enough to tailor analyses to new 
syndromes and emerging diseases.[Footnote 2] In calling for such a 
national capability, HSPD-21 reflects the centrality of state and 
local resources in supporting the capability, stating that state and 
local government officials should be involved in system design and 
that the capability should be principally aimed at enhancing the 
capabilities of state and local governments. 

In June 2010, we reported that although the federal government has 
undertaken some potentially useful steps for supporting a national 
biosurveillance capability, there is no unifying framework for 
integrating dispersed capabilities and responsibilities and no entity 
with authority to guide the implementation of a national effort that 
encompasses all stakeholders with biosurveillance responsibilities. We 
recommended that the National Security Staff designate a focal point 
to develop a national biosurveillance strategy.[Footnote 3] According 
to National Security Staff officials, they have designated a Sub- 
Interagency Policy Committee, which they said serves as the focal 
point for an ongoing effort to develop the national biosurveillance 
strategy. 

[Side bar: Prior GAO reports in Response to 9/11 Commission Act 
Mandate: 

GAO-10-171, Biosurveillance: Developing a Collaboration Strategy Is 
Essential to Fostering Interagency Data and Resource Sharing (December 
18, 2009): 

What we found: The Department of Homeland Security’s (DHS) National 
Biosurveillance Integration Center was not fully equipped to carry out 
its mission because it lacks key resources—data and personnel—from its 
partner agencies, which may be at least partially attributed to 
collaboration challenges it has faced. 

What we recommended: DHS work with its interagency partners to 
establish a strategy and performance measures for collaboration. As of 
March 2011, DHS had not finalized a collaboration strategy, but 
officials reported that they had been working with interagency 
partners to develop it. 

GAO-10-645, Biosurveillance: Efforts to Develop a National 
Biosurveillance Capability Need a Strategy and a Designated Leader, 
(June 30, 2010): 

What we found: Biosurveillance activities were dispersed across 
federal agencies and no single entity had responsibility or authority 
for coordinating a strategic approach to building and maintaining a 
national biosurveillance capability. 

What we recommended: The National Security Staff create a focal point 
to lead development of a national strategy. In August 2011, the 
National Security Staff informed us that it had created a Sub- 
Interagency Policy Committee within its Domestic Resilience Group to 
coordinate the development of a National Strategy for Biosurveillance. 
Source: GAO. End of side bar] 

The Implementing Recommendations of the 9/11 Commission Act of 2007 
(9/11 Commission Act) directed us to examine the state of federal, 
state, local, and tribal biosurveillance efforts and the use of 
resources to implement and execute biosurveillance systems.[Footnote 
4] This report, which focuses on nonfederal, governmental--state, 
tribal, local, and insular--biosurveillance capabilities, is the third 
in a series designed to respond to that mandate.[Footnote 5] Given the 
centrality of nonfederal jurisdictions in supporting a national 
biosurveillance capability, and to respond to the state, local, and 
tribal aspect of the 9/11 Commission Act's mandate, this report 
focuses on the following questions: 

1. In the absence of a national biosurveillance strategy, what federal 
efforts support state and local jurisdictions' biosurveillance 
capabilities? 

2. What challenges, if any, have selected state and local 
jurisdictions faced in building and maintaining biosurveillance 
capabilities? 

3. How does the federal government support tribal and insular 
participation in a national biosurveillance capability and what 
challenges does it face? 

4. To what extent has the federal government assessed nonfederal 
jurisdictions' capacity to contribute to a national biosurveillance 
capability? 

To address our objectives, we reviewed key legislation and 
presidential directives related to biosurveillance, including the 
Homeland Security Act of 2002,[Footnote 6] the Public Health Security 
and Bioterrorism Preparedness and Response Act of 2002,[Footnote 7] 
the Pandemic and All-Hazards Preparedness Act of 2006,[Footnote 8] and 
Homeland Security Presidential Directives (HSPD) 9,[Footnote 9] 10, 
[Footnote 10] and 21. This report focuses on surveillance efforts for 
zoonoses--diseases that can be transferred between animals and humans--
and other emerging infectious diseases with the potential to cause 
catastrophic human health effects.[Footnote 11] At the federal level, 
we consulted officials at the Departments of Agriculture (USDA), 
Homeland Security (DHS), Health and Human Services (HHS), and the 
Interior (DOI), which have key missions, statutory responsibilities, 
directives, or programmatic objectives for biosurveillance activities 
within the scope of this report, including protecting human and animal 
health and national security. We also discussed biosurveillance at the 
state and city level with officials from the Department of Justice's 
Federal Bureau of Investigation. 

To provide perspectives on the federal efforts that support state 
biosurveillance capabilities and the challenges officials face 
building and maintaining those capabilities, we selected a 
nongeneralizable sample of seven states based on a variety of factors 
that might affect biosurveillance efforts--including the structure of 
a state's public health system, its geography, and its amount and type 
of agriculture. The states selected were Utah, Colorado, New Jersey, 
California, Delaware, North Carolina, and Mississippi. In each of 
these states, we interviewed three groups of officials: (1) officials 
in public-health departments, (2) officials in state agriculture 
departments, and (3) officials in various departments that included 
wildlife infectious-disease control and monitoring in their missions. 
We also interviewed public-health officials with responsibility for 
human infectious-disease control and monitoring in two cities with an 
increased risk of bioterrorism--New York City and Washington, D.C.-- 
that received direct funding from federal agencies to support 
preparedness capabilities. Among other things, we discussed the 
federal efforts that support their biosurveillance capabilities and 
the challenges they face in building and maintaining biosurveillance 
capabilities. 

We analyzed the information collected during state and city interviews 
and developed follow-up questionnaires to confirm and enhance 
information from the interviews about the federal programs and 
initiatives that support state and local biosurveillance capabilities 
and the challenges officials face. We sent follow-up questionnaires to 
public health departments in all seven states and two cities and to 
agriculture and wildlife officials in the seven states. Within each 
public-health department, we sent separate questionnaires to 
laboratory and epidemiology officials. In total, we distributed 32 
questionnaires and received 27 responses. Of the 27 respondents, 7 
were epidemiologists, 7 were public health laboratory officials, 6 
were state agriculture officials, and 7 were state wildlife officials. 
All of the public-health, agriculture, and wildlife departments 
represented by the 27 respondents had also been represented in our 
initial interviews. However, in some cases the lead official who 
responded to the questionnaire had not attended the interview. 

The questionnaires had a section on federal support for state and 
local biosurveillance capabilities and a section on challenges. The 
content of the federal-support section varied for human-health and 
animal-health respondents, but the challenges section was the same for 
both. We asked respondents to consider federal-support efforts and 
challenges over the last 2 years. Because the states and cities in 
this review were not selected in a probability sample, neither the 
information derived from interviews with officials nor the 
questionnaire responses are generalizable across the 50 states or the 
tens of thousands of localities in the United States. Rather, both the 
interviews and the questionnaire results offer some perspective on the 
value of select federal activities and challenges faced by a group of 
state and city officials who are actively engaged in efforts to detect 
and respond to major disease events. In addition, although we 
interviewed officials responsible for public-health emergency 
management in most state public-health departments that we visited, we 
did not administer follow-up questionnaires to the officials 
responsible for planning and preparing for emergency response, because 
their response focus was generally not central to our scope. Because 
this report focuses on detection of and situational awareness of 
potentially catastrophic zoonotic and emerging infectious-disease 
events, certain federal efforts that federal agencies consider 
important for supporting state and local preparedness may not have 
been identified by state and city officials during our interviews and 
follow-up questionnaires. 

To consider the relationship between our findings at the nonfederal 
level and our previous findings at the federal level about building 
and maintaining a national biosurveillance capability, we reviewed our 
June 2010 findings about the centrality of nonfederal capabilities to 
a biosurveillance enterprise.[Footnote 12] We also reviewed our June 
2010 findings about the purpose of a national biosurveillance strategy 
and the benefits it could provide for guiding the effort to support a 
national biosurveillance capability. We determined that because the 
federal government relies on nonfederal resources to support a 
national biosurveillance capability, our June 2010 findings about 
using the strategy to determine how to leverage resources, weigh the 
costs and benefits of investments, and define roles and 
responsibilities were particularly germane to the federal government's 
efforts to partner with nonfederal biosurveillance enterprise partners 
to support a national biosurveillance capability. 

To understand how the federal government supports biosurveillance in 
tribal and insular areas, we consulted officials from HHS's Indian 
Health Service (IHS); HHS's Centers for Disease Control and 
Prevention's (CDC) Office of State, Tribal, Local and Territorial 
Support; CDC's Office of Surveillance, Epidemiology, and Laboratory 
Services, CDC's National Center for Emerging and Zoonotic Infectious 
Diseases, USDA's Office of Tribal Relations; USDA's Animal and Plant 
Health Inspection Service; DOI's Bureau of Indian Affairs; and DOI's 
Office of Insular Affairs, which have responsibility for working with 
tribal or insular councils and governments, generally, or on health- 
related matters. In addition, to develop additional context about 
health infrastructure and surveillance in insular areas, we 
interviewed representatives from the Pacific Island Health Officers 
Association (PIHOA), an association that works in the U.S.-Affiliated 
Pacific Islands to provide regional healthcare solutions and 
strengthen crosscutting public-health infrastructure.[Footnote 13] 

To evaluate the extent to which the federal government has assessed 
nonfederal jurisdictions' capacity to contribute to a national 
biosurveillance capability, we reviewed relevant presidential 
directives and federal-agency documents, along with our prior work and 
recommendations on building and maintaining a national biosurveillance 
capability, for criteria. We determined that such an assessment is 
called for in HSPD-10[Footnote 14] and CDC's National Biosurveillance 
Strategy for Human Health[Footnote 15] and is a critical activity for 
developing an effective national strategy containing the elements we 
advocated in prior work on national strategies. To determine what 
types of assessment activities had been undertaken and whether an 
enterprisewide assessment of nonfederal biosurveillance capabilities 
had been conducted, we reviewed relevant assessments and federal 
documents. We also interviewed federal officials at all five federal 
departments previously listed, officials in each of the seven states, 
officials in the two cities, and officials at 10 professional and 
research institutions that include public health, animal health, or 
laboratories in their missions about assessment efforts, to determine 
whether they had participated in or had any familiarity with an 
enterprisewide assessment of nonfederal capabilities. More detailed 
information about our scope and methods appears in appendix I. 

We conducted this performance audit from August 2010 to October 2011 
in accordance with generally accepted government auditing standards. 
[Footnote 16] Those standards require that we plan and perform the 
audit to obtain sufficient, appropriate evidence to provide a 
reasonable basis for our findings and conclusions based on our audit 
objectives. We believe that the evidence obtained provides a 
reasonable basis for our findings and conclusions based on our audit 
objectives. 

Background: 

Biosurveillance in Brief: 

As shown in figure 1, biosurveillance is a concept that emerged in 
response to increased concern about biological threats from emerging 
infectious diseases and bioterrorism. Biosurveillance is carried out 
by and depends on a wide range of dispersed entities, including state, 
tribal, local, and insular jurisdictions. As we reported in June 2010, 
because of the vast array of activities and entities associated with 
effective biosurveillance, ongoing interagency and intergovernmental 
collaboration is crucial.[Footnote 17] 

Figure 1: Biosurveillance in Brief: 

[Refer to PDF for image: illustration] 

What is it? 
In the biological context, surveillance is the ongoing collection, 
analysis, and interpretation of data to help monitor for pathogens in 
plants, animals, and humans; food; and the environment. The general 
aim of surveillance is to help develop policy, guide mission 
priorities, and provide assurance of the prevention and control of 
disease. In recent years, as concerns about consequences of a 
catastrophic biological attack or emerging infectious diseases grew, 
the term biosurveillance became more common in relation to an array of 
threats to our national security. Biosurveillance is concerned with 
two things: (1) reducing, as much as possible, the time it takes to 
recognize and characterize biological events with potentially 
catastrophic consequences and (2) providing situational awareness—that 
is, information that signals an event might be occurring, information 
about what those signals mean, and information about how events will 
likely unfold in the near future. 

Why is it important? 
Although catastrophic events are rare, there are a number of threats 
of biological origin with the potential to cause catastrophic 
consequences. Since the 1970s, newly emerging diseases have been 
identified at the unprecedented rate of one or more per year. 
Moreover, terrorism experts have warned that both terrorists and 
nations have sought to obtain biological weapons. Finally, the nation’ 
s food and agriculture systems face threats from natural and 
intentional origin that could have devastating consequences in terms 
of both health and economic loss. 

How is it done? 
Biosurveillance requires effective organizational systems, people, and 
technologies to ensure the nation’s ability to detect a biological 
event with potential for catastrophic consequences and to provide 
situational awareness for response that gives decision makers and the 
public accurate information about how to prevent, manage, or mitigate 
catastrophic consequences. The backbone of biosurveillance is 
traditional disease-surveillance systems, which help professionals to 
recognize unusual disease signals and analyze their meaning, but 
generally have inherent limitations that affect the speed with which 
their results can be determined, communicated, and acted upon. 
Numerous federal, state, local, and private-sector entities with 
responsibility for monitoring plant, animal, and human health, food, 
and the environment have roles to play both in supporting traditional 
surveillance activities and in designing systems to focus specifically 
on enhancing detection and situational awareness. Because of the vast 
array of activities and entities associated with effective 
biosurveillance, ongoing interagency and intergovernmental 
collaboration is crucial. 

Source: GAO analysis of agency data (data); Art Explosion (images). 

[End of figure] 

Traditional Disease Surveillance Supports Biosurveillance: 

The backbone of biosurveillance is traditional disease-surveillance 
systems. Traditional disease-surveillance systems are designed to 
collect information on the health of humans and animals to support a 
variety of public-welfare and economic goals. These systems support 
biosurveillance efforts by recording national health and disease 
trends and providing specific information about the scope and 
projection of outbreaks to inform response. State and local public- 
health agencies have the authority and responsibility for carrying out 
most public-health actions, including disease surveillance and 
response to public-health emergencies in their jurisdictions.[Footnote 
18] State laws or regulations mandate disease reporting at the state 
and local level, but the state-based systems are coordinated at the 
national level by a voluntary set of reporting criteria and case 
definitions. For example, the mainstay of traditional disease 
surveillance in humans is the National Notifiable Diseases 
Surveillance System, through which state public-health departments 
voluntarily report their notifiable disease data to CDC. The National 
Notifiable Disease List includes those diseases that CDC and state 
public-health officials have identified as posing a serious public- 
health risk for which case reports would help inform prevention and 
control efforts. Diseases on the nationally notifiable list range from 
sexually transmitted diseases, such as Human Immunodeficiency Virus 
and syphilis, to potential bioterrorism agents, such as anthrax and 
tularemia. 

[Side bar: National Notifiable Disease List: The Council of State and 
Territorial Epidemiologists, in consultation with CDC, updates the 
list of notifiable conditions and national surveillance case 
definitions every year. The list includes those diseases that CDC and 
state public-health officials have identified as posing a serious 
public-health risk for which case reports would help inform prevention 
and control efforts. State public-health departments verify cases of 
notifiable diseases, monitor disease incidence, and identify possible 
outbreaks within their states. States voluntarily report their 
notifiable disease data to CDC to support the National Notifiable 
Diseases Surveillance System. The agency publishes current data on 
notifiable diseases in its Morbidity and Mortality Weekly Report 
Source: GAO. End of side bar] 

Similarly, to help protect the nation's agricultural sector, USDA has 
routine reporting systems and disease-specific surveillance programs, 
which rely on state-collected data, for domesticated animals and some 
wildlife that can provide information to support the early detection 
goal of biosurveillance. Many states have a statutory or regulatory 
list of diseases that animal-health officials are required to report 
to the state departments of agriculture. State animal-health officials 
obtain information on the presence of specific, confirmed clinical 
diseases in the United States from multiple sources--including 
veterinary laboratories, public-health laboratories, and 
veterinarians--and report this information to USDA's National Animal 
Health Reporting System (NAHRS). This system is designed to provide 
data from state animal-health departments on the presence or absence 
of confirmed World Organization for Animal Health reportable diseases 
in specific commercial livestock, poultry, and aquaculture species in 
the United States. 

For wildlife, USDA's Animal and Plant Health Inspections Service's 
Wildlife Services division is charged with conducting surveillance of 
wildlife to detect zoonotic or other diseases that may pose threats to 
agriculture. The division's National Wildlife Disease Program is 
charged with conducting routine surveillance for targeted diseases and 
responding to mortality and morbidity events, particularly those 
occurring near humans or livestock. The program has wildlife disease 
biologists in most states that work to coordinate with state, local, 
and tribal officials to conduct surveillance and respond to events. In 
addition, DOI's U.S. Geological Survey's (USGS) National Wildlife 
Health Center is charged with addressing wildlife disease throughout 
the United States. This center provides disease diagnosis, field 
investigation, disease management and research, and training. It also 
maintains a database on disease findings in wild animals and on 
wildlife mortality events, although there is currently no national 
reporting system for wildlife diseases. 

[Side bar: One Health Initiative: 
Recognizing that human and animal diseases are interconnected, several 
organizations—-including the American Medical Association, the 
American Veterinary Medical Association, USDA, and HHS—-have taken 
steps to support the One Health concept, which is a worldwide strategy 
for expanding interdisciplinary collaboration and communications in 
all aspects of health care for humans and animals. Source: One Health 
Initiative. End of side bar] 

Disease-reporting systems help professionals to recognize unusual 
disease signals and analyze their meaning, but generally have inherent 
limitations that affect the speed with which their results can be 
determined, communicated, and acted upon. Many surveillance programs 
incorporate other methods of surveillance that have the potential to 
augment and enhance the detection and situational-awareness benefits 
of traditional disease reporting. For example, syndromic surveillance 
uses health-related data collected before diagnosis to look for 
signals or clusters of similar illnesses that might indicate an 
outbreak. An example of syndromic surveillance data is prediagnostic 
health-related information like patients' chief complaints recorded by 
hospital emergency room staff. However, we reported in September 2004 
and November 2008 that the ability of syndromic surveillance to more- 
rapidly detect emerging diseases or bioterror events has not yet been 
demonstrated.[Footnote 19] Another method used in disease surveillance 
efforts is sentinel surveillance, in which practitioners monitor for 
specific disease events in a targeted subset rather than an entire 
population. Sentinel surveillance can also promote early detection, 
for example by monitoring sentinel chicken flocks and testing for the 
presence of antibodies to arboviruses, such as West Nile virus, which 
could be spread by mosquitoes to humans. 

Numerous federal, state, local, and private-sector entities with 
responsibility for monitoring animal and human health have roles to 
play both in supporting traditional surveillance activities and in 
designing systems to focus specifically on enhancing detection and 
situational awareness. 

Biosurveillance Roles and Responsibilities in Nonfederal Jurisdictions: 

Conducting biosurveillance is a shared responsibility among multiple 
local, state, and federal agencies, as well as among professionals 
across various disciplines in state, tribal, local, and insular 
jurisdictions. However, there is variation in organization and 
structure among public-health, animal-health, and wildlife functions 
at the state, tribal, local, and insular levels. For example, as shown 
in figure 2, a state's public-health structure may or may not be 
centralized. 

Figure 2: State and Local Public Health Structure: 

[Refer to PDF for image: pie-chart] 

States have a decentralized structure, where local health departments 
often collaborate with, but are organizationally independent of the 
state health agency: 37%; 

States function with some combination of decentralized and centralized 
public health structures, where state and local health departments 
share responsibility for providing services at the local level or 
services are provided through the state or an agency organized or 
operated by local governments: 35%; 

States have a centralized structure, where state health agencies 
provide local public health services: 20%; 

States have no local health departments: 8%. 

Source: GAO analysis of Association of State and Territorial Health 
Officials data. 

[End of figure] 

On the other hand, livestock and poultry health is largely centralized 
within state departments of agriculture, relying on accredited 
veterinarians across the state for detection. By contrast, wildlife 
disease surveillance largely lacks structure entirely and is dependent 
upon chance observations of unusual numbers of sick or dead wildlife, 
or both, being observed and reported to state or local wildlife 
agencies. The exception is USDA's National Wildlife Disease Program, 
which coordinates national surveillance and reporting of targeted 
diseases that may pose threats to human health or agricultural 
resources. 

Some of the nonfederal partners with key responsibilities in the 
biosurveillance enterprise are presented in table 1. 

Table 1: Selected Biosurveillance Roles and Responsibilities: 

Skilled Personnel: 

Nonfederal partner: Epidemiologists; 
Description: Epidemiologists are specialists who study how diseases 
are distributed and transmitted in populations and the factors that 
influence or determine this distribution and transmission. 
Epidemiologists may study disease in populations of animals as well as 
among human populations. Epidemiologists at state health departments 
are often responsible for analyzing data collected through disease- 
reporting systems, conducting outbreak investigations, and designing 
and evaluating disease-prevention and control efforts. 

Nonfederal partner: Informaticians; 
Description: Public-health informaticians use systematic application 
of information, computer science, and technology to support public 
health. Public-health agencies at all levels seek staff with expertise 
in both public-health programs and information systems to help design, 
implement, and manage computer applications that support public-health 
goals. 

Nonfederal partner: State public-health veterinarians; Description: 
State Public Health Veterinarians typically work for the state health 
department and generally work in zoonotic disease control and 
prevention with a focus on protecting public health. Public-health 
veterinarians in state health departments are usually housed in 
epidemiology divisions, but may be employed by the toxicology or 
environmental divisions in health departments. 

Nonfederal partner: State wildlife professionals; Description: State 
wildlife professionals are veterinarians, epidemiologists, biologists, 
or management personnel who work for state departments of wildlife, 
parks and recreation, or natural resources and environment. These 
professionals are responsible for the conservation and maintenance of 
wildlife species and work to mitigate public-health and safety 
problems caused by wildlife, including the spread of zoonotic diseases. 

Nonfederal partner: Clinicians and diagnosticians; Description: Early 
detection of a bioterrorism event or the emergence of a naturally 
occurring infectious-disease threat may depend on an astute clinician 
diagnosing the first few cases, or recognizing suspicious clinical 
signs that require further investigation by experts in infectious 
diseases. Laboratory diagnosticians provide critical expertise to 
effectively identify and respond to public-health emergencies through 
testing and monitoring of diseases. Clinicians can include public-
health nurses, physicians, pharmacists, accredited veterinarians, 
veterinarian technicians, veterinary pathologists, wildlife 
biologists, and laboratory diagnosticians. 

Organizations: 

Nonfederal partner: State and local health departments; Description: 
States, through the use of their state and local health departments, 
have principal responsibility for protecting the public's health and 
therefore take the lead in conducting disease surveillance. They 
verify cases of notifiable diseases, monitor disease incidence, and 
identify possible outbreaks within their states. Generally, local 
health departments are responsible for conducting initial 
investigations into reports of infectious diseases. Local health 
departments are also responsible for sharing information they obtain 
from providers or other sources with their state department of health. 
State epidemiologists work within the state health departments and 
lead efforts to analyze data collected through the disease-reporting 
network, decide when and how to supplement passive reporting with 
active surveillance methods, conduct outbreak and other disease 
investigations, and design and evaluate disease-prevention and control 
efforts. They also transmit state data to CDC, providing routine 
reporting on selected diseases. 

Nonfederal partner: State departments of agriculture; Description: 
State departments of agriculture provide services and regulations 
regarding the health of agricultural animals. States maintain a list 
of reportable diseases and require accredited veterinarians to report 
disease occurrences. State veterinarians coordinate the efforts of 
state animal-health officials who have authority for disease 
reporting, detection, and often, diagnosis. These officials also work 
with their federal government counterparts in the prevention, 
detection, and eradication of a number of foreign and domestic 
diseases associated with national animal-disease programs. 

Nonfederal partner: Laboratories; 
Description: Public-health and animal-health laboratories serve a 
critical role in both initial detection and ongoing situational 
awareness of biological events. For example, public-health 
laboratories perform almost all testing to detect and monitor newly 
emerging infectious diseases such as West Nile virus and Severe Acute 
Respiratory Syndrome (SARS). For more information about these 
laboratories, see appendix II. 

Source: GAO. 

[End of table] 

Public-and Animal-Health Structures Vary among Tribes and Most Insular 
Jurisdictions; Many Work with Federal Agency Partners: 

Tribal Jurisdictions. As of October 2010, there were 565 federally 
recognized tribes--340 in the continental United States and 225 in 
Alaska.[Footnote 20] Federally recognized Indian tribes are Native 
American groups eligible for the special programs and services 
provided by the United States to Indians because of their status as 
Indians.[Footnote 21] Under the Indian Self-Determination and 
Education Assistance Act, as amended, federally recognized Indian 
tribes can enter into self-determination contracts or self-governance 
compacts with the federal government to take over administration of 
certain federal programs for Indians previously administered on their 
behalf by the Department of the Interior or HHS.[Footnote 22] 

The Bureau of Indian Affairs, within DOI, and the IHS, within HHS, are 
the primary agencies that operate Indian programs within those two 
departments. IHS is charged with providing health care to the 
approximately 1.9 million American Indians and Alaska Natives who are 
members or descendants of federally recognized tribes.[Footnote 23] 
These services are provided at federally or tribally operated health- 
care facilities, which receive IHS funding and are located in 12 
geographic regions overseen by IHS area offices. These IHS-funded 
facilities vary in the services that they provide. For example, some 
facilities offer comprehensive hospital services, while others offer 
only primary-care services. Although American Indian tribes are 
sovereign entities, IHS facilities follow disease-reporting 
regulations and use disease-reporting channels for the state in which 
tribal patients geographically reside. For example, tribal patients 
who live within the boundaries of Utah, New Mexico, or Arizona could 
use the same IHS facility in Shiprock, New Mexico. If a patient whose 
tribal residence is geographically located in Arizona presents at the 
Shiprock facility with a disease that the state of Arizona has 
designated as reportable, IHS would report it to Arizona public health 
officials. Tribes that manage their own health services use the 
national notifiable disease reporting system. 

Land-based agricultural resources are vital to the economic and social 
welfare of many tribes. The Intertribal Agriculture Council is an 
organization of tribal agriculture producers and conducts programs 
designed to further the goal of improving tribal agriculture by 
promoting the Indian use of Indian resources through contracts and 
cooperative agreements with federal agencies. 

Insular Jurisdictions. The United States has strategic and economic 
pacts with two jurisdictions in the Atlantic Ocean and six in the 
Pacific Basin. These jurisdictions are together referred to as insular 
areas and include the territories of American Samoa, Guam, and the 
U.S. Virgin Islands; the commonwealths of the Northern Mariana Islands 
and Puerto Rico; and the freely associated states of the Federated 
States of Micronesia, the Republic of the Marshall Islands, and the 
Republic of Palau. The pacts with the insular areas include the 
provision of federal assistance which, for example, can include 
funding to support public-health preparedness efforts, such as 
building and maintaining basic public-health capabilities. 

The insular areas rely on district hospitals, laboratories, and 
clinicians, or other health professionals, to detect and identify a 
potential disease outbreak or emerging disease. An astute clinician, 
laboratorian, or other health professional may be the first to 
identify an emerging disease or a potential outbreak by identifying 
new patterns in a disease seen in patients at their hospital. To 
confirm these suspicions, practitioners depend on the laboratory 
network supported by PIHOA--an association that works to provide 
regional health-care solutions for the Pacific insular areas. The lab 
network consists of 10 hospitals and public-health labs, with varying 
levels of laboratory capacity, in the Pacific insular areas. All the 
hospital laboratories, except for those in Guam--which has a separate 
public-health laboratory--play a dual role in providing both clinical 
and public-health laboratory services in their own jurisdictions. The 
laboratories in this network have limited testing capabilities, 
though, and often medical officials must send specimens to Hawaii, the 
U.S. mainland, or Australia for additional testing. 

CDC officials said that the Pacific insular areas present a challenge 
to global disease spread and detection, because the region has 
experienced outbreaks of emerging infectious disease and has lower 
detection capacity. According to CDC officials, in the age of routine 
air travel and with the rights granted to foreign nationals of some 
Pacific insular areas under the Compacts of Free Association, the risk 
of insular residents traveling to U.S. territories, Hawaii, and the 
mainland with undiagnosed and potentially dangerous infectious 
diseases is troublesome. Additionally, according to DOI officials, 
issues surrounding international travel create challenges to ensuring 
timely response to disease outbreak events in insular areas. 

USDA operates disease-eradication and investigation activities, export 
certification, and surveillance actions in most U.S. insular areas. In 
addition, USDA's National Wildlife Disease Program has an office in 
Hawaii that supports activities to conduct surveillance for and 
respond to outbreaks of disease in wildlife that pose threats to human 
health and agricultural resources. 

DOI's USGS National Wildlife Health Center, located in Madison, 
Wisconsin, assists state and federal agencies with wildlife health- 
related issues and has a Honolulu Field Station, which is staffed by a 
wildlife disease specialist and three biological technicians. The 
Honolulu Field Station was established to serve state and federal 
agencies in Hawaii and the Pacific, including the insular areas. The 
Honolulu Field Station provides training to biologists regarding 
response to unusual wildlife mortalities and performs laboratory and 
field investigations to determine the cause of death in wildlife. 

[Side bar: Vectors Transmit Zoonotic Diseases: According to CDC, some 
of the world’s most destructive diseases are vector-borne—that is they 
are transmitted to humans and animals by vectors such as ticks, 
mosquitoes, or fleas. CDC also contends the United States is at a 
greater risk than ever from vector-borne diseases—such as West Nile 
virus, Lyme disease, dengue fever, chikungunya, and Rocky Mountain 
spotted fever—due to globalization and climate change. Source: GAO 
analysis of CDC data (data); CDC, James Gathany (photos). End of side 
bar] 

Humans, Livestock, Wildlife, and the Spread of Zoonotic Diseases: 

About 75 percent of the new diseases that have affected humans over 
the past 10 years are zoonotic and have been caused by pathogens 
originating from an animal. Many of these diseases have the potential 
to spread through various means over long distances and to become 
global problems. As shown in figure 3, these emerging and reemerging 
diseases transmit between animals--including livestock and wildlife-- 
and humans. In some cases, disease transmission is direct, in others 
the animals act as intermediate or accidental hosts, while in others 
transmission occurs via arthropod--for example, mosquitoes or ticks-- 
vectors. Examples of such emerging and zoonotic diseases include: West 
Nile virus, H1N1, SARS, avian influenza, and rabies. Potential 
bioterrorism threats also include the use of zoonotic diseases as 
weapons of mass destruction, such as anthrax, plague, tularemia, and 
brucellosis. 

Figure 3: Examples of Zoonotic Diseases and Their Affected Populations: 

[Refer to PDF for image: illustration] 

Humans and Wildlife: 
Lyme disease; Monkeypox; Hantavirus; Ebola; SARS. 

Humans and Livestock: 
Bovine spongiform encephalopathy; Escherichia coli; Cowpox; Rift 
Valley fever. 

Wildlife and Livestock: 
Rabies; West Nile Virus; Tuberculosis; Anthrax; Tularemia; Plague; 
Salmonellosis; Avian influenza; Brucellosis. 

Source: GAO analysis of USGS data (data); Art Explosion (images). 

[End of figure] 

Habitat loss and human encroachment on rural and wildlife environments 
are bringing populations of humans and animals, both farmed and wild, 
into closer and more-frequent contact. Increasingly, wildlife are 
involved in the transmission of diseases to people, pets, and 
livestock, and managing wildlife vectors is an integral part of 
efforts to control the spread of zoonotic diseases. Diseases among 
wildlife can also provide early warnings of environmental damage, 
bioterrorism, and other risks to human health. DOI's USGS National 
Wildlife Health Center, which is the only federal laboratory in the 
United States dedicated to wildlife disease investigation, focuses on 
developing methods to reduce or eliminate the transmission of diseases 
among wildlife, domestic animals, and humans. 

We Previously Recommended That the National Security Staff Develop a 
National Biosurveillance Strategy: 

In June 2010, we reported that while some high-level biodefense 
strategies have been developed, there is no broad, integrated national 
strategy that encompasses all stakeholders with biosurveillance 
responsibilities that can be used to guide the systematic 
identification of risk, assessment of resources needed to address 
those risks, and the prioritization and allocation of investment 
across the entire biosurveillance enterprise. We found that the 
decision makers responsible for developing a national biosurveillance 
capability are spread across multiple agencies and departments, and 
rely on support from state and local authorities. We noted that our 
prior work on complex undertakings like biosurveillance can benefit 
from strategic oversight mechanisms, such as a focal point and a 
national strategy, to coordinate and lead efforts across the multiple 
federal departments with biosurveillance responsibilities. We 
recommended that the Homeland Security Council, which was established 
to serve as a mechanism for ensuring coordination of federal homeland 
security-related activities and development of homeland-security 
policies, should direct the National Security Staff to establish a 
focal point and charge this focal point with the responsibility for 
developing a national biosurveillance strategy.[Footnote 24] 

[Side bar: Brucellosis and Feral Swine: According to USDA, more than 4 
million feral swine are found in at least 35 states and destroy 
farmland and crops, compete with native wildlife for food, and can 
spread disease to other animals and people. 

Hunting feral swine is a popular sport among hunters, and also serves 
as a population control method which wildlife agencies support, but 
there are more than 24 diseases that people can get from feral swine. 
While most of these diseases are spread by eating undercooked meat, 
the germs that cause swine brucellosis are spread by swine through 
birthing fluids and semen. People become exposed to the germs through 
contact with an infected swine’s blood, fluids, or tissues (such as 
muscles, testicles, liver, or other organs). Domestic swine are also 
threatened by brucellosis through contact with infected feral swine. 
Source: GAO analysis of USDA data (data); USDA (photo). [End of side 
bar] 

In August 2011, the National Security Staff reported that it had 
created a biosurveillance Sub-Interagency Policy Committee, under the 
guidance of the Domestic Resilience Group, to serve as a focal point 
in order to coordinate the development of a National Strategy for 
Biosurveillance. They said the strategy, and the implementation 
guidance to it, will define the overall purpose of the U.S. government 
biosurveillance effort, and will pay particular attention to the 
assignment of roles and responsibilities. These efforts are the first 
steps taken to address the findings in our June 2010 report. 

Absent a Strategy and Biosurveillance-Specific Capability Efforts, 
Existing Federal Activities Help Support State and Local Capabilities: 

In the absence of a national biosurveillance strategy, the federal 
government has some efforts, including emergency preparedness, disease-
specific surveillance, and laboratory enhancement programs, that 
provide resources and information that state and city officials say 
are critical to their efforts to build and maintain capabilities. The 
federal programs and initiatives that officials identified during 
interviews as useful for supporting their biosurveillance capabilities 
generally fell into four categories, which respondents to our follow- 
up questionnaire ranked in descending order of importance as follows: 
(1) grants and cooperative agreements, (2) nonfinancial technical and 
material assistance, (3) guidance, and (4) information 
sharing.[Footnote 25] As we reported in June 2010, about federal 
biosurveillance activities, without a strategic approach to build and 
maintain a national biosurveillance capability, these efforts continue 
to be uncoordinated and not specifically targeted at ensuring the most-
effective and efficient biosurveillance capability. 

Federal Grants and Cooperative Agreements Provide Essential Support 
for State and Local Biosurveillance Capabilities: 

Nearly all--26 of 27--of the questionnaire respondents identified 
grants and cooperative agreements as the most important type of 
federal assistance they receive. During interviews, state and local 
officials in multiple agriculture, public-health, and wildlife 
departments said that they are completely or largely dependent on 
federal funding for biosurveillance-related activities and that their 
biosurveillance capabilities would be limited without these federal 
grants and cooperative agreements. 

[Side bar: Cooperative agreements: 
Unlike a grant, a cooperative agreement provides for substantial 
involvement between the federal agency and the recipient in the 
programmatic or research activity. Source: Office of Management and 
Budget. End of side bar] 

State and city officials we interviewed noted that grants and 
cooperative agreements generally serve a dual purpose in that they 
both provide guidance on federal priorities, goals, and objectives and 
provide financial support to pursue those priorities. For example, 
when we asked public-health officials about the federal efforts that 
support their capabilities, five of nine public-health departments 
cited the guidance on planning and federal priorities that they 
receive in conjunction with the Public Health Emergency Preparedness 
(PHEP) cooperative agreement. At the same time, six of nine public- 
health departments we interviewed cited PHEP funding as critical for 
supporting their capability resources, such as additional staff to 
increase investigation and diagnostic capacity, and for building and 
maintaining those capabilities identified as priorities. Officials 
from one public-health department said that the funding they receive 
for PHEP and another CDC cooperative agreement--Epidemiology 
Laboratory and Capacity for Infectious Diseases (ELC)--pays the 
salaries of 70 percent of their communicable-disease staff, including 
the salaries of their scientists, researchers, physicians, and data 
analysts. Moreover, these officials said the federal cooperative 
agreements enable the department to conduct outbreak investigations 
that were not possible before PHEP and ELC funding was available. 
Similarly, laboratory officials in one state we visited said that the 
cooperative agreements enable the department to pay for additional 
public-health positions, training, and laboratory testing efforts and 
equipment, and without the cooperative agreements, their laboratory 
testing capacity would be considerably reduced. 

[Side bar: Capabilities: 

Capability: In the context of emergency management and related 
functions, a capability is the combination of leadership and 
organization, planning, personnel, training, equipment and systems, 
and assessment needed to successfully execute a particular mission. 

Core Capability: For biosurveillance, the particular mission is (1) 
detecting and characterizing signs of potentially catastrophic disease 
outbreaks in a timely fashion to minimize their effects and (2) 
providing situational awareness to respond effectively. Because of the 
variation in approaches and organization across jurisdictions, the 
specific activities considered “core” may differ by respondent; 
however, at a minimum, these would include conducting investigations 
and providing laboratory diagnostics. 

Based on the concepts expressed in interviews with state and city 
officials,we provided the following definition for “federal efforts 
that support core capabilities” in our follow-up questionnaire: This 
federal support is essential to core biosurveillance capabilities. 
Without this support, it would not be possible to carry out core 
functions or those functions would be significantly diminished. 

A National Biosurveillance Capability: A national biosurveillance 
capability is the combination of capabilities of all jurisdictions and 
entities that constitute the biosurveillance enterprise working in 
concert to achieve the timely detection and situational awareness 
goals of biosurveillance, particularly for potentially catastrophic 
biological events. 
Source: GAO. End of side bar] 

In interviews, agriculture officials in five of seven states said that 
their departments depend on federal funding to conduct surveillance 
efforts. For example, officials from three of the states said federal 
grants and cooperative agreements enable their departments to, among 
other things, collect and test specimens and purchase equipment for 
surveillance efforts. Similarly, wildlife officials from four states 
we interviewed said that their dependence on federal funding dictates 
priorities for certain surveillance efforts--such as the funding for 
avian influenza and chronic wasting disease surveillance efforts--and 
they would likely not conduct active surveillance efforts like these 
without federal support.[Footnote 26] In follow-up questionnaires, we 
asked officials to identify the federal grants and cooperative 
agreements that were essential to their core biosurveillance 
capabilities. Table 2 shows the federal grants and cooperative 
agreements most commonly identified as essential to their core 
biosurveillance capabilities by the 27 officials who responded to our 
questionnaire, by group. For more information on questionnaire 
results, see appendix III. 

Table 2: Grants and Cooperative Agreements Most Commonly Identified by 
City and State Questionnaire Respondents as Essential for Supporting 
Their Core Biosurveillance Capabilities: 

Grant or cooperative agreement: Public Health Emergency Preparedness 
cooperative agreement (PHEP); 
Description: CDC provides funding and technical assistance through the 
PHEP cooperative agreement for the development and strengthening of 
recipients' response capabilities during public health incidents. PHEP 
awardees include 50 states, 8 territories and freely associated 
states, and 4 localities; 
Respondents identifying the federal initiative as essential: Group: 
Public health epidemiology; 
Number: 7 of 7.
Group: Public health laboratory; 
Number: 7 of 7. 

Grant or cooperative agreement: Epidemiology and Laboratory Capacity 
for Infectious Diseases cooperative agreement (ELC); Description: CDC 
supports public health capacity by providing public health departments 
funding through the ELC cooperative agreement to hire and train staff, 
buy laboratory equipment and supplies for diagnosing emerging 
pathogens, and invest in information technology to improve disease 
reporting and monitoring. CDC also provides technical support and 
funding, through this cooperative agreement, to states to develop and 
enhance syndromic surveillance systems; Respondents identifying the 
federal initiative as essential: Group: Public health epidemiology; 
Number: 7 of 7
Group: Public health laboratory; 
Number: 7 of 7. 

Grant or cooperative agreement: Avian influenza cooperative agreement; 
Description: USDA provides funding to states through cooperative 
agreements for expanded bird monitoring programs, including the 
collection of samples from domesticated and wild birds for avian 
influenza testing; 
Respondents identifying the federal initiative as essential: Group: 
Agriculture; 
Number: 6 of 6. 

Grant or cooperative agreement: Chronic wasting disease cooperative 
agreements; 
Description: USDA provides coordination and assistance with research, 
surveillance, disease management, diagnostic testing, technology, 
communications, information dissemination, education, and funding for 
state chronic wasting disease surveillance programs; Respondents 
identifying the federal initiative as essential: Group: Wildlife; 
Number: 6 of 7. 

Source: GAO. 

Note: Each group of officials was asked about just those federal 
grants and cooperative agreements that pertain to their own field. For 
example, only public health epidemiologists and public health 
laboratory officials were asked about PHEP, and only lead agriculture 
officials were asked about avian influenza grants. Out of the 27 
officials who responded to our questionnaire, 7 of the respondents 
were epidemiologists, 7 of the respondents were public health 
laboratory officials, 6 of the respondents were state agriculture 
officials, and 7 of the respondents were state wildlife officials. 

[End of table] 

Nonfinancial Technical and Material Assistance Helps Build Capacity 
across Jurisdictional Boundaries: 

Respondents to our follow-up questionnaire ranked nonfinancial 
technical and material assistance as the second-most important type of 
federal support for building and maintaining biosurveillance 
capabilities. According to state and local officials, the nonfinancial 
assistance efforts they identified help to, among other things, 
support biosurveillance capacity by improving state and local capacity 
to identify and diagnose diseases. For example, state public-health, 
agriculture, and wildlife officials said that training opportunities 
sponsored by the federal government help enhance and standardize their 
laboratory testing methods, epidemiological investigations, and 
specimen-collection procedures, which helps state and local officials 
develop more efficient and effective disease diagnostic capabilities. 
In addition, in interviews, officials from both public health and 
agriculture said that the chance to work together on concrete projects 
like avian influenza planning and surveillance projects gave them an 
ongoing reason to communicate and collaborate. 

Public-health officials from five of nine public health departments we 
visited said, in interviews, that they rely on CDC's subject-matter 
expertise to either guide their efforts during an event--such as the 
2009 H1N1 outbreak--or to answer questions about a specific 
investigation. Moreover, public-health officials in three of seven 
states said that without this and other types of nonfinancial 
assistance, their department would not be able to conduct as many 
investigations and the efficiency with which they could diagnose a 
disease would decrease. In addition, public-health officials from one 
state said the ability to get CDC's help confirming results and to 
send specimens with unusual characteristics, which are difficult to 
identify, increases the state's laboratory capacity and improves the 
efficiency with which the state can diagnose an unusual disease. 

Similarly, agriculture officials we interviewed in one state said if 
they did not have the National Veterinary Services Laboratory (NVSL) 
to provide confirmation for unusual disease samples, they would be 
less prepared to handle disease outbreaks.[Footnote 27] Finally, 
wildlife officials from one state said working in the field with 
federal officials to trap animals and collect samples has enhanced 
their relationships with federal officials, their knowledge of new 
sampling procedures and surveillance data management, and their 
ability to work with USDA officials during the grant process. In 
follow-up questionnaires, we asked officials to identify the federal 
nonfinancial and technical assistance efforts that were essential to 
their core biosurveillance capabilities. Table 3 shows the federal 
nonfinancial and technical assistance efforts most commonly identified 
as essential to their core biosurveillance capabilities by the 27 
officials who responded to our questionnaire, by group. For more 
information on questionnaire results, see appendix III. 

Table 3: Types of Nonfinancial Assistance Most Commonly Identified by 
City and State Questionnaire Respondents as Essential for Supporting 
Their Core Biosurveillance Capabilities: 

Nonfinancial Assistance: Expert consultation for epidemiological 
investigation; 
Description: CDC provides support to state and local officials during 
outbreaks through conference calls, one-on-one discussions, and the 
provision of epidemiology aides to assist public-health departments 
with their investigations; 
Respondents Identifying the Federal Initiative as Essential: Group: 
Public health, epidemiology; 
Number: 6 of 7. 

Nonfinancial Assistance: Standards to improve disease reporting; 
Description: Federal agencies develop standards, such as the Public 
Health Information Network, to improve disease reporting and 
information sharing. The Public Health Information Network is a 
national initiative to improve the capacity of public health 
organizations to use and exchange information electronically by 
promoting the use of standards and defining functional and technical 
requirements; 
Respondents Identifying the Federal Initiative as Essential: Group: 
Public health, epidemiology; 
Number: 6 of 7. 

Nonfinancial Assistance: Secondary laboratory confirmation; 
Description: CDC provides secondary laboratory confirmation testing 
support to state and local public-health departments to confirm 
unusual diseases or to verify positive test results for select agents--
biological agents and toxins that have the potential to pose a severe 
health threat; 
Respondents Identifying the Federal Initiative as Essential: Group: 
Public health, epidemiology; 
Number: 6 of 7;
Respondents Identifying the Federal Initiative as Essential: Group: 
Public health, laboratory; 
Number: 7 of 7. 

Nonfinancial Assistance: Laboratory equipment; Description: CDC 
supplies state public-health laboratories with critical reagents and 
assays for a wide variety of laboratory tests to ensure laboratory 
tests are properly conducted; Respondents Identifying the Federal 
Initiative as Essential: Group: Public health, epidemiology; 
Number: 6 of 7; 
Respondents Identifying the Federal Initiative as Essential: Group: 
Public health, laboratory; 
Number: 7 of 7. 

Nonfinancial Assistance: Laboratory testing of specimens with unusual 
characteristics; 
Description: CDC provides laboratory-testing support to states and 
localities, including the testing of specimens with unusual 
characteristics, which may be difficult for state or local 
laboratories to identify; 
Respondents Identifying the Federal Initiative as Essential: Group: 
Public health, laboratory; 
Number: 7 of 7. 

Nonfinancial Assistance: Training; 
Description: Federal agencies provide various types of training 
opportunities to state and local officials, including training that 
covers new sampling and testing methods, new reporting standards, or 
safety standards; 
Public health, laboratory; 
Respondents Identifying the Federal Initiative as Essential: 7 of 7. 

Nonfinancial Assistance: Equipment and supplies; Description: Federal 
agencies provide states with equipment and supplies, such as sampling 
kits, assays, and personal protective equipment, to help states 
conduct outbreak investigations; Respondents Identifying the Federal 
Initiative as Essential: Group: Agriculture; 
Number: 5 of 6. 

Nonfinancial Assistance: Laboratory testing; Description: Several 
federal laboratories support states' efforts to diagnose a disease. 
For example, NVSL is a federal reference laboratory--a laboratory that 
conducts and confirms tests for other laboratories. The Foreign Animal 
Disease Diagnostic Laboratory tests for highly contagious diseases 
such as foot-and-mouth disease. The USGS National Wildlife Health 
Center is the only federal laboratory in the United States dedicated 
to wildlife disease investigation and offers laboratory support to 
states for wildlife disease diagnostics. USDA's National Wildlife 
Research Center has the ability to provide surge diagnostics for 
wildlife samples when necessary.; Respondents Identifying the Federal 
Initiative as Essential: Group: Wildlife; 
Number: 3 of 7. 

Source: GAO. 

Note: Each group of officials was asked about just those types of 
federal nonfinancial assistance that pertain to their own field. Out 
of the 27 officials who responded to our questionnaire, 7 of the 
respondents were epidemiologists, 7 of the respondents were public- 
health laboratory officials, 6 of the respondents were state 
agriculture officials, and 7 of the respondents were state wildlife 
officials. 

[End of table] 

Most Guidance Accompanies Federal Funding Programs, but Officials Also 
Find Other Guidance Useful: 

The category of federal assistance ranked third overall in importance 
by state and city questionnaire respondents is guidance. Additionally, 
during our site visits, the majority of state and city officials we 
interviewed--16 of 23--said the primary source of federal guidance 
related to biosurveillance accompanies federal grants and cooperative 
agreements and serves the purpose of shaping programmatic goals, 
objectives, and priorities. For example, the public-health 
epidemiologists and laboratory director for one city said that the 
detailed capability guidance that accompanied the most recent round of 
PHEP funding helped the city perform a gap analysis, the results of 
which will serve as a planning guide over the next 5 years. In 
addition, four of nine public-health departments we spoke with 
discussed guidance that supports their efforts to build and maintain 
biosurveillance capabilities by supporting specific activities that 
constitute their capabilities, for example, guidance regarding 
standardized case definitions, disease-reporting requirements, and 
sampling procedures for unusual or emerging disease agents. Public- 
health officials in one state we visited said that guidance on 
standardization is essential to ensure states are able to move 
information to CDC more efficiently, and without standardization it 
would be difficult to exchange information with their partners. 
Similarly, agriculture officials in one state we visited said federal 
sampling standards help interpret information about disease occurrence 
in other states, because the significance of results is uniform 
nationwide. These officials said that without this guidance, they 
would need to develop protocols state-by-state to interpret results, 
which would lead to a loss of efficiency in animal diagnostic 
laboratory protocols and interpretation of results. 

In follow-up questionnaires, we asked respondents to characterize the 
various types of guidance, which had previously been identified in 
interviews, as very useful, moderately useful, somewhat useful, or not 
useful in supporting their biosurveillance capabilities. Table 4 shows 
the sources of federal guidance the 27 officials who responded to our 
questionnaire--by group--most commonly identified as very useful for 
supporting biosurveillance capabilities. For more information on 
questionnaire results, see appendix III. 

Table 4: Types of Federal Guidance Most Commonly Identified by City 
and State Questionnaire Respondents as Being Very Useful for 
Supporting Their Core Biosurveillance Capabilities: 

Type of nonfinancial assistance: Description: Respondents identifying 
the federal initiative as very useful. 

Type of nonfinancial assistance: Federal guidance for disease- 
reporting requirements; 
Description: Federal agencies develop disease-reporting requirements 
for state and local jurisdictions for those diseases posing a serious 
public-health, animal-health, or economic risk for which case reports 
would help inform prevention and control efforts; Respondents 
identifying the federal initiative as very useful: Group: Public 
health, epidemiology; 
Number: 5 of 7. 

Type of nonfinancial assistance: Federal guidance for standardized 
case definitions; 
Description: Federal agencies provide guidance for standardizing case 
definitions to improve disease reporting and information sharing. For 
example, CDC published the Case Definitions for Infectious Conditions 
Under Public Health Surveillance, which provides uniform criteria for 
state health-department personnel to use when reporting notifiable 
diseases to CDC; 
Respondents identifying the federal initiative as very useful: Group: 
Public health, epidemiology; 
Number: 5 of 7. 

Type of nonfinancial assistance: Federal guidance regarding safety and 
security measures for specimen handling; Description: Federal agencies 
provide states and localities with guidance concerning the appropriate 
methods for handling, storing, and shipping specimens; 
Respondents identifying the federal initiative as very useful: Group: 
Public health, epidemiology; 
Number: 5 of 7. 

Type of nonfinancial assistance: Federal guidance for best practices 
for laboratory testing protocols; 
Description: Federal agencies provide states and localities with 
guides outlining the best practices for laboratory testing protocols; 
Respondents identifying the federal initiative as very useful: Group: 
Public health, laboratory; 
Number: 6 of 7. 

Type of nonfinancial assistance: Federal priorities, goals, and 
objectives communicated through grant and cooperative agreement 
guidance; 
Description: Federal grant and cooperative-agreement guidance 
generally provides instructions to state agencies about applying for 
and executing federal projects with funding, including federal 
priorities, goals, and objectives for the use of the funding; 
Respondents identifying the federal initiative as very useful: Group: 
Agriculture; 
Number: 4 of 6.
Respondents identifying the federal initiative as very useful: Group: 
Wildlife; 
Number: 3 of 7. 

Source: GAO. 

Note: Each group of officials was asked about just those types of 
federal guidance that pertain to their own field. Out of the 27 
officials who responded to our questionnaire, 7 of the respondents 
were epidemiologists, 7 of the respondents were public health 
laboratory officials, 6 of the respondents were state agriculture 
officials, and 7 of the respondents were state wildlife officials. 

[End of table] 

Information-Sharing Tools and Analytical Products Provide Critical 
Information about Disease Outbreaks: 

Information-sharing tools and analytical products was the category 
ranked fourth in importance by our 27 questionnaire respondents. In 
interviews, officials said that without the knowledge they gain 
through these tools and products they would lack critical information 
about emerging-disease situations in neighboring states and throughout 
the nation. For example, public-health officials in one state noted 
that they would lack context about a health situation in their state 
without the knowledge they gain through these systems and reports 
about incidents in neighboring states and throughout the nation. In 
addition, they said these tools are useful in helping them to better 
understand baselines for various diseases they observe in their own 
jurisdictions. Public-health officials in another state we interviewed 
noted that without the information provided by PulseNet, their ability 
to detect foodborne outbreaks would be diminished. 

[Side bar: Southeastern Cooperative Wildlife Disease Study (SCWDS): 
The wildlife agencies of 19 states (shaded on map) and Puerto Rico and 
the U.S. Geological Survey of DOI fund regional wildlife research and 
service projects through SCWDS, and USDA’s Veterinary Services 
provides support for national and international surveillance 
activities where diseases may spread among wildlife and livestock. 
SCWDS provides wildlife-disease expertise to state and federal 
agencies responsible for wildlife and domestic livestock resources. 
SCWDS aims to detect causes of illness and death in wildlife, 
characterize the effect of diseases and parasites upon wild animal 
populations, identify disease interrelationships between wildlife and 
domestic livestock, and determine the role of wildlife in transmission 
of human diseases. Source: GAO analysis of SCWDS data (data); MapQuest 
(map). End of side bar] 

Likewise, agriculture officials we interviewed in one state said 
without the compiled information that federal agencies share with 
them--for example, disease data on USDA's Veterinary Service 
Laboratory Submissions website--they would be operating blindly and 
would need to spend time contacting other states to know what is 
happening outside their borders.[Footnote 28] They said this 
information is particularly useful when it comes to animal movement 
across state lines, so that they are aware of those diseases of 
concern in different areas of the country. Similarly, wildlife 
officials from one state said that the information shared by federal 
agencies provides awareness of disease threats in their state and 
information about how to respond if they encounter the disease in 
question. They said that the lack of this information could delay the 
state's detection of a potentially devastating disease, because 
outbreak signals--like animal die-offs would have to trigger an 
investigation in their state--before they had any awareness of looming 
disease threats. In follow-up questionnaires, we asked officials to 
identify the types of information sharing tools and analytical 
products that were essential to their core biosurveillance 
capabilities. Table 5 shows the types of information sharing tools and 
analytical products most commonly identified as essential to their 
core biosurveillance capabilities by the 27 officials who responded to 
our questionnaire, by group. For more information on questionnaire 
results, see appendix III. 

Table 5: Types of Information-Sharing Tools and Analytical Products 
Most Commonly Identified by City and State Questionnaire Respondents 
as Essential to Supporting Their Core Biosurveillance Capabilities: 

Type of information-sharing tools and analytical products: PulseNet; 
Description: PulseNet is an early warning system for outbreaks of 
foodborne diseases. The network has participants from public-health 
laboratories in all 50 states, federal regulatory agencies, and some 
state agricultural laboratories and is coordinated by CDC. PulseNet 
contributes to the identification and investigation of outbreaks of 
foodborne and bacterial diseases through comparison of the molecular 
"fingerprints" of foodborne pathogens from patients and their food, 
water, and animal sources; 
Respondents identifying the federal initiative as essential: Group: 
Public health, epidemiology; 
Number: 7 of 7; 
Respondents identifying the federal initiative as essential: Group: 
Public health, laboratory; 
Number: 7 of 7. 

Type of information-sharing tools and analytical products: Meetings 
and conferences sponsored by professional associations; Description: 
Professional associations sponsor meetings and conferences, in 
association with federal partners. In addition to providing 
information about a specific topic, these events help foster 
information sharing between state and federal officials; Respondents 
identifying the federal initiative as essential: Group: Agriculture; 
Number: 5 of 6. 

Type of information-sharing tools and analytical products: USDA 
Veterinary Service Laboratory Submissions website; Description: State 
officials can submit and access disease data, such as wild-bird avian 
influenza data, through the USDA Veterinary Services Laboratory 
Submissions site; 
Respondents identifying the federal initiative as essential: Group: 
Agriculture; 
Number: 5 of 6. 

Type of information-sharing tools and analytical products: Information 
and reports of disease occurrence from the Southeastern Cooperative 
Wildlife Disease Study (SCWDS); 
Description: SCWDS, which receives funding from the Department of the 
Interior and the United States Geological Survey (USGS) National 
Wildlife Health Center, provides reports and coverage maps that 
identify disease occurrence for select diseases; Respondents 
identifying the federal initiative as essential: Group: Wildlife; 
Number: 5 of 7. 

Source: GAO. 

Note: Each group of officials was asked about just those types of 
federal information-sharing tools and analytical products that pertain 
to their own field. Out of the 27 officials who responded to our 
questionnaire, 7 of the respondents were epidemiologists, 7 of the 
respondents were public health laboratory officials, 6 of the 
respondents were state agriculture officials, and 7 of the respondents 
were state wildlife officials. 

[End of table] 

In June 2010, when we recommended that the National Security Staff 
lead the development of a national biosurveillance strategy, we noted 
that an effective national biosurveillance strategy could help 
identify the resources currently being used to support a 
biosurveillance capability, additional resources that may be needed, 
and opportunities for leveraging resources.[Footnote 29] Although not 
generalizable to the whole biosurveillance enterprise, our findings 
suggest that there are existing federal resources that nonfederal 
officials find essential to their efforts and could provide a starting 
point for considering how to leverage nonfederal resources. Because 
the resources that constitute a national biosurveillance capability 
are largely owned by nonfederal entities, a national strategy that 
considers how to leverage existing efforts and resources in federal, 
state, tribal, local, and insular jurisdictions could improve efforts 
to build and maintain a national biosurveillance capability. 

State and Local Officials Reported Challenges Related to State 
Policies, Core Capability Resources, and Planning and Leadership to 
Support Biosurveillance Capabilities: 

State and city officials we spoke with reported a variety of 
challenges in building and maintaining biosurveillance capabilities. 
These challenges generally fell into three different groups: (1) state 
policies enacted in response to fiscal constraints, (2) obtaining and 
maintaining resources to support capabilities, and (3) leadership and 
planning challenges. In the follow-up questionnaire, we asked 
respondents how challenges identified in the interviews affect their 
capabilities and to rank the top three challenges they face. For each 
challenge respondents identified facing, we asked them to indicate 
whether or not the current combination of resources, leadership, and 
planning in their jurisdictions were adequate to address that 
challenge. The challenges reported here are only those that 
respondents indicated are not currently adequately addressed. For 
additional information about questionnaire results related to 
challenges, see appendix IV. 

State Policies May Constrain Hiring, Travel, and Information 
Technology, Even When Federal Funding Is Available: 

One set of challenges that state and city officials described to us 
had to do with the state and local budget crises and the policies 
states have put in place to respond to this challenge. Specifically, 
in interviews with state public-health, agriculture, and wildlife 
departments, multiple officials reported barriers that state policies 
presented for building and maintaining a biosurveillance capability. 
Among these barriers were (1) an inability to use federal funding for 
new positions because of state hiring restrictions, (2) an inability 
to attend national trainings and conferences (even when federal travel 
funding is available) because of state travel restrictions, and (3) an 
inability to participate in training and other online forums sponsored 
by federal agencies and professional associations because of state 
restrictions on when and how they can use information technology in 
their offices. 

In follow-up questionnaires, 20 of 27 respondents identified these 
kinds of state policies as a challenge to building and maintaining 
biosurveillance capability. One respondent who ranked this kind of 
challenge among the top three challenges noted that state policies on 
hiring require the use of contractors rather than full-time equivalent 
personnel. As a consequence, the respondent noted, the knowledge 
accrued through the course of on-the-job training leaves the agency 
when a given contract ends. 

Although federal agencies who work to help support capabilities in 
state and local jurisdictions have limited ability to directly affect 
state policies, CDC officials say they are aware of the issue and 
agree that it is a challenge--in some cases severely hampering states' 
ability to move forward with capability building. The CDC officials 
said they have discussed the issue with their state and local partners 
as part of a larger effort to explore various funding options to help 
better support capability building. 

State and City Officials Report Concerns about Resources: 

A second set of challenges reflected general concerns about the 
resources that support biosurveillance capabilities, such as 
appropriately trained personnel, systems, and equipment. Nineteen of 
27 respondents to our follow-up questionnaires reported facing 
workforce shortages among skilled professionals--epidemiologists, 
informaticians, statisticians, laboratory staff, animal-health staff, 
or animal-disease specialists. One respondent who rated this 
particular challenge among the top three noted that noncompetitive 
salaries had resulted in lack of interest in positions and high 
turnover. As a consequence, according to the respondent, investments 
in training yield lower returns and quality of the overall workforce 
is affected. 

Sixteen of 27 questionnaire respondents reported problems with 
training availability. A state wildlife official who rated training 
availability as the top current challenge noted that without proper 
training, staff in the field--who often have duties other than disease 
surveillance--lack an understanding of the importance of surveillance 
and reporting, as well as knowledge of the techniques to carry it out. 
Fourteen of 27 questionnaire respondents indicated issues with 
workforce competency--hiring and retaining professionals with adequate 
training and education. One of the respondents that rated this 
challenge among the top three noted that without properly trained 
staff to support them, initiatives languish. She also noted that the 
need for the few skilled personnel to provide on-the-job training and 
education consumes time and affects workflow. 

Fifteen of 27 questionnaire respondents reported that keeping up with 
ongoing systems maintenance and enhancement needs has been 
challenging. One respondent who rated ongoing systems maintenance and 
enhancement among the top three challenges said that public-health 
informatics, including state-of-the-art database systems and effective 
electronic linkages, are critical to surveillance, but place demands 
on resources to attract and maintain public-health informatics 
expertise and support database applications. Thirteen of 27 
questionnaire respondents reported challenges maintaining adequate 
laboratory capacity. One laboratory official who ranked this among the 
top three challenges stated that many at the public-health lab are 
nearing retirement and it has been difficult to attract and retain 
younger laboratory scientists to work in public health. 

State and City Officials Report Leadership and Planning Challenges 
That Could Be Considered in a National Biosurveillance Strategy: 

The third set of challenges state and city officials that we 
interviewed reported included (1) difficulty planning for longer-term 
capability-building efforts because of uncertainty from year to year 
about whether project funds would be available; (2) difficulty 
planning to invest in basic capabilities for multiple disease threats 
because federal funding has focused on specific diseases rather than 
strategically building core capabilities; (3) limited leadership and 
planning--at all levels of the biosurveillance enterprise--to support 
regional and integrated disease data-surveillance approaches; and (4) 
differing priorities and other partnership issues. Many of the 
challenges that state and city officials identified are similar to 
issues we reported regarding biosurveillance at the federal level. We 
noted that many of the challenges like these that face the 
biosurveillance enterprise are complex, inherent to building 
capabilities that cross traditional boundaries, and not easily 
resolved. We recommended in June 2010 that a leadership mechanism, 
such as a focal point, and a strategy could help define the scope of 
the problems to be addressed, in turn leading to specific objectives 
and activities for tackling those problems, better allocation and 
management of resources, and clarification of roles and 
responsibilities. 

In our follow-up questionnaires, by far the single most-commonly 
reported challenge was funding instability and insecurity, with 25 of 
27 questionnaire respondents identifying it as a challenge that has 
not been adequately addressed. Among those, 23 ranked it as one of the 
top three challenges and 16 of those ranked it as their top challenge. 
In interviews, officials in both the human-and animal-health 
communities noted that they receive little or no support from state 
budgets for surveillance activities, leaving them largely reliant on 
federal funding for this type of activity. Moreover, two agriculture 
officials noted that it is difficult for states to develop long-term 
plans for building and maintaining capabilities because they do not 
know how much funding they will receive from year to year. For 
example, three of the nine visits we made to state public-health 
departments occurred near the application deadline for the new PHEP 
cooperative agreements. All three sets of public health officials 
reported receiving news of a last minute reduction in funding--which 
according to CDC officials equaled 12 percent--that resulted in the 
need to significantly revise their PHEP application and accompanying 
plan for building and maintaining capabilities, in a short time frame. 

In interviews, agriculture officials in three of the seven states we 
visited said they receive little or no funding in their state budgets 
to support biosurveillance activities and depend on federal funding, 
which they say has been decreasing. Because of the decreases in 
funding, the agriculture officials from one state said that their 
department has decreased its staff level by half over the past 6 
years, and these officials noted that without federal funding the 
department's biosurveillance capabilities would be minimal. Likewise, 
wildlife officials in five of the seven states we visited said that 
they receive little or no funding for surveillance from their state 
budgets and rely on federal programs to support surveillance. 

Federal officials agreed that funding insecurity and instability is a 
serious challenge affecting states' ability to plan for and execute 
capability-building efforts. In October 2010, CDC's Advisory Committee 
to the Director--recognizing much of CDC's effect results from the 
funds it provides state, tribal, local, and territorial public-health 
departments--charged its State, Tribal, Local and Territorial 
Workgroup to produce recommendations to maximize resources and develop 
capacity throughout this nonfederal community.[Footnote 30] A 
subworkgroup was created specifically to consider issues arising from 
the fiscal challenges facing states and localities. 

According to CDC officials, the workgroup has discussed moving 
cooperative agreements like PHEP and ELC to a 2-year cycle to give 
state and local public-health departments more time to work within 
state-imposed restrictions, but they cannot make such a change without 
legislative action. In addition, CDC officials stated that they 
attempt to communicate budget decisions to their nonfederal partners 
in a timely manner. For example, they said that they provided guidance 
to PHEP applicants to help them plan around funding uncertainty by 
communicating the minimum funding available and advising them to plan 
for the next fiscal year using the current year's funding level with 
the expectation that it will likely be reduced. However, these 
officials also noted that when federal agencies have to operate on a 
continuing resolution, it restricts their ability to plan and obligate 
funds, which in turn can result in reductions and delays in funding 
activities at the state and local level. 

An official from DOI's USGS National Wildlife Health Center also 
attributed funding instability and insecurity to the annual 
appropriations cycle, because federal agencies also do not know what 
the budget will be from year to year. Like CDC officials, he said that 
multiyear appropriations would allow for more long-term planning. USDA 
officials also acknowledged that their nonfederal partners face 
challenges planning for and developing capabilities because of funding 
uncertainty. Officials from USDA's Animal and Plant Health Inspection 
Service's Veterinary Services said they are working to streamline the 
cooperative agreement process to provide additional flexibility to the 
states by producing fewer but broader agreements that would allow the 
states to better prioritize their needs. 

Twenty-one of the 27 state and city officials who responded to our 
follow-up questionnaire reported that the common federal approach of 
funding capabilities in response to specific diseases or initiatives-- 
for example, West Nile virus--limited their ability to develop core 
capabilities that could provide surveillance capacity that cut across 
health threats and for emerging-disease threats. Along these lines, 
one of the respondents who rated this challenge among the top three 
said that broad-based surveillance activities are crucial for 
detecting new and emerging diseases, but funding targeted for specific 
diseases does not allow for focus on a broad range of causes of 
morbidity and mortality. 

Federal officials agreed that the disease-specific nature of funding 
is a challenge to states' ability to invest in core capabilities. CDC 
officials said this long-standing issue stems from the way CDC 
receives funding, which is disease-specific and, in turn, awarded to 
the states that way. According to officials, funding authorized under 
the Patient Protection and Affordable Care Act (PPACA) has recently 
offered some authority for flexible biosurveillance capability 
investments.[Footnote 31] For example, they said the PPACA program 
supports additional epidemiologists and laboratory support staff and 
infrastructure improvements, among other things, at the state and 
local level. Additionally, CDC officials noted that the all-hazards 
nature of PHEP grants supports states' ability to invest in 
crosscutting core capabilities. 

An official from DOI's USGS National Wildlife Health Center similarly 
noted that the structure of funding is a challenge for agencies at all 
levels, and said he would like to see more broad-based funding to 
allow for long-term investments to retain and develop capacity to 
address disease issues. USDA officials also acknowledge that 
stovepiped, or disease-specific, funding presents a challenge for 
their nonfederal partners when planning for and investing in 
crosscutting capabilities. Within USDA's Animal and Plant Health 
Inspection Service, officials from Veterinary Services said that they 
are moving away from funding disease-and program-specific items and 
toward a new funding approach, intended to reduce stovepiping and 
provide for additional flexibility. USDA's Wildlife Services officials 
also find stovepiped funding challenging, but said that they have 
little control over the issue. 

In interviews and follow-up questionnaires, city and state officials 
also reported challenges with the leadership and planning for 
integrated biosurveillance approaches. Sixteen of 27 respondents to 
our follow-up questionnaires reported a lack of leadership and 
mechanisms to support regional approaches to disease surveillance. 
Similarly, 17 of 27 respondents reported that integrating information 
across disease domains is a challenge because of a lack of leadership 
and mechanisms to facilitate information sharing and data integration 
among public-health, agriculture, and wildlife disease-control 
functions. One respondent who ranked integrating human and animal 
surveillance information among the top three challenges said that the 
lack of leadership and mechanisms to do so is a barrier to effective 
and efficient disease response. 

Federal agencies with biosurveillance roles have acknowledged that 
attention to integrated biosurveillance approaches is needed. In 
response to HSPD-21, CDC created the National Biosurveillance Strategy 
for Human Health, collaborating with federal and nonfederal partners, 
to provide a foundation for a long-term effort to improve a nationwide 
capability to manage human health-related data and information. The 
strategy lays out six priority areas for attention to address critical 
gaps and opportunities for improvement. Among the six is integrated 
biosurveillance, about which the strategy states that, because the 
responsibility for public health is shared across multiple levels of 
government, professional practice, and scientific disciplines, the 
timely exchange of reliable and actionable information is essential. 
Although the strategy includes goals for enhancing integration of 
human-health data, these goals have not yet been the central focus of 
implementation plans for the strategy. However, according to CDC 
officials, the efforts to establish objectives for enhancing 
management of human-health information as part of the strategy has 
been important for larger HHS efforts, such as implementing the 
National Health Security Strategy.[Footnote 32] Officials also said 
these activities are important to the efforts the National Security 
Staff has underway to guide the biosurveillance enterprise. In 
addition, CDC officials stated that the BioSense program is being 
redesigned to improve the ability for jurisdictions to share data with 
each other during specific events, which could foster more regional 
data sharing.[Footnote 33] 

An official from DOI's USGS National Wildlife Health Center said it 
would be helpful to have a national strategy or framework to guide all 
of those involved in wildlife health to respond in a coordinated, 
appropriate, and proportionate way to wildlife disease issues. In 
addition, he said the framework is needed to outline the shared 
responsibilities related to threat detection and assessment, policy 
development, and management actions. According to the official, DOI 
plans to begin working on such a framework for wildlife surveillance 
with its partners in the near future. USDA officials also acknowledged 
that nonfederal partners have faced challenges with leadership and 
planning for integrated biosurveillance approaches. USDA officials 
from Animal and Plant Health Inspection Service's Wildlife Services 
said they could enhance the integration of biosurveillance capacities 
for their nonfederal partners by providing access to their existing 
networks. However, the officials said they would need a source of 
funding for the increased efforts required to meet the needs of 
nonfederal partners. Officials from Veterinary Services stated that to 
address integration challenges, they try to engage their nonfederal 
partners in planning activities, but are looking to the National 
Security Staff's work on the national biosurveillance strategy to help 
address larger challenges. 

Some challenges identified by state and local officials reflected an 
opportunity for better partnerships between the federal and the state 
and local governments. Fourteen of 27 respondents to our follow-up 
questionnaires indicated that competing federal priorities present 
challenges. For example, in one interview, state officials said that 
grant guidance can be contradictory with regards to funding streams, 
and one grant may recommend focusing on a certain priority and then 
other grants recommend other priorities that do not complement the 
other grant's guidance. In addition, 12 of 27 questionnaire 
respondents reported having vague or insufficient guidance. In 
interviews, state and local officials who identified this issue noted 
that there is no user-friendly central repository of best practices 
for maintaining and enhancing capabilities and that guidance lacks 
concrete examples for things like developing state planning documents 
or fostering integrated biosurveillance efforts. Finally, 12 of 27 
questionnaire respondents reported federalism challenges, such as 
conflict between national and local priorities, philosophies, and 
approaches to conducting biosurveillance. For example, in an 
interview, public-health officials in one state told us that they have 
to spend valuable time and resources convincing their federal partners 
not to overreact to electronic laboratory results of disease that are 
considered dangerous, such as plague, but are also endemic in low 
levels within their jurisdictions: 

Officials from CDC stated that they are aware of these kinds of 
challenges facing their nonfederal partners and of the need to improve 
federal and nonfederal coordination among programs. These officials 
said states may have different priorities than those at the federal 
level due the need to balance their state responsibilities to address 
health concerns of the state with their other activities conducted 
with varying federal agencies and programs. According to the 
officials, they are committed--in national strategy efforts--to 
building on current capabilities at all levels of government and will 
take into consideration the issues and challenges states experience in 
working with their federal biosurveillance partners. They also noted 
that as they developed guidance for PHEP recipients for the most 
recent round of cooperative agreements--Public Health Preparedness 
Capabilities: National Standards for State and Local Planning--they 
involved approximately 200 stakeholders and experts to help public- 
health departments better organize their work and determine whether 
they have the resources to build and sustain all the capabilities. 
Additionally, they said that they attempted to ensure that their 
nonfederal partners do not experience continual shifts in PHEP 
priorities by implementing a new process for reviewing and approving 
proposed changes to PHEP guidance. 

They also described several efforts to coordinate grant guidance 
within CDC and with other federal partners to improve effectiveness 
and reduce conflicting activities or redundant reporting. Among these 
efforts were multiple workgroups and other activities to engage with 
federal and nonfederal partners, as well as a Memorandum of 
Understanding with multiple federal departments that fund preparedness 
activities. According to CDC officials, the memorandum establishes a 
formal framework that supports joint federal planning and better 
coordinates emergency public health and health care preparedness 
consistent with national strategies and priorities. 

An official from DOI's USGS National Wildlife Health Center agrees 
that partners throughout the biosurveillance enterprise experience 
federalism challenges. He said that a national strategy or framework 
that clearly outlines roles and responsibilities could help alleviate 
these issues. USDA officials also acknowledged that their nonfederal 
partners have faced these kinds of challenges. Officials from USDA 
Animal and Plant Health Inspection Service's Wildlife Services said 
that they recently created a plan to achieve a more unified cross- 
program approach to addressing wildlife-disease issues that will 
affect the agency and its stakeholders. These officials stated that 
enhanced integration of the USDA resources, expertise, personnel, and 
infrastructure needed to address issues of wildlife-disease 
surveillance--among other things--should help their nonfederal 
partners to mitigate this challenge. Officials from Veterinary 
Services stated that to address federalism challenges, they seek to 
proactively engage their nonfederal partners in planning activities, 
but are looking to the National Security Staff's work on the national 
biosurveillance strategy to help address the larger challenge. 

In our June 2010 report, we called for a national strategy that could 
begin to address the difficult but critical issues of who pays for 
biosurveillance capabilities and how a national capability will be 
sustained in the future.[Footnote 34] Our findings about the 
challenges with planning and investing in core capabilities, while not 
generalizable to all nonfederal jurisdictions, suggest that there may 
be some common issues with the structure of funding that affect longer-
term planning and investments in core biosurveillance capabilities. We 
also reported in June 2010 that clarifying the numerous governmental 
and private-sector entities' roles and responsibilities for leading, 
partnering, or supporting biosurveillance activities could help ensure 
timely disease detection and situational awareness across multiple 
domains.[Footnote 35] Our findings similarly suggest that there may be 
some common issues with promoting integrated biosurveillance 
approaches at the nonfederal level. As part of a national 
biosurveillance strategy, considering challenges like these may help 
partners across the enterprise find shared solutions as they strive to 
build and maintain an integrated national biosurveillance capability. 

Federal Agencies Provide Some Support, but Biosurveillance 
Capabilities in Tribal and Insular Areas Are Limited by Resources and 
Infrastructure: 

As with the state and local jurisdictions, the federal government does 
not have efforts designed specifically to build and maintain tribal or 
insular biosurveillance capabilities to support a national 
biosurveillance capability. However, tribal and insular jurisdictions 
also receive certain cooperative agreements and technical assistance 
that federal officials say can help support biosurveillance capacity. 
At the same time, federal officials reported that limited resources 
and infrastructure in tribal and insular jurisdictions present 
challenges to building their capacity. 

Federal Agencies Have Provided Financial and Technical Assistance That 
Can Support Tribal and Insular Capabilities: 

According to federal and professional association officials that work 
with tribal and insular jurisdictions, federal agencies provide 
disease-specific funding and cooperative agreements, as well as 
training and technical assistance, to support public-health and animal-
health surveillance capacity. 

[Side bar: The Pacific Public Health Surveillance Network: Created by 
the Secretariat of the Pacific Community and the World Health 
Organization in 1996, the goal of Pacific Public Health Surveillance 
Network is to improve public-health surveillance and response in the 
Pacific Islands in a sustainable way. PIHOA officials said the U.S.-
Affiliated Pacific Islands relies on two of the network’ s services—
PacNet and EpiNet—to provide them with an awareness and updates 
concerning disease outbreaks or emerging diseases in the region. 
PacNet is an online listserv for health practitioners to share 
information regarding epidemic threats. EpiNet consists of 
multidisciplinary national/territorial outbreak-response teams. In 
addition to updates concerning disease outbreaks and outbreak- 
response information, district hospitals can also obtain expert 
technical assistance by linking in to either PacNet or EpiNet. Source: 
GAO analysis of HHS data. End of side bar] 

Insular areas are eligible for the PHEP and ELC cooperative agreements 
from CDC. PHEP funds public-health preparedness projects in American 
Samoa, Guam, U.S. Virgin Islands, Northern Mariana Islands, Puerto 
Rico, Federated States of Micronesia, Republic of the Marshall 
Islands, and Republic of Palau. In addition, ELC--which builds 
epidemiological and laboratory capacity--is awarded to Puerto Rico and 
the Republic of Palau. 

According to officials from PIHOA, federal agencies also provide 
specimen testing for Pacific insular areas--which have no reference 
laboratory capacity of their own--for disease agents that the islands' 
clinical laboratory network is not equipped or certified to handle. 
PIHOA developed the Regional Lab Initiative for the transportation of 
human specimens, and PIHOA serves as a steward for the specimen 
transportation network by negotiating specimen-transportation 
contracts with commercial airlines, developing shipping standards for 
laboratory specimens, and overseeing the Regional Lab Initiative 
budget. PIHOA officials said that federal funding for this initiative 
is critical to enable Pacific insular areas to transport specimens for 
testing to those laboratories with greater capabilities. 

According to CDC officials, their Division of Global Migration and 
Quarantine also works with the insular areas to enhance crosscutting 
public-health initiatives, with a focus on disease surveillance and 
help public-health departments tie into various CDC programs. For 
example, the division has been working with Guam since late 2009 to 
move towards electronic data sharing of health information to improve 
timeliness and response to catastrophic events, including better 
linkages to the National Notifiable Disease Surveillance System. 
During a 2010 mumps outbreak in Guam and the Federated States of 
Micronesia, the division also played a coordination role and 
facilitated the shipment of lab specimens. Officials said that the 
Guam mumps outbreak helped identify gaps in their surveillance 
capacity, and the division followed up with targeted training to 
address the gaps. The division is also working to enhance the quality 
of American Samoa's public-health records to enhance its ability to 
submit electronic public-health data into the World Health 
Organization's syndromic surveillance system for the Pacific Islands 
region. 

For animal health in the insular areas, USDA has employees and offices 
in some insular areas. USDA Veterinary Medical Officers in the field 
interact with producers, respond to reports of potential Foreign 
Animal Diseases, help administer disease eradication and control and 
surveillance activities, and assist with export certification out of 
these field-office sites. DOI provides diagnostic service to determine 
causes of mortality in wildlife. For example, in American Samoa and 
Palau, DOI performs necropsy surveys of free-ranging wildlife (both 
terrestrial and marine) to determine the cause of death. The agency 
reported that all bird carcasses necropsied are routinely tested for 
avian influenza.[Footnote 36] The agency also reported that the 
ability to ship samples from American Samoa and Palau to Honolulu, 
Hawaii, has allowed the agency to gain a greater understanding of 
causes of wildlife mortality in those regions. In case of catastrophic 
mortality, DOI officials said the agency would probably send someone 
out to the area to provide on-site assistance and collaborate with 
local agencies to deal with the issue and resolve it to its logical 
conclusion. For example, DOI officials have offered response 
assistance to Palau to help with unusual poultry mortality events in 
efforts to effect early detection of avian influenza. DOI also 
provides annual workshops to agencies to communicate findings and 
provide on-site training on wildlife disease response. 

Tribal nations are not eligible for PHEP or ELC funding, but CDC 
advises states to include tribes in their required all-hazards public- 
health capability planning for PHEP funding. In addition, IHS has 
cooperative agreements with Tribal Epidemiology Centers, to support 
local public health and provide data analyses for the tribes. As shown 
in figure 4, there are 12 Tribal Epidemiology Centers located around 
the country. The 12 Tribal Epidemiology Centers typically serve 30-100 
tribes in their region. Officials from IHS said that the Tribal 
Epidemiology Centers may offer a foundation for building tribal 
biosurveillance capabilities. However, biosurveillance is not the 
primary job or mission of the epidemiology centers. The priorities of 
the centers are driven by the needs of the tribes, and the centers 
help the tribes create a structure for intervention to prevent the 
major conditions affecting the tribal population. 

Figure 4: Tribal Epidemiology Centers: 

[Refer to PDF for image: illustrated U.S. map] 

United South Eastern Tribes; 
Great Lakes; 
Southern Plains; 
Northern plains; 
Rocky Mountain; 
Albuquerque Area Southwest; 
Navajo;
Inter-Tribal Council of Arizona, Inc. 
California; 
Northwest; 
Alaska Native; 
Urban Indian Health Institute. 

Source: Indian Health Service. 

[End of figure] 

Federal agencies also provide technical assistance and training to 
tribal jurisdictions. The Office for State, Tribal, Local and 
Territorial Support within CDC provides training and technical 
assistance to improve data and surveillance standards in tribal areas 
and work to foster public-health workforce development in tribal 
areas. In addition, IHS provides, without charge, software for 
automated electronic surveillance that can be implemented by IHS, 
tribal, and Urban American Indian and Alaska Native sites to help with 
automated reporting and information sharing. The initial project, 
IHS's Influenza Awareness System, focused on influenza-like illness, 
but according to IHS officials is currently expanding to include other 
notifiable diseases. IHS also provides technical assistance to tribes, 
sometimes through the Tribal Epidemiology Centers, and also provides 
some training, which is available to any American Indian or Alaska 
Native. The primary focus of the training is not biosurveillance but 
basic public-health functions, but federal officials who work with 
these jurisdictions say that any effort to build public-health 
infrastructure increases biosurveillance capabilities over their 
existing levels. 

Additionally, according to USDA officials, tribes can participate in 
the same disease-control and eradication programs (such as 
tuberculosis, brucellosis, scrapie, and chronic wasting disease) as 
states through grants and cooperative agreements. These officials said 
these cooperative agreements increase tribes' biosurveillance 
capability, particularly with tribes that have more-robust existing 
infrastructure, like Navajo Nation, which has a full-time 
veterinarian. USDA officials with responsibility for wildlife said 
they also provide cooperative agreements and training to support 
tribal wildlife disease surveillance. 

Federal Working Groups and Outreach Efforts Can Help Support 
Biosurveillance Capabilities: 

To help build public-health and animal-health surveillance capacity, 
federal agencies have also created working groups and other outreach 
efforts to tribal and insular jurisdictions. For example, the Office 
for State, Tribal, Local and Territorial Support within CDC works with 
health departments to increase public-health capacity through a 
working group that helps build capacity across jurisdictions, for 
example between tribes and corresponding state or local health 
departments. CDC has developed Pacific working groups to address 
various issues in the Pacific insular areas, such as the Public Health 
Preparedness and Response Working Group and an epidemiology working 
group. According to officials, these working groups help coordinate 
activities between various CDC departments and the Pacific insular 
areas. 

USDA's Native American Program Coordinator serves as a tribal liaison, 
providing assistance to tribes and has developed a relationship with 
the large land-owning tribes that participate in its programs. The 
officials said that the tribal liaison has built this relationship 
over the years by attending the Intertribal Agriculture Council's 
Meetings, a gathering of tribal agriculture producers. They noted that 
because of the tribal liaison's continuous outreach, they believe that 
the tribes know whom to call if unusual animal disease symptoms appear 
in animals on their lands. 

Federal Agencies Face Unique Challenges Supporting Tribal and Insular 
Jurisdictions: 

Federal officials, as well as officials from professional associations 
like the Council of State and Tribal Epidemiologists and PIHOA 
described infrastructure and demographic challenges they face in 
helping to build biosurveillance capabilities in tribal and insular 
jurisdictions. For example, CDC officials said that, overall, there is 
a low capacity to detect and report diseases in both tribal and 
insular jurisdictions, and that better assurance for detection of 
potentially catastrophic signs would require enhancement of basic 
systems and public-health functions. HHS officials said that tribes, 
insular areas, and states face similar public-health infrastructure 
challenges, but the challenges are more severe in tribal and insular 
areas. For example, IHS and CDC officials said some tribes have 
serious public-health infrastructure limitations--for example, some 
have minimal or no functioning health-department structure--so 
officials said the idea of building biosurveillance capabilities is 
not a realistic pursuit in these areas. 

[Side bar: USDA’s Traceability Program: On February 5, 2010, USDA 
announced a new framework for animal-disease traceability in the 
United States. 

Approximately 30 tribes receive funding for the Traceability Program, 
which according to a senior USDA official is at the core of 
surveillance efforts at the tribal level. 

According to USDA, the program will (1) only apply to animals moved 
interstate, (2) be administered by the states and tribes to provide 
more flexibility, (3) encourage the use of lower-cost technology, and 
(4) be implemented transparently through federal regulations and the 
full rulemaking process. Source: USDA (data); USDA, Stephen Ausmus 
(photo). [End of side bar] 

USDA and DOI officials also reported capacity challenges--such as few 
veterinary and wildlife personnel on the ground in tribal and insular 
areas--that limit biosurveillance capabilities. Additionally, 
officials said that the federal cooperative agreements offered by 
federal agencies do not always provide for the infrastructure 
enhancement needed for tribal and insular areas, because they assume a 
basic level of capacity that these jurisdictions often do not have. 
However, USDA, DOI, and HHS officials also cautioned that despite the 
limited infrastructure in some of the tribal and insular areas, it 
would not be practical from a cost-benefit standpoint to invest in 
complete biosurveillance systems for every tribe and insular area. For 
example, for small tribal nations and insular areas it may not make 
sense to expect them to support and maintain separate laboratory 
facilities, especially when there are other nearby state resources 
available that could support testing for those populations. 

Along the same lines, HHS officials said that tribes and their federal 
and state partners have historically faced disease-reporting 
challenges. CDC officials noted that as sovereign nations, tribes 
typically prefer to work directly with federal agencies, rather than 
state governments, but because of the nature of public health, it 
often makes sense for tribes and states to share data or conduct joint 
investigations with the states. CDC officials said that data sharing 
between tribes in states is challenging, because tribes may have 
limited public-health capacity. The officials said that Tribal 
Epidemiology Centers offer some promise for facilitating information 
sharing, but some states have been reluctant to share health data with 
Tribal Epidemiology Centers, because until recently they lacked public-
health authority--a legal designation that governs the ability of 
governmental entities to collect, receive, and share data for public-
health purposes under the Health Insurance Portability and 
Accountability Act of 1996 (HIPAA).[Footnote 37] Tribal Epidemiology 
Centers are operated by nonprofit organizations that typically had no 
legal health authority to handle such data. However, in 2010, PPACA 
designated these centers public-health authorities under HIPAA. 
[Footnote 38] This provision allows the IHS-funded Tribal Epidemiology 
Centers to access federal and state data sets for research purposes, 
just as state health departments do. However, these centers still are 
nonprofit organizations that are competitively selected on a periodic 
basis and there is no guarantee that the entire nation will continue 
to have center coverage. HHS officials said the designation of the 
centers as public-health authorities will likely facilitate more 
sharing among states and tribes, but it is a relatively new 
development, so it is too soon to determine the effect. 

[Side bar: American Indian and Alaska Native Health Research Advisory 
Council: 

The Health Research Advisory Council was established to provide HHS a 
venue for consulting with tribes about health research priorities and 
needs in American Indian and Alaska Native communities and 
collaborative approaches in addressing these issues and needs. The 
Council serves three primary functions: 

(1) obtaining input from tribal leaders on health research priorities 
and needs for their communities; 
(2) providing a forum through which HHS operating and staff divisions 
can better communicate and coordinate American Indian and Alaska 
Native health research activities; and; 

(3) providing a conduit for disseminating information to Tribes about 
research findings from studies focusing on the health of American 
Indian and Alaska Native populations.
Source: GAO analysis of HHS data. End of side bar] 

Federal officials also reported facing demographic and logistical 
challenges in working with tribal nations. Complications in data 
collection and reporting arise from the nature of tribal boundaries 
and populations. Specifically, tribes are not defined by geographic 
boundaries, tribal members may not live on tribal lands, and tribal 
lands may cross state boundaries. Officials also said population size 
and geography vary for tribes and many tribes are in remote locations, 
including about half of the more than 500 federally recognized tribes 
located in Alaska. An official from IHS noted that, in general, tribal 
communities do not have populations large enough to justify building 
complete, individual surveillance programs and that tribes generally 
do not have infrastructure or resources to support such an effort. 

According to USDA officials, every tribe has a different relationship 
with the state it is located in and with the federal government. Some 
tribes have direct relationships with the state agriculture department 
because most tribes do not have veterinarians. In some cases, the 
states may take care of the surveillance needs for a tribe, and in 
other cases, the tribes may have their own surveillance capacity. In 
general, tribes do not have funding to establish and maintain 
laboratories. Tribes typically use the state labs that are part of the 
National Animal Health Laboratory Network (NAHLN), the facilities at 
Plum Island, the Ames, Iowa lab, or state labs that are not part of 
NAHLN. (For more information about laboratories, see appendix II.) DOI 
officials said that tribes are interested in wildlife management and 
disease surveillance, but do not have the resources, as tribes need to 
build capabilities at the most basic level--like wildlife biologists 
and management expertise. 

Federal agencies, as well as association officials, reported similar 
resource, demographic, and logistical challenges in insular areas. 
Officials at the Council of State and Territorial Epidemiologists, 
PIHOA, and CDC said the Pacific insular areas are challenged in 
identifying disease outbreaks and emerging diseases. According to 
PIHOA officials, this is due to workforce shortages for doctors, 
nurses, epidemiologists, and laboratory officials, and the limited 
laboratory capacity on the islands. Although the islands can currently 
depend on laboratories outside Pacific insular areas to conduct 
testing, and there are currently initiatives and programs in place to 
improve laboratory capacity on the islands, it may take several days 
to detect a disease. 

CDC officials said timely reporting cannot be ensured in the Pacific 
insular areas and there is limited ability to build public-health 
infrastructure in the territories. For example, they said the public- 
health systems will have to transition to more formal mechanisms of 
information sharing, because currently events trigger regional 
partners to respond in an ad hoc and unsystematic way. To address some 
of these challenges, PIHOA developed the Public Health Infrastructure 
Initiative, partially funded by CDC's National Public Health 
Improvement Initiative, which is supported by PPACA's Prevention and 
Public Health Fund, to help improve Pacific insular areas' public- 
health systems at every level. Through this initiative, PIHOA is 
working with Pacific insular areas officials to develop public-health 
curricula to improve the epidemiological and surveillance capabilities 
of the islands. 

According to DOI officials, aside from Guam, insular areas in the 
Pacific region have little to no existing veterinary capacity to deal 
with animal or zoonotic diseases. DOI officials said they would like 
to get more wildlife disease data from places like Guam and the 
Commonwealth of the Northern Mariana Islands, but the lack of reliable 
in-territory contacts there has made it difficult to establish those 
relationships. 

The Federal Government Has Not Comprehensively Assessed Nonfederal 
Biosurveillance Capabilities: 

Various federal agencies and professional associations with public- 
health missions have assessed some aspects of nonfederal 
biosurveillance capabilities, such as the evaluation of laboratory, 
epidemiology, surveillance, and other capacities, but the federal 
government has not systematically or comprehensively assessed state 
and local governments' ability to contribute to a national 
biosurveillance capability. An assessment of capabilities that support 
biosurveillance is called for in HSPD-10, which states that the United 
States requires a periodic assessment that identifies gaps or 
vulnerabilities in our biodefense capabilities--of which surveillance 
and detection is a key part--to guide prioritization of federal 
investments.[Footnote 39] We have previously reported that a national 
biosurveillance capability depends upon participation from nonfederal 
jurisdictions and that few of the resources required to support the 
capability are wholly owned by the federal government.[Footnote 40] 
Therefore, assessing the baseline and identifying investment needs for 
a national biosurveillance capability necessarily involves assessing 
nonfederal entities' ability to support a national capability. 

No federal, state, local, or association official we spoke to was able 
to identify a systematic approach--planned or underway--to assessing 
state and local biosurveillance capabilities and identifying 
strengths, weaknesses, and gaps across the biosurveillance enterprise. 
However, certain aspects of public-health capabilities have been 
assessed by federal agencies and professional associations. For 
example, CDC's most-recent round of guidance associated with the PHEP 
cooperative agreements has begun to define elements, priorities, 
resource considerations, and metrics for building and assessing public-
health surveillance, epidemiology, and laboratory capabilities. 
According to CDC officials, these national standards are designed to 
assist states and localities in self-assessing their ability to 
address the prioritized planning resource elements of each capability 
and then to assess their ability to demonstrate the functions and 
tasks within each capability. CDC officials stated that this self- 
assessment enables states and localities to identify their gaps in 
preparedness, determine their specific jurisdictional goals and 
priorities, develop plans for building and sustaining capabilities, 
and prioritize preparedness investments. CDC officials noted that 
these data and data collected through the ELC could, with the right 
attention and resources, offer an opportunity to provide more-cohesive 
information for a national assessment in the future. 

In addition, for the past 4 years the Association of Public Health 
Laboratories has conducted an assessment of the District of Columbia 
and the 50 state public-health laboratories' capacity to respond to 
biological, chemical, radiological, and other threats, such as 
pandemic influenza. Similarly, the Council of State and Territorial 
Epidemiologists has conducted four assessments since 2001 to assess 
the epidemiology capacity of state, local, and territorial health 
departments in the United States. Further, CDC funded a survey of 
state, local, and territorial syndromic surveillance capabilities that 
was conducted by the International Society of Disease Surveillance. 

According to several federal and state officials, a comprehensive 
assessment of the biosurveillance enterprise may identify a baseline 
status, strengths, weaknesses, and gaps across the biosurveillance 
enterprise and improve the nation's ability to conduct 
biosurveillance, but state officials also noted that states would need 
additional funding to overcome any gaps identified by a federal 
assessment. For example, officials from one federal agency said that a 
comprehensive assessment of state and local biosurveillance 
capabilities would help identify vulnerabilities in the enterprise, 
assess needs, and help target resources to those areas. Similarly, 
another federal official who oversees programs for tribal entities 
noted that knowing more about tribes' strengths, weaknesses, and gaps 
would enable their division to better understand where they need to 
provide additional assistance or focus resources during an event. 

State officials we interviewed also discussed how a national 
assessment could identify best practices in biosurveillance and inform 
states and federal resource decisionmaking. For example, public health 
officials from one state said that information about the capability 
needed to support a national biosurveillance capability would be 
helpful to support lessons learned and identify best practices. 
Similarly, wildlife officials from one state said they lack knowledge 
about the types of wildlife surveillance conducted by other states and 
other states' baseline capabilities. They said an assessment of 
capabilities could determine how their efforts compare to other 
states, which would provide information to state decision makers to 
guide resource decisions. According to public-health officials from 
another state, some gaps in biosurveillance are already fairly well 
understood--such as electronic lab reporting and workforce 
sufficiency. These officials said that a formalized national 
assessment would bring these gaps to the attention of federal agencies 
and hoped that federal agencies would address these gaps with 
additional funding, guidelines, and the prioritization of investments. 

Although federal, state, and local officials we interviewed generally 
agreed that a comprehensive national assessment may improve the 
nation's ability to conduct biosurveillance, all the officials we 
interviewed acknowledged that such an assessment would be a complex 
undertaking. Federal, state, and local officials said the size, 
variability, and complexity of the biosurveillance enterprise-- 
including federal, state, and local biosurveillance efforts--make it 
difficult to define precisely what should be measured and identifying 
the most appropriate assessment participants would be difficult. For 
example, public-health officials from one state said it would be 
important to identify definitions and create measurements with which 
to evaluate capacities, otherwise it would be difficult to maintain a 
narrow scope for the assessment. They also noted that the development 
of this type of assessment would require the input of multiple 
stakeholders. Other officials also noted that it may be difficult to 
identify the most appropriate parties to provide information for the 
assessment. For example, agriculture officials from one state said 
that identifying the most appropriate person to complete the 
assessment would be difficult, because a state veterinarian will have 
a different perspective from someone who regularly works in the field. 
The difficulty in conducting a comprehensive national assessment is 
exacerbated not only by the magnitude of the undertaking--assessing 
the capabilities of the states, tribes, insular areas, and the tens of 
thousands of localities in the United States--but also by the lack of 
a clear mission and a vision for the desired end state of a national 
biosurveillance capability. In our June 2010 strategy recommendation, 
we noted that the National Security Staff and its focal point should 
define the mission and desired end state.[Footnote 41] 

Until it conducts an assessment of nonfederal biosurveillance 
capabilities, the federal government will continue to lack key 
information about the baseline status, strengths, weaknesses, and gaps 
across the biosurveillance enterprise to guide development and 
maintenance of a national biosurveillance capability. Officials we 
interviewed at all levels, as well as federal guidance and directives 
like HSPD-21, acknowledge that a national biosurveillance capability 
necessarily rests on the cumulative capabilities of state and local 
agencies that constitute a large portion of the biosurveillance 
enterprise. A national strategy like the one we recommended in June 
2010--one capable of guiding federal agencies and its key stakeholders 
to systematically identify risks, resources to address those risks, 
and investment priorities--may be better positioned to guide 
development and maintenance of the capability if it takes into account 
the particular challenges and opportunities inherent in partnering 
with nonfederal jurisdictions such as state, tribal, local, and 
insular governments. Moreover, efforts to build the capability would 
benefit from a framework that facilitates assessment of nonfederal 
jurisdictions' baseline capabilities and critical gaps across the 
entire biosurveillance enterprise. 

Conclusions: 

A key component of preparedness for a potentially catastrophic 
biological event is the ability to detect a dangerous pathogen early 
and assess its potential spread and effect. Experts have noted, and 
our reviews of both federal and nonfederal government biosurveillance 
activities confirm, that the federal government has undertaken 
numerous efforts to support timely detection and situational awareness 
for potentially catastrophic biological events, but these efforts are 
not well integrated. As we reported in June 2010, current efforts lack 
a unifying framework and structure for integrating dispersed 
capabilities and responsibilities across the biosurveillance 
enterprise. Further we noted that without this unifying framework, it 
will be difficult to create an integrated approach to building and 
sustaining a national biosurveillance capability as envisioned in HSPD-
21. 

Officials at all levels of government, as well as HSPD-21's vision of 
a national biosurveillance capability, acknowledge that state and 
local capabilities are at the heart of the biosurveillance enterprise. 
According to federal, state, and local officials, early detection of 
potentially serious disease indications nearly always occurs first at 
the local level, making the personnel, training, systems, and 
equipment that support detection at the state and local level a 
cornerstone of our nation's biodefense posture. Therefore, to be most 
effective, a national biosurveillance strategy like the one we 
recommended in June 2010--one capable of guiding federal agencies and 
their key stakeholders to systematically identify risks, resources to 
address those risks, and investment priorities--would address the 
particular challenges and opportunities inherent in partnering with 
state and local jurisdictions. Moreover, efforts to build the 
capability would benefit from a framework that facilitates assessment 
of jurisdictions' baseline capabilities and critical gaps across the 
entire biosurveillance enterprise. 

Recommendations for Executive Action: 

In order to help build and maintain a national biosurveillance 
capability in a manner that accounts for the particular challenges and 
opportunities of reliance on state and local partnerships, we 
recommend the Homeland Security Council direct the National Security 
Staff to take the following action as part of its implementation of 
our previous recommendation for a national biosurveillance strategy: 

* Ensure that the national biosurveillance strategy (1) incorporates a 
means to leverage existing efforts that support nonfederal 
biosurveillance capabilities, (2) considers challenges that nonfederal 
jurisdictions face in building and maintaining biosurveillance 
capabilities, and (3) includes a framework to develop a baseline and 
gap assessment of nonfederal jurisdictions' biosurveillance 
capabilities. 

Agency Comments and Our Evaluation: 

We provided a draft of this report for review to the National Security 
Staff, DHS, HHS, DOI, USDA, the Department of Justice; and the state 
and city officials who contributed to our review. The National 
Security Staff acknowledged the accuracy of the information contained 
in the report but did not comment on the recommendation. DHS provided 
a written response to the draft report, which is summarized below and 
presented in its entirety in appendix V of this report. USDA provided 
an oral response that is summarized below. DHS, HHS, DOI, USDA, the 
Department of Justice, the North Carolina Division of Public Health, 
and the Utah Department of Agriculture and Food provided technical 
comments, which we incorporated where appropriate. 

In written comments, DHS concurred with our findings. DHS noted that 
its National Biosurveillance Integration Center has key 
biosurveillance roles and responsibilities, and stated that to support 
the Center's mission, DHS is working with the National Security Staff 
on the Sub-Interagency Policy Committee on Biosurveillance. DHS 
further stated that it understands the importance of and supports the 
inclusion of nonfederal biosurveillance resources in the National 
Biosurveillance Strategy under development. 

In oral comments, USDA concurred with our findings and 
recommendations. Overall,. Specifically, USDA's Animal and Plant 
Health Inspection Service's Veterinary Services and Wildlife Services 
supported our recommendation to leverage support, consider challenges, 
and develop a framework to understand the current capacity and conduct 
a needs assessment for nonfederal identities to conduct 
biosurveillance activities. USDA stated that it will continue to work 
with the National Security Staff in development of the National 
Biosurveillance Strategy. USDA noted that its Animal and Plant Health 
Inspection Service has an established national program--the National 
Wildlife Disease Program--that is currently available to provide the 
infrastructure and leadership necessary to implement these 
recommendations, and should be incorporated into an integrated system. 
USDA noted that the program has a history of providing leadership for 
national surveillance during various outbreaks, which demonstrates its 
overall abilities to develop and maintain broad local, state, tribal 
and private efforts to conduct targeted biosurveillance activities. 

We are sending copies of this report to the Special Assistant to the 
President for National Security Affairs; the Attorney General; the 
Secretaries of Homeland Security, Health Human and Services, 
Agriculture, and the Interior; and interested congressional 
committees. The report is also available at no charge on GAO's website 
at [hyperlink, http://www.gao.gov. 

If you or your staff have any questions about this report please 
contact me at (202) 512-8777 or jenkinswo@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major 
contributions to this report are listed in appendix VI. 

Signed by: 

William O. Jenkins, Jr. 
Director, Homeland Security and Justice Issues: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

To address our objectives, we reviewed key legislation and 
presidential directives related to biosurveillance, including the 
Homeland Security Act of 2002;[Footnote 42] the Public Health Security 
and Bioterrorism Preparedness and Response Act of 2002;[Footnote 43] 
the Pandemic and All Hazards Preparedness Act of 2006;[Footnote 44] 
and Homeland Security Presidential Directives (HSPD) 9, 10, and 21. 
This report focuses on surveillance efforts for zoonoses--diseases 
affecting animals and humans--and other emerging infectious diseases 
with the potential to cause catastrophic human-health effects. 

Our work issued in June 2010 on biosurveillance efforts at the federal 
level explored surveillance for the following biosurveillance domains: 
human health, animal health, plant health, food, and the environment 
(specifically, air and water). Given further complexity arising from 
the number of and variation among states, localities, tribes, and 
insular areas, we narrowed the disease scope for this report. We 
focused on zoonotic disease agents, because of the particular threats 
associated with them and because threats from zoonotic disease agents 
clearly illustrate the potential benefits of an integrated 
biosurveillance capability. Given the focus on surveillance for 
zoonoses and other emerging infectious diseases in humans, certain 
federal efforts--for example, the Department of Homeland Security's 
air-monitoring system BioWatch--are not discussed. Similarly, certain 
types of waterborne, foodborne, plant, or animal diseases--for example 
Foot and Mouth Disease--that could have devastating economic 
consequences or dire human-health effects are not the focus of this 
report. 

At the federal level, we consulted officials at the Departments of 
Agriculture, Homeland Security, Health and Human Services, and the 
Interior, which have key missions, statutory responsibilities, 
directives, or programmatic objectives for biosurveillance activities 
within the scope of this report, including protecting human and animal 
health and national security. We also discussed biosurveillance issues 
at the state and city level with officials from the Department of 
Justice's Federal Bureau of Investigation. 

To develop background on and contextual understanding of the federal 
efforts that support state biosurveillance capabilities and the 
challenges officials face building and maintaining those capabilities, 
we interviewed officials from 10 professional associations and 
research organizations and asked for recommendations on factors to 
consider when selecting states for site visits. We interviewed 
officials from the following organizations: 

* International Society for Disease Surveillance, 

* Council of State and Territorial Epidemiologists, 

* Trust for America's Health, 

* National Association of State Public Health Veterinarians, 

* American Phytopathological Society, 

* Association of Public Health Laboratories, 

* U.S. Animal Health Association, 

* American Association of Veterinary Laboratory Diagnosticians, 

* Association of State and Territorial Health Officials, and: 

* OneHealth. 

On the basis of information collected during interviews with officials 
from professional associations and research organizations and a review 
of published reports and studies, we identified several factors that 
could be associated with variability in approaches, philosophies, and 
challenges faced by states in conducting biosurveillance. We selected 
seven states for site visits with the dual goals of capturing 
variation on each of these factors and accounting for each in 
commonalities identified across the states we visited. The factors we 
identified and their application to our site selection are shown in 
table 6. 

Table 6: Factors Identified and Their Application to Our Site 
Selection: 

Factor considered: Geographic location/political culture; Application 
of factor to selection: We visited coastal states in the eastern and 
western United States, as well as noncoastal states. We also visited 
states with large urban populations and states with more rural 
populations. In addition, we visited at least one state that has an 
international border. 

Factor considered: State/local public-health organizational structure; 
Application of factor to selection: We visited at least one state with 
a centralized public-health structure, at least one with a 
decentralized public-health structure, at least one with a shared or 
mixed relationship, and at least one with no local public-health 
departments.[A] 

Factor considered: Strength of capabilities and programs (based on 
expert recommendations); 
Application of factor to selection: We visited at least one state 
identified by professional association officials as having strong 
public-health capabilities as a result of leadership and political 
will, connections between public and animal health or attention to 
health security as a public-health and national-security issue. We 
also visited at least one state that the professional association 
officials identified as part of a group of states that had chronically 
struggled with resource issues. 

Factor considered: Presence and type of agriculture; Application of 
factor to selection: According to association officials we 
interviewed, the extent to which a state has agricultural interest has 
a bearing on its animal-health resources and programs. We visited at 
least one state with a large industry presence for one or more of the 
following types of agriculture: commercial fishing, chickens, turkey, 
hogs, and cattle. 

Factor considered: Public-health priorities; Application of factor to 
selection: In 2007 and 2008, the Association of State and Territorial 
Health Officials surveyed the states for their State-by-State Profile 
of Public Health. As part of that effort, the association asked states 
to select from a list indicating their top five priorities. Within the 
list were two priorities particularly relevant to health preparedness 
generally and biosurveillance capabilities specifically. Respectively 
these are: (1) assuring preparedness for a health emergency and (2) 
focusing on early detection or population-protection measures. We 
selected at least one state that selected neither of the priorities 
and at least one state that selected one or both. There were no states 
that selected priority (2) but did not select priority (1) in our 
sample. 

Source: GAO. 

[A] As identified in the Association of State and Territorial Health 
Officials 2008 State-by-State Profile of Public Health. 

[End of table] 

The states selected were California, Colorado, Delaware, Mississippi, 
New Jersey, North Carolina, and Utah. In every state, we interviewed 
three groups of officials: 

1. Officials in public-health departments, including state 
epidemiologists, who had responsibility for infectious-disease 
control, disease monitoring, and emergency response in humans. 

2. Officials, generally including the state veterinarian, in state 
agriculture departments who had responsibility for infectious-disease 
control and monitoring in livestock and poultry. 

3. Officials in various departments that included wildlife infectious- 
disease control and monitoring in their missions. For example, one of 
these was a State Department of Wildlife and Fisheries. 

We also interviewed public-health officials with responsibility for 
human infectious-disease control and monitoring in two cities with an 
increased risk of bioterrorism--New York City and Washington, D.C.-- 
that received direct funding from federal agencies to support 
preparedness capabilities. 

We analyzed the information collected during state and city interviews 
and developed follow-up questionnaires to confirm and enhance 
information from the interviews about the federal programs and 
initiatives that support state and local biosurveillance capabilities 
and the challenges officials face. We sent follow-up questionnaires to 
public-health departments in all seven states and two cities and to 
agriculture and wildlife officials in the seven states. Within each 
public-health department, we sent separate questionnaires to 
laboratory and epidemiology officials. In total, we distributed 32 
questionnaires and received 27 responses. Of the 27 respondents, 7 
were epidemiologists, 7 were public-health laboratory officials, 6 
were state agriculture officials, and 7 were state wildlife officials. 
All of the public-health, agriculture, and wildlife departments 
represented by the 27 respondents had also been represented in our 
initial interviews. However, in 7 cases--6 laboratory directors and 1 
state veterinarian--the lead officials to whom we directed the 
questionnaire had not been present at the initial interviews. We 
pretested the public-health questionnaire with a laboratory official 
who was not at the original interviews in order to ensue the questions 
could be understood outside of the context of the interview. 

Each questionnaire had two sections: one on federal support to states 
and cities and one on challenges faced by states and cities. The 
content of the federal support section varied for human-health and 
animal-health respondents, but the challenges section was the same for 
both human-and animal-health respondents. The specific federal 
programs and challenges we asked about were based on initial 
interviews with the different groups of respondents. We asked 
respondents to consider federal efforts over the last 2 years. Because 
the states and cities in this report were not selected in a 
probability sample, neither the information derived from interviews 
with officials nor the questionnaire responses are generalizable 
across the 50 states or the tens of thousands of localities in the 
United States. Rather, both the interviews and the questionnaire 
results offer some perspective on the value of select federal 
activities to, and challenges faced by, a group of state officials who 
are actively engaged in efforts to detect and respond to major disease 
events. In addition, although we interviewed officials responsible for 
public-health emergency management in most state public-health 
departments that we visited, we did not administer follow-up 
questionnaires to the officials responsible for planning and preparing 
for emergency response, because their response focus was generally not 
central to our scope. Because this report focuses on detection of and 
situational awareness of potentially catastrophic zoonotic and 
emerging infectious-disease events, certain federal efforts that 
federal agencies consider important in supporting state and local 
preparedness may not have been identified by state and city officials 
during our interviews and follow-up questionnaires. 

To consider the relationship between our findings at the nonfederal 
level and our previous findings at the federal level about building 
and maintaining a national biosurveillance capability, we reviewed our 
June 2010 findings about the centrality of nonfederal capabilities to 
a biosurveillance enterprise. We also reviewed our June 2010 findings 
about the purpose of a national biosurveillance strategy and the 
benefits it could provide for guiding the effort to support a national 
biosurveillance capability. We determined that because the federal 
government relies on nonfederal resources to support a national 
biosurveillance capability, our June 2010 findings about using the 
strategy to determine how to leverage resources, weigh the costs and 
benefits of investments, and define roles and responsibilities were 
particularly germane to the federal government's efforts to partner 
with nonfederal biosurveillance enterprise partners to support a 
national biosurveillance capability. 

To understand how the federal government supports biosurveillance in 
tribal and insular areas, we consulted officials from components of 
federal departments with responsibility for working with tribal or 
insular councils and governments, generally, or on health-related 
matters. These included: the Department of Health and Human Services's 
Indian Health Service; the Department of Health and Human Services's 
Centers for Disease Control and Prevention's (CDC) Office of State, 
Tribal, Local and Territorial Support; CDC's Office of Surveillance, 
Epidemiology, and Laboratory Services, CDC's National Center for 
Emerging and Zoonotic Infectious Diseases, the Department of 
Agriculture's Office of Tribal Relations and the Department of 
Agriculture's Animal and Plant Health Inspection Service; the 
Department of the Interior's Bureau of Indian Affairs; and the 
Department of the Interior's Office of Insular Affairs. In addition, 
to develop additional background and context about health 
infrastructure and surveillance in insular areas, we interviewed 
representatives from the Pacific Island Health Officers Association 
(PIHOA), which works in the U.S.-Affiliated Pacific Islands to 
strengthen crosscutting public-health infrastructure, including health-
workforce development, quality assurance, health data systems, public- 
health planning, and public-health laboratories. The findings in this 
report about insular areas focus on the U.S.-Affiliated Pacific 
Islands. With the exception of Puerto Rico and the U.S. Virgin 
Islands, all commonwealths, territories, possessions, and freely 
associated states of the United States fall within the U.S.-Affiliated 
Pacific Islands. 

To evaluate the extent to which the federal government has assessed 
nonfederal governments' capacity to contribute to a national 
biosurveillance capability, we reviewed relevant presidential 
directives and federal-agency documents like the National 
Biosurveillance Strategy for Human Health, along with our prior work 
and recommendations on building and maintaining a national 
biosurveillance capability. We determined that such assessment is 
called for in HSPD-10 and CDC's National Biosurveillance Strategy for 
Human Health[Footnote 45] and is a critical activity for developing an 
effective national strategy containing the elements we advocated in 
prior work on national strategies.[Footnote 46] To determine what 
types of assessment activities had been undertaken and whether an 
enterprisewide assessment of biosurveillance of nonfederal 
capabilities had been conducted, we reviewed relevant assessments and 
federal documents like the Council of State and Territorial 
Epidemiologist's 2009 National Assessment of Epidemiology Capacity and 
CDC's Public Health Preparedness series. In addition, we interviewed 
federal officials at all five federal departments, state officials in 
each of the seven states, city officials in the two cities, and 
officials at 10 professional and research institutions that include 
public health, animal health, or laboratories in their missions about 
assessment efforts, including whether they had participated in or had 
any familiarity with an enterprisewide assessment of nonfederal 
capabilities. 

We conducted this performance audit from August 2010 to October 2011 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

[End of section] 

Appendix II: Laboratories, Laboratory Networks, and Their Roles in 
Biosurveillance: 

Public-health and animal-health laboratories serve a critical role in 
both initial detection and ongoing situational awareness of biological 
events. 

Table 7: Laboratories and Laboratory Networks: 

Laboratory: Public-health laboratories; Role in biosurveillance: 
Public-health laboratories are state and local governmental health 
labs that conduct complex testing to protect the public from diseases 
and other health threats. Public-health laboratories serve as the 
nation's early warning system for diseases and other health hazards. 
They protect our health by monitoring continuously for diseases and 
other health hazards. Public-health laboratories work very closely 
with the Centers for Disease Control and Prevention (CDC) and other 
federal health agencies. 

Laboratory: Veterinary diagnostic laboratories; Role in 
biosurveillance: Each state has a publicly funded veterinary 
diagnostic laboratory, but the sizes and diagnostic capabilities of 
these laboratories vary widely. Certain laboratories specialize by 
species, based on the local needs within a specified geographic area, 
but the majority of state laboratories cover a broad range of species 
and conditions. In most states, animal-health diagnostic laboratories 
are associated with state departments of agriculture and, depending on 
the state, are located at veterinary colleges, land-grant university 
departments of veterinary science, or state agencies for public 
health. These facilities handle or forward the majority of specimens 
for diagnosis and monitoring of disease. 

Laboratory: National Veterinary Services Laboratories (NVSL); Role in 
biosurveillance: The NVSL has two testing facilities located in Ames, 
Iowa, and the Foreign Animal Disease Diagnostic Laboratory on Plum 
Island, New York. These laboratories provide diagnostic services and 
serve as reference laboratories for certain infectious diseases. 
Additionally, NVSL oversee and conduct laboratory testing in 
conjunction with federally mandated eradication programs; screen 
samples for the presence of exotic diseases at the request of federal 
and state regulatory staff; assist in investigating unusual 
agricultural animal disease occurrence in the United States; conduct 
testing for routine support of national and state animal-health 
management; and help ensure the United States meets animal export 
requirements. 

Laboratory: U.S. Geological Survey's National Wildlife Health Center; 
Role in biosurveillance: Headquartered in Madison, Wisconsin, with a 
field station in Honolulu, Hawaii, the National Wildlife Health Center 
is a Biological Security Level-Three laboratory (BSL-3) which allows 
investigators to determine causes of wildlife mortality and to work 
with highly infectious disease agents such as plague, West Nile virus, 
and other zoonoses. It also serves as a containment facility for the 
investigation of highly pathogenic, newly discovered disease agents 
for which little information exists. Other responsibilities include: 
research on the ecology of various diseases; public outreach and 
education. 

Laboratory: Department of Health and Human Services/CDC's Laboratory 
Response Network (LRN); 
Role in biosurveillance: LRN is charged with maintaining an integrated 
network of federal, military, state, local, and international 
laboratories that can respond to bioterrorism, chemical terrorism, and 
other public-health emergencies. The biological component of LRN 
provides network capacity to test for biological agents in a variety 
of formats including clinical specimens, and food and environmental 
samples. The laboratories in this component are classified as either 
reference, national, or sentinel laboratories, depending on the types 
of tests that the laboratory can perform and how it handles infectious 
agents.[A] 

Laboratory: U.S. Department of Agriculture's Animal and Plant Health 
Inspection Service and the National Institute of Food and 
Agriculture's (NIFA)[B] National Animal Health Laboratory Network 
(NAHLN); 
Role in biosurveillance: NAHLN is responsible for a functional 
national network of existing veterinary diagnosis laboratories to 
rapidly and accurately detect and report animal diseases of national 
interest. These laboratories include federal, state, and university 
laboratories. Federal laboratories include the NVSL, which serve as 
international reference laboratories and conduct tests and confirm 
tests for other laboratories for certain infectious diseases, such as 
foot-and-mouth disease. 

Laboratory: Integrated Consortium of Laboratory Networks (ICLN); Role 
in biosurveillance: The ICLN is a coordinated and operational system 
of laboratory networks that is designed to provide timely, high- 
quality, and interpretable results for early detection of acts of 
terrorism and other events that require integrated laboratory-response 
capabilities. The ICLN's individual laboratory networks focus on 
detecting biological threat agents that affect humans, animals, or 
plants and that contaminate the air, water, or food supply. The 
laboratory networks that constitute the ICLN are: LRN; NAHLN; U.S. 
Department of Agriculture's Animal and Plant Health Inspection Service 
and NIFA's National Plant Diagnostic Network; U.S. Department of 
Agriculture's Food Safety Inspection Service and Department of Health 
and Human Services's Food and Drug Administration's Food Emergency 
Response Network (FERN); and the Environmental Protection Agency's 
Environmental Response Laboratory Network (ERLN). 

Source: GAO analysis of U.S. government data. 

[A] Reference laboratories can perform tests to detect and confirm the 
presence of a threat agent and ensure a timely response. Sentinel 
laboratories are hospital-based facilities that are in direct contact 
with the public. If these laboratories detect suspicious specimens, 
they forward the suspect samples to reference laboratories. National 
laboratories have unique resources to handle highly infectious 
diseases and to identify and definitively characterize new strains and 
novel agents. 

[B] NIFA is the former U.S. Department of Agriculture Cooperative 
State Research, Education, and Extension Service. 

[End of table] 

[End of section] 

Appendix III: Responses to Follow-Up Questionnaire Concerning Federal 
Programs and Initiatives That May Support Nonfederal Biosurveillance 
Capabilities: 

This appendix contains the results of our follow-up questionnaire for 
each of the four categories of federal programs and initiatives that 
state and city officials identified during interviews. Presented below 
are the questions and response totals to the follow-up questionnaires 
we sent to (1) state and city public-health epidemiology officials 
(called the Epidemiology group in this appendix), (2) state and city 
public-health laboratory officials (the Laboratory group), (3) state 
agriculture officials (the Agriculture group), and (4) state wildlife 
officials (the Wildlife group) by group, and descriptions of the 
federal programs and initiatives listed. 

The content of the questionnaire varied for the different respondent 
groups. For example, public-health officials (the Epidemiology and 
Laboratory groups) were asked about some information sharing and 
analytical products, whereas animal-health officials (the Agriculture 
and Wildlife groups) were asked about others. This was based on 
earlier interviews with these different groups of officials. Of the 27 
officials who responded to these questionnaires, 7 were from the 
Epidemiology group, 7 were from the Laboratory group, 6 were from the 
Agriculture group, and 7 were from the Wildlife group. For more detail 
on the method by which these questionnaires were administered, see 
appendix I. 

[Side bar: Response Options on Follow-up Questionnaire for Federal 
Programs and Initiatives: 
Supports Core Capabilities: This federal support is essential to core 
biosurveillance capabilities. Without this support, it would not be 
possible to carry out core functions or those functions would be 
significantly diminished. 

Supports Capability Enhancement: Without this support, core functions 
are adequately maintained, but enhanced biosurveillance methods and 
mechanisms cannot be built or maintained. 

Not Used To Support Capabilities: The federal government provides this 
type of support to your jurisdiction, but it is not used to support or 
to enhance biosurveillance capabilities. 

Support Not Received: Your jurisdiction does not receive this type of 
support from the federal government. 

Do Not Know: You are not familiar with the federal support or its 
function falls too far outside your role and responsibilities to offer 
perspective on how it contributes to biosurveillance capabilities. 

Source: GAO. End of side bar] 

Table 8 shows response from the public-health Epidemiology and 
Laboratory groups to the following question concerning Information 
Sharing & Analytical Products: How, if at all, has each of the 
following items supported biosurveillance capabilities in your area of 
responsibility over the last 2 years? (Note: This category-- 
Information Sharing and Analytical Products--includes those federally- 
supported mechanisms used to share information and data regarding 
disease trends and patterns.) 

Table 8: Responses from the Epidemiology and Laboratory Groups 
Concerning Information Sharing and Analytical Products: 

Information-sharing tools and analytical products: CaliciNet; 
Description: To increase the quality of national norovirus 
surveillance, the Centers for Disease Control and Prevention (CDC) has 
developed and implemented an electronic norovirus outbreak 
surveillance network, CaliciNet, with state and local public-health 
laboratories. This network compares norovirus sequences to be able to 
rapidly link norovirus outbreaks with a common food source as well as 
to identify emerging norovirus strains; Number of respondents who 
selected each of the following options: Group: Epidemiology; 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 1 of 7; Not used to support 
capabilities/Support not received/Do not know: 3 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 3 of 7; Not used to support 
capabilities/Support not received/Do not know: 3 of 7. 

Information-sharing tools and analytical products: CDC's Health Alert 
Network; 
Description: The Health Alert Network is a nationwide system serving 
as a platform for the distribution of health alerts. Among other 
things, the network is to provide early warning alerts and to secure 
capability to securely transmit surveillance, laboratory, and other 
sensitive data; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 2 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 4 of 7; 
Supports capability enhancement: 2 of 7; Not used to support 
capabilities/Support not received/Do not know: 1 of 7. 

Information-sharing tools and analytical products: Conference calls 
with federal agencies; 
Description: Some federal agencies conduct regular conference calls or 
organize calls during an event--such as a flu outbreak--to facilitate 
the sharing of information; 
Number of respondents who selected each of the following options: 
Group: 
Epidemiology; 
Supports core capabilities: 4 of 7; 
Supports capability enhancement: 3 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 3 of 7; Not used to support 
capabilities/Support not received/Do not know: 1 of 7. 

Information-sharing tools and analytical products: Conference calls 
with national associations in which federal officials also 
participate; Description: Some national associations conduct regular 
conference calls or organize calls to address specific issues--such as 
the updating of the national notifiable disease list--to facilitate 
the sharing of information; 
Number of respondents who selected each of the following options: 
Group: Epidemiology; 
Supports core capabilities: 4 of 7; 
Number of respondents who selected each of the following options: 
Supports capability enhancement: 3 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 2 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7. 

Information-sharing tools and analytical products: Direct information 
sharing by individual federal officials; Description: Some state and 
local officials have developed relationships with individual federal 
officials with whom they may call or e-mail to discuss specific issues 
and share information.; Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 4 of 7; 
Supports capability enhancement: 3 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 5 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7. 

Information-sharing tools and analytical products: Electronic 
Laboratory Exchange Network (eLEXNET); Description: eLEXNET provides a 
web-based system for real-time sharing of food-safety laboratory data 
among federal, state, and local agencies. It allows public-health 
officials at multiple government agencies engaged in food-safety 
activities to compare and coordinate laboratory analysis findings in a 
secure setting. eLEXNET captures food-safety sample and test-result 
data from participating laboratories and uses them for risk-assessment 
and decision-support purposes, improving the early detection of 
problem products.; Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 1 of 7; Not used to support 
capabilities/Support not received/Do not know: 5 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 3 of 7; Not used to support 
capabilities/Support not received/Do not know: 3 of 7. 

Information-sharing tools and analytical products: Environmental 
Response Laboratory Network (ERLN); 
Description: ERLN provides federal, state, and local decision makers 
with reliable analytical data used to identify chemical, biological, 
and radiological contaminants collected in support of response and 
clean-up activities. ERLN goals include providing laboratory testing 
capability and capacity to meet the Environmental Protection Agency's 
responsibilities for surveillance, response, decontamination, and 
recovery from incidents involving the release of chemical, biological, 
or radiological contaminants; facilitating the coordination of labs 
capable of responding efficiently and effectively to incidents; and 
establishing relationships and priorities with other federal 
laboratory networks; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 1 of 7; Not used to support 
capabilities/Support not received/Do not know: 5 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 2 of 7; Not used to support 
capabilities/Support not received/Do not know: 3 of 7. 

Information-sharing tools and analytical products: Epidemic 
Information Exchange (Epi-X); 
Description: Epi-X connects state and local public-health officials so 
that they can share information about outbreaks and other acute health 
events, including those possibly related to bioterrorism. It is 
intended to provide epidemiologists and others with a secure, web- 
based platform that can be used to provide emergency notification of 
outbreaks and requests for CDC assistance. Epi-X provides tools for 
searching, tracking, and reporting on diseases; Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 5 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 4 of 7; Not used to support 
capabilities/Support not received/Do not know: 2 of 7. 

Information-sharing tools and analytical products: FluView; 
Description: CDC collects, compiles, and analyzes information on 
influenza activity year round in the United States and produces 
FluView, a weekly influenza surveillance report, from October through 
mid-May. The collection of these data enables CDC to: find out when 
and where influenza activity is occurring, track influenza-related 
illness, determine what influenza viruses are circulating, detect 
changes in influenza viruses, measure the effect influenza is having 
on deaths in the United States; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 4 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 2 of 7; Not used to support 
capabilities/Support not received/Do not know: 4 of 7. 

Information-sharing tools and analytical products: Food Emergency 
Response Network (FERN); 
Description: FERN integrates the nation's food-testing laboratories at 
the federal, state, and local levels into a network that is able to 
respond to emergencies involving biological, chemical, or radiological 
contamination of food. The network also seeks to strengthen laboratory 
capacities and capabilities, as well as act as surge capacity; Group: 
Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 1 of 7; Not used to support 
capabilities/Support not received/Do not know: 4 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 4 of 7; 
Supports capability enhancement: 1 of 7; Not used to support 
capabilities/Support not received/Do not know: 2 of 7. 

Information-sharing tools and analytical products: Foodborne Disease 
Active Surveillance Network (FoodNet); Description: FoodNet provides a 
network for responding to new and emerging foodborne diseases of 
national importance, monitoring the burden of foodborne disease, and 
identifying the sources of specific foodborne diseases. It consists of 
active surveillance and related epidemiological studies, which help 
public-health officials better understand the epidemiology of 
foodborne diseases in the United States. Participating FoodNet sites 
may also be employed to coordinate enhanced surveillance and 
epidemiologic investigation if a novel foodborne disease threat is 
suspected in order to more rapidly identify the source and extent of 
the threat; Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 2 of 7; Not used to support 
capabilities/Support not received/Do not know: 3 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 2 of 7; Not used to support 
capabilities/Support not received/Do not know: 3 of 7. 

Information-sharing tools and analytical products: Graphs and maps 
produced from the National Electronic Disease Surveillance System 
(NEDSS)[A] and other nationally notifiable data; Description: CDC 
publishes graphs depicting disease trends, and disease incidence 
rates, as well as maps of the United States that identify the 
locations of disease incidence, which are based on data collected 
through NEDSS and other systems; Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 3 of 7; Not used to support 
capabilities/Support not received/Do not know: 1 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 4 of 7; Not used to support 
capabilities/Support not received/Do not know: 3 of 7. 

Information-sharing tools and analytical products: Homeland Security 
Information Network; 
Description: The Homeland Security Information Network is a national 
secure and trusted web-based portal for information sharing and 
collaboration between federal, state, local, tribal, territorial, 
private sector, and international partners engaged in the homeland 
security mission; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 1 of 7; Not used to support 
capabilities/Support not received/Do not know: 5 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 2 of 7; Not used to support 
capabilities/Support not received/Do not know: 5 of 7. 

Information-sharing tools and analytical products: Influenza-like 
Illness Surveillance Program (ILINet); Description: ILINet is an 
electronic reporting system developed by CDC to conduct surveillance 
for influenza-like illness. CDC is able to use the information 
collected from ILINet Providers to estimate influenza-like illness on 
a national and regional scale and to analyze data for trends in 
influenza-like illness prevalence; Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 4 of 7; 
Supports capability enhancement: 3 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 0 of 7; Not used to support 
capabilities/Support not received/Do not know: 4 of 7. 

Information-sharing tools and analytical products: Laboratory Response 
Network (LRN)[B] Results Messenger; 
Description: LRN Results Messenger is a software solution created to 
provide LRN labs with the immediate ability to manage and share 
standard laboratory data. LRN Results Manager provides basic 
laboratory data management, including the ability to enter and share 
sample and results data; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 1 of 7; Not used to support 
capabilities/Support not received/Do not know: 3 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 6 of 7; 
Supports capability enhancement: 1 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7. 

Information-sharing tools and analytical products: Morbidity and 
Mortality Weekly Report (MMWR); 
Description: MMWR is a public-health bulletin published by CDC. The 
MMWR includes reports on disease epidemics, trends, prevention and 
control of illness, injuries, and deaths. This information represents 
the primary manner that state and local public-health officials, the 
media, and the public are informed of public-health issues from CDC. 
The MMWR publishes data from the National Notifiable Disease 
Surveillance System each week and in an annual Summary of Notifiable 
Diseases. These data are the official statistics, in tabular and 
graphic form, for the reported occurrence of nationally notifiable 
infectious diseases in the United States; Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 3 of 7; Not used to support 
capabilities/Support not received/Do not know: 1 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 4 of 7; Not used to support 
capabilities/Support not received/Do not know: 2 of 7. 

Information-sharing tools and analytical products: PulseNet; 
Description: PulseNet is an early warning system for outbreaks of 
foodborne diseases. The network has participants from public-health 
laboratories in all 50 states, federal regulatory agencies, and some 
state agricultural laboratories and is coordinated by CDC. PulseNet 
contributes to the identification and investigation of outbreaks of 
foodborne and bacterial diseases through comparison of the molecular 
"fingerprints" of foodborne pathogens from patients and their food, 
water, and animal sources; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 7 of 7; 
Supports capability enhancement: 0 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 7 of 7; 
Supports capability enhancement: 0 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7. 

Information-sharing tools and analytical products: TB Genotyping 
Information Management System (TB GIMS); Description: TB GIMS is a 
secure web-based system designed to improve access and dissemination 
of genotyping information nationwide. The system stores and manages 
genotyping data on TB patients in the United States, provides 
immediate notification of genotyping results and updates to TB labs 
and programs, links isolate data to patient-level surveillance data, 
provides reports on genotype clusters, and provides national, state, 
and county maps of genotype clusters; Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 4 of 7; 
Supports capability enhancement: 0 of 7; Not used to support 
capabilities/Support not received/Do not know: 3 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 0 of 7; Not used to support 
capabilities/Support not received/Do not know: 5 of 7. 

Information-sharing tools and analytical products: Working groups 
organized by federal agencies; 
Description: Some federal agencies organize working groups that bring 
together federal, state, and local officials to work on a specific 
issue--such as the State, Local, Territorial and Tribal Working 
Group[C] that helped CDC develop the National Biosurveillance Strategy 
for Human Health and the accompanying Concept Plan for Implementation; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 5 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 2 of 7; Not used to support 
capabilities/Support not received/Do not know: 2 of 7. 

Source: GAO. 

[A] NEDSS (National Electronic Disease Surveillance System) is an 
Internet-based infrastructure for public-health surveillance data 
exchange that uses specific PHIN (Public Health Information Network) 
and NEDSS Data Standards. NEDSS is not a single, monolithic 
application, but a system of interoperable subsystems, components and 
systems modules that include software applications developed and 
implemented by CDC; those developed and implemented by state and local 
health departments; and those created by commercial services and 
vendors. 

[B] LRN is charged with maintaining an integrated network of federal, 
military, state, local, and international laboratories that can 
respond to bioterrorism, chemical terrorism, and other public-health 
emergencies. The biological component of LRN provides network capacity 
to test for biological agents in a variety of formats including 
clinical specimens, and food and environmental samples. The 
laboratories in this component are classified as either reference, 
national, or sentinel laboratories, depending on the types of tests 
that the laboratory can perform and how it handles infectious agents: 

[C] The State, Local, Territorial and Tribal Working Group members 
provided input regarding the development of a national biosurveillance 
capability from the state and local public-health and medical 
perspectives. This work group consisted of both governmental public- 
health and clinical-medicine entities. Several members were employed 
by state, tribal, territorial, or local government agencies. Others, 
although they do not officially represent their organizations, were 
employed by academic, private, and national professional institutions. 

[End of table] 

Table 9 shows responses from the Agriculture and Wildlife groups to 
the following question concerning Information Sharing & Analytical 
Products: How, if at all, has each of the following items supported 
biosurveillance capabilities in your area of responsibility over the 
last 2 years? (Note: This category--Information Sharing and Analytical 
Products--includes those federally-supported mechanisms used to share 
information and data regarding disease trends and patterns.) 

Table 9: Responses from the Agriculture and Wildlife Groups Concerning 
Information Sharing and Analytical Products: 

Information sharing tools & analytical products: Arboviral 
Surveillance System (ArboNet); 
Description: ArboNet is an Internet-based national arboviral 
surveillance system developed by state health departments and CDC in 
2000. ArboNet collects reports of arboviral diseases and other data 
from all states and three local districts (New York City; Washington, 
D.C.; 
and Puerto Rico). Data are reported by local health departments weekly 
for routine analysis and dissemination; Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 6; 
Supports capability enhancement: 2 of 6; Not used to support 
capabilities/Support not received/Do not know: 1 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
 Supports capability enhancement: 1 of 7; Not used to support 
capabilities/Support not received/Do not know: 5 of 7. 

Information sharing tools & analytical products: Direct information 
sharing by individual federal officials; Description: Some state 
officials have developed relationships with individual federal 
officials with whom they may call or e-mail to discuss specific issues 
and share information; Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 4 of 6; 
Supports capability enhancement: 1 of 6; Not used to support 
capabilities/Support not received/Do not know: 1 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 4 of 7; Not used to support 
capabilities/Support not received/Do not know: 0 of 7. 

Information sharing tools & analytical products: Information and 
reports of disease occurrence from the Southeastern Cooperative 
Wildlife Disease Study (SCWDS); 
Description: SCWDS, which receives funding from the Department of the 
Interior and the United States Geological Survey (USGS) National 
Wildlife Health Center, provides reports and coverage maps that 
identify disease occurrence for select diseases; Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 6; 
Supports capability enhancement: 4 of 6; Not used to support 
capabilities/Support not received/Do not know: 1 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 1 of 7; Not used to support 
capabilities/Support not received/Do not know: 1 of 7. 

Information sharing tools & analytical products: Meetings and 
conferences sponsored by professional associations; Description: 
Professional associations sponsor meetings and conferences, in 
association with federal partners. In addition to providing 
information about a specific topic, these events help foster 
information sharing between state and federal officials; Group: 
Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 6; 
Supports capability enhancement: 1 of 6; Not used to support 
capabilities/Support not received/Do not know: 0 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 5 of 7; Not used to support 
capabilities/Support not received/Do not know: 1 of 7. 

Information sharing tools & analytical products: Morbidity and 
mortality reports from CDC regarding zoonotic diseases; Description: 
CDC provides the MMWR on its website. The MMWR identifies cases of 
several diseases in humans, including zoonotic diseases such as 
brucellosis, West Nile virus, and plague, and in some cases provides 
disease counts by state; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 6; 
Supports capability enhancement: 2 of 6; Not used to support 
capabilities/Support not received/Do not know: 3 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 5 of 7; Not used to support 
capabilities/Support not received/Do not know: 1 of 7. 

Information sharing tools & analytical products: National Animal 
Health Reporting System (NAHRS) and associated reports; Description: 
United States Department of Agriculture's (USDA) NAHRS is a 
comprehensive reporting system for World Organization for Animal 
Health (OIE)-reportable diseases in the United States. Under NAHRS, 
participating state animal-health officials report monthly on the 
occurrence of confirmed OIE-reportable diseases in U.S. livestock, 
poultry, and aquaculture species. States receive a monthly report from 
this system; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 4 of 6; 
Supports capability enhancement: 1 of 6; Not used to support 
capabilities/Support not received/Do not know: 1 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 4 of 7; Not used to support 
capabilities/Support not received/Do not know: 2 of 7. 

Information sharing tools & analytical products: State-by-state 
reports of disease occurrence for select diseases; Description: 
Federal agencies, such as USDA, provide state-by-state reports of 
disease occurrence for select diseases that include case counts. For 
example, USDA's Wildlife Services provides reports and coverage maps 
of select disease in wildlife that pose a risk to humans and livestock; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 4 of 6; 
Supports capability enhancement: 1 of 6; Not used to support 
capabilities/Support not received/Do not know: 1 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 4 of 7; Not used to support 
capabilities Support not received Do not know: 2 of 7. 

Information sharing tools & analytical products: USDA Veterinary 
Service Laboratory Submissions website; Description: State officials 
can submit and access disease data, such as avian influenza data, 
through the USDA Veterinary Services Laboratory Submissions site; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 6; 
Supports capability enhancement: 1 of 6; Not used to support 
capabilities/Support not /Do not know: 0 of 6; Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 2 of 7; Not used to support 
capabilities Support not received/Do not know: 4 of 7. 

Information sharing tools & analytical products: USGS National 
Biological Information Infrastructure; Description: The USGS National 
Biological Information Infrastructure is a broad, collaborative 
program to provide increased access to data and information on the 
nation's biological resources. The USGS National Biological 
Information Infrastructure links diverse, high-quality biological 
databases, information products, and analytical tools maintained by 
partners and other contributors in government agencies, academic 
institutions, nongovernment organizations, and private industry.; 
Group: Agriculture; 
Number of respondents who selected each of the following options:: 
Supports core capabilities: 0 of 6; 
Number of respondents who selected each of the following options:: 
Supports capability enhancement: 0 of 6; Number of respondents who 
selected each of the following options:: Not used to support 
capabilities/Support not received/Do not know: 6 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options:: 
Supports core capabilities: 1 of 7; 
Number of respondents who selected each of the following options:: 
Supports capability enhancement: 2 of 7; Number of respondents who 
selected each of the following options:: Not used to support 
capabilities/Support not received/Do not know: 4 of 7. 

Information sharing tools & analytical products: USGS National 
Wildlife Health Center website; 
Description: State officials can visit the USGS National Wildlife 
Health Center website to obtain information about disease trends, 
learn about emerging diseases in wildlife, and obtain fact sheets on 
diseases. The National Wildlife Health Center also provides Wildlife 
Morbidity and Mortality Quarterly Reports on its website as well as 
online databases such as avian influenza surveillance data in wild 
birds.; 
Group: Agriculture; 
Number of respondents who selected each of the following options:: 
Supports core capabilities: 0 of 6; 
Number of respondents who selected each of the following options:: 
Supports capability enhancement: 2 of 6; Number of respondents who 
selected each of the following options:: Not used to support 
capabilities/Support not received/Do not know: 4 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options:: 
Supports core capabilities: 3 of 7; 
Number of respondents who selected each of the following options:: 
Supports capability enhancement: 4 of 7; Number of respondents who 
selected each of the following options:: Not used to support 
capabilities/Support not received/Do not know: 0 of 7. 

[End of table] 

Source: GAO. 

Table 10 shows responses from the public health Epidemiology and 
Laboratory groups to the following question concerning Nonfinancial 
Technical & Material Assistance: How, if at all, has each of the 
following items supported biosurveillance capabilities in your area of 
responsibility over the last 2 years? (Note: This category-- 
Nonfinancial Technical & Material Assistance--includes those types of 
technical assistance [e.g., training and subject-matter expertise] and 
material assistance [e.g., supplies and equipment] that support the 
development and maintenance of biosurveillance capabilities.) 

Table 10: Responses from the Epidemiology and Laboratory Groups 
Concerning Nonfinancial Assistance: 

Type of nonfinancial assistance: Conferences; 
Description: Federal agencies and national associations sponsor 
conferences that state and local officials attend in order to, among 
other things, learn about new issues, share information, and make new 
connections with other officials; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 4 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Type of nonfinancial assistance: Exercises; 
Description: Federal agencies sponsor exercises in which state or 
local officials participate to practice responding to a specific 
situation, such as a terrorist attack. These exercises enable state or 
local officials to then evaluate their response efforts and identify 
gaps; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 3 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 4 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7. 

Type of nonfinancial assistance: Expert consultation for 
epidemiological investigation; 
Description: CDC provides support to state and local officials during 
outbreaks through conference calls, one-on-one discussions, and the 
provision of epidemiology aides to assist public-health departments 
with their investigations; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 6 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7. 

Type of nonfinancial assistance: Expert information-technology 
consultation; 
Description: CDC provides expert information-technology consultation 
to states and localities when they are developing new electronic 
systems, such as syndromic surveillance systems; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 3 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 4 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Type of nonfinancial assistance: Expert laboratory consultation; 
Description: CDC provides expert laboratory-consultation services, 
such as advice about sampling methods, to state and local public- 
health officials to help improve testing capabilities; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 2 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 6 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Type of nonfinancial assistance: Laboratory equipment; 
Description: CDC supplies state public-health laboratories with 
critical reagents and assays for a wide variety of laboratory tests to 
ensure laboratory tests are properly conducted; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 6 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 7 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Type of nonfinancial assistance: Laboratory testing of specimens with 
unusual characteristics; 
Description: CDC provides laboratory testing support to states and 
localities, including the testing of specimens with unusual 
characteristics, which may be difficult for state or local 
laboratories to identify; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 7 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Type of nonfinancial assistance: Legal/Regulatory; 
Description: Federal agencies may provide legal or regulatory support, 
such as model regulations, for states; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 3 of 7; 
Not used to support capabilities/Support not received/Do not know: 3 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 4 of 7; 
Not used to support capabilities/Support not received/Do not know: 3 
of 7. 

Type of nonfinancial assistance: Personnel to enhance epidemiologic 
capacity; 
Description: CDC provides personnel, such as Epidemic Intelligence 
Service officers, to states to enhance their disease-investigation 
capacity. For example, the Epidemic Intelligence Service is a 2-year 
postgraduate on-the-job training program for health professionals 
interested in the practice of applied epidemiology. Epidemic 
Intelligence Service officers conduct epidemiologic investigations, 
research, and public-health surveillance and increase the 
epidemiologic capacity of the state; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 3; 
Supports capability enhancement: 3 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 3 
of 7. 

Type of nonfinancial assistance: Secondary laboratory confirmation; 
Description: CDC provides secondary laboratory confirmation-testing 
support to state and local public-health departments to confirm 
unusual diseases or to verify positive test results for select agents--
biological agents and toxins that have the potential to pose a severe 
health threat; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 6 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 7 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Type of nonfinancial assistance: Standards to improve disease 
reporting; 
Description: Federal agencies develop standards, such as the Public 
Health Information Network (PHIN), to improve disease reporting and 
information sharing. The PHIN is a national initiative to improve the 
capacity of public health to use and exchange information 
electronically by promoting the use of standards and defining 
functional and technical requirements; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 4 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 4 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7. 

Type of nonfinancial assistance: Systems to enhance epidemiologic 
capacity; 
Description: CDC develops and provides systems, such as the Early 
Aberration Reporting System, to enhance state and local epidemiologic 
capacity. The Early Aberration Reporting System assists state and 
local officials with their analysis of surveillance data; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 3 of 7; 
Not used to support capabilities/Support not received/Do not know: 3 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 5 
of 7. 

Type of nonfinancial assistance: Tools to support epidemiologic 
investigations; 
Description: CDC provides tools, such as Epi Info, to support state 
and local epidemiologic investigations. Epi Info provides public-
health workers with a means to quickly create data-collection 
instruments, conduct data analysis, and report results during an 
epidemiologic investigation; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 4 
of 7. 

Type of nonfinancial assistance: Training; 
Description: Federal agencies provide various types of training 
opportunities to state and local officials, including training that 
covers new sampling and testing methods, new reporting standards, or 
safety standards; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 4 of 7; 
Supports capability enhancement: 3 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 7 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Source: GAO. 

[End of table] 

Table 11 shows responses from the Agriculture and Wildlife groups to 
the following question concerning Nonfinancial Technical & Material 
Assistance: How, if at all, has each of the following items supported 
biosurveillance capabilities in your area of responsibility over the 
last 2 years? (Note: This category--Nonfinancial Technical & Material 
Assistance--includes those types of technical assistance [e.g., 
training and subject-matter expertise] and material assistance [e.g., 
supplies and equipment] that support the development and maintenance 
of biosurveillance capabilities.) 

Table 11: Responses from the Agriculture and Wildlife Groups 
Concerning Nonfinancial Assistance: 

Type of nonfinancial assistance: Conferences; 
Description: Federal agencies and national associations sponsor 
conferences that state and local officials attend in order to, among 
other things, learn about new issues, share information, and make new 
connections with other officials; 
Group: Agriculture; 
:
2 of 6; 
:Supports capability enhancement: 3 of 6; 
:Not used to support capabilities/Support not received/Do not know: 1 
of 6. 

Group: Wildlife; 
:
0 of 7; 
:Supports capability enhancement: 5 of 7; 
:Not used to support capabilities/Support not received/Do not know: 2 
of 7. 

Type of nonfinancial assistance: Disease guides describing clinical 
signs of diseases for easier identification, and other technical 
information; 
Description: The USGS National Wildlife Health Center makes available 
guides on wildlife diseases, such as the Field Manual of Wildlife 
Diseases: General Field Procedures and Diseases of Birds, and fact 
sheets on diseases, such as chronic wasting disease, that provide 
information on clinical signs, diagnosis, and management of wildlife 
diseases. In addition, USDA's Wildlife Services provides fact sheets 
on wildlife diseases and manuals for conducting surveillance for 
select wildlife diseases; 
Group: Agriculture; 
3 of 6; 
:Supports capability enhancement: 3 of 6; 
:Not used to support capabilities/Support not received/Do not know: 0 
of 6. 

Group: Wildlife; 
2 of 7; 
:Supports capability enhancement: 5 of 7; 
:Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Type of nonfinancial assistance: Equipment and supplies; 
Description: Federal agencies provide states with equipment and 
supplies, such as sampling kits, assays, and personal protective 
equipment, to help states conduct outbreak investigations; 
Group: Agriculture; 
5 of 6; 
:Supports capability enhancement: 0 of 6; 
:Not used to support capabilities/Support not received/Do not know: 1 
of 6. 

Group: Wildlife; 
2 of 7; 
:Supports capability enhancement: 2 of 7; 
:Not used to support capabilities/Support not received/Do not know: 3 
of 7. 

Type of nonfinancial assistance: Exercises; 
Description: Federal agencies sponsor simulations and drills in which 
participants practice responding to a specific situation, such as a 
terrorist attack. These exercises enable state or local officials to 
then evaluate their response efforts and identify gaps; 
Group: Agriculture; 
2 of 6; 
:Supports capability enhancement: 3 of 6; 
:Not used to support capabilities/Support not received/Do not know: 1 
of 6. 

Group: Wildlife; 
0 of 7; 
:Supports capability enhancement: 1 of 7; 
:Not used to support capabilities/Support not received/Do not know: 6 
of 7. 

Type of nonfinancial assistance: Field support; 
Description: Federal agencies provide field support to states to 
enhance their disease-investigation capacity. For example, federal 
agencies may send additional biologists to help collect samples during 
a disease outbreak; 
Group: Agriculture; 
3 of 6; 
:Supports capability enhancement: 2 of 6; 
:Not used to support capabilities/Support not received/Do not know: 1 
of 6. 

Group: Wildlife; 
1 of 7; 
:Supports capability enhancement: 3 of 7; 
:Not used to support capabilities/Support not received/Do not know: 3 
of 7. 

Type of nonfinancial assistance: Information technology expertise; 
Description: Federal agencies provide expert information-technology 
consultation to states when they are developing new electronic 
systems, such as assistance for establishing or upgrading case- 
management systems; 
Group: Agriculture; 
2 of 6; 
:Supports capability enhancement: 3 of 6; 
:Not used to support capabilities/Support not received/Do not know: 1 
of 6. 

Group: Wildlife; 
0 of 7; 
:Supports capability enhancement: 2 of 7; 
:Not used to support capabilities/Support not received/Do not know: 5 
of 7. 

Type of nonfinancial assistance: Laboratory testing; 
Description: Several federal laboratories support states' efforts to 
diagnose a disease. For example, the National Veterinary Services 
Laboratory (NVSL) is a federal reference laboratory--a laboratory that 
conducts and confirms tests for other laboratories. The Foreign Animal 
Disease Diagnostic Laboratory tests for highly contagious diseases 
such as foot-and-mouth disease. The USGS National Wildlife Health 
Center is the only federal laboratory in the United States dedicated 
to wildlife-disease investigation and offers laboratory support to 
states for wildlife-disease diagnostics. USDA's Wildlife Services' 
National Wildlife Research Center also has the capacity to provide 
surge diagnostics for wildlife samples when large surveillance 
activities are activated, for example this center conducted most of 
the environmental screening for H5N1 during the avian influenza 
campaign; 
Group: Agriculture; 
4 of 6; 
:Supports capability enhancement: 1 of 6; 
:Not used to support capabilities/Support not received/Do not know: 1 
of 6. 

Group: Wildlife; 
3 of 7; 
:Supports capability enhancement: 4 of 7; 
:Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Type of nonfinancial assistance: Personnel to enhance disease 
investigation capacity; 
Description: Federal agencies provide personnel to states to enhance 
their disease-investigation capacity. For example, Veterinary Services 
Area Officers from USDA conduct disease surveillance and respond to 
emergency animal-disease outbreaks at the state level. USDA Wildlife 
Services's National Wildlife Disease Program has wildlife disease 
biologists across the country, often colocated with state agencies, to 
assist with planning and conducting surveillance to detect wildlife 
diseases that may threaten human health or agricultural resources. In 
addition, the Wildlife Disease Specialists from the USGS National 
Wildlife Health Center conduct disease-surveillance efforts in the 
field and provide expert disease knowledge with state officials to 
help diagnose diseases in wildlife; 
Group: Agriculture; 
4 of 6; 
:Supports capability enhancement: 2 of 6; 
:Not used to support capabilities/Support not received/Do not know: 0 
of 6. 

Group: Wildlife; 
2 of 7; 
:Supports capability enhancement: 4 of 7; 
:Not used to support capabilities/Support not received/Do not know: 1 
of 7. 

Type of nonfinancial assistance: Subject-matter expertise for 
investigations, sampling, and testing; 
Description: Federal agencies assist state animal-health officials 
with their disease investigations by providing subject-matter 
expertise for sampling, testing, and disease knowledge; 
Group: Agriculture; 
2 of 6; 
:Supports capability enhancement: 3 of 6; 
:Not used to support capabilities/Support not received/Do not know: 1 
of 6. 

Group: Wildlife; 
1 of 7; 
:Supports capability enhancement: 6 of 7; 
:Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Type of nonfinancial assistance: Training; 
Description: Federal agencies deliver or sponsor various training to 
state and local officials, including training that covers new sampling 
and testing methods, new reporting standards, or safety standards; 
Group: Agriculture; 
3 of 6; 
:Supports capability enhancement: 2 of 6; 
:Not used to support capabilities/Support not received/Do not know: 1 
of 6. 

Group: Wildlife; 
2 of 7; 
:Supports capability enhancement: 4 of 7; 
:Not used to support capabilities/Support not received/Do not know: 1 
of 7. 

[End of table] 

Source: GAO. 

Table 12 shows responses from the public-health Epidemiology and 
Laboratory groups to the following question concerning Grants & 
Cooperative Agreements: How, if at all, has each of the following 
items supported biosurveillance capabilities in your area of 
responsibility over the last 2 years? (Note: This category--Grants & 
Cooperative Agreements--refers to federal funding that may support the 
development and maintenance of biosurveillance capabilities.) 

Table 12: Responses from the Epidemiology and Laboratory Groups 
Concerning Grants and Cooperative Agreements: 

Grant or cooperative agreement: Patient Protection and Affordable Care 
Act's (PPACA) Prevention and Public Health Fund Grants; 
Description: CDC provides funding and capacity-building assistance 
(including technical consultation, skills building /training, 
information, and technology-transfer assistance) through the PPACA 
Prevention and Public Health Fund Grants to help state, tribal, local, 
and territorial health departments improve: (1) the planning, 
coordination, and implementation of public health infrastructure 
investments; and (2) the evaluation (including dissemination of best 
practices) of public-health infrastructure investments; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 3 
of 7. 

Grant or cooperative agreement: City-Readiness Initiative Program; 
Description: CDC provides funding to the 50 states and four localities 
for the City-Readiness Initiative Program through the Public Health 
Emergency Preparedness (PHEP) cooperative agreement. CDC's Office of 
Public Health Preparedness and Response, Division of State and Local 
Readiness administers the PHEP cooperative agreement, provides annual 
guidance on preparedness activities that support the National Response 
Framework, and coordinates technical assistance; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 5 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 7 
of 7. 

Grant or cooperative agreement: Emerging Infections Program; 
Description: CDC provides funding to Emerging Infections Program 
participants to conduct active population-based surveillance and 
research for emerging infectious diseases of public health importance. 
The Emerging Infections Program is a network of CDC and 10 state 
health departments working with collaborators, including academic 
institutions and other federal agencies; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 2 of 7; 
Not used to support capabilities/Support not received/Do not know: 4 
of 7; 
Group: Laboratory; 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 5 
of 7. 

Grant or cooperative agreement: Epidemiology and Laboratory Capacity 
for Infectious Diseases cooperative agreement (ELC); 
Description: CDC supports public-health capacity by providing public-
health departments funding through the ELC cooperative agreement to 
hire and train staff, buy laboratory equipment and supplies for 
diagnosing emerging pathogens, and invest in information technology to 
improve disease reporting and monitoring. CDC also provides technical 
support and funding, through this cooperative agreement, to states to 
develop and enhance syndromic surveillance systems; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 7 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 7 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Grant or cooperative agreement: Federal funding specifically for the 
development or enhancement of syndromic surveillance systems; 
Description: Federal agencies, such as CDC, provide states with 
funding and technical support to develop and enhance syndromic 
surveillance systems; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 4 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 2 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 4 of 7; 
Not used to support capabilities/Support not received/Do not know: 3 
of 7. 

Grant or cooperative agreement: Food Emergency Response Network (FERN) 
funding; 
Description: USDA and the Department of Health and Human Services 
(HHS) provide laboratory funding for FERN, which integrates the 
nation's food-testing laboratories at the federal, state, and local 
levels into a network that is able to respond to emergencies involving 
biological, chemical, or radiological contamination of food. The 
network also seeks to strengthen laboratory capacities and 
capabilities, as well as act as surge capacity; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 5 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 3 
of 7. 

Grant or cooperative agreement: Hospital Preparedness Program; 
Description: HHS's Office of the Assistant Secretary for Preparedness 
and Response provides funding through the Hospital Preparedness 
Program to states, territories, and eligible municipalities to improve 
surge capacity and enhance community and hospital preparedness for 
public-health emergencies; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 3 of 7; 
Not used to support capabilities/Support not received/Do not know: 3 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 4 of 7; 
Not used to support capabilities/Support not received/Do not know: 2 
of 7. 

Grant or cooperative agreement: Immunization Grant Program (Section 
317); 
Description: The federal government provides funding for all states, 
six cities, territories, and protectorates that provide vaccines to 
underinsured children and adolescents not served by other programs, 
and as funding permits, to uninsured and underinsured adults. The 
funding also supports recipients' efforts to conduct vaccine-
preventable disease--like measles--surveillance; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 6 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 4 
of 7. 

Grant or cooperative agreement: Public Health Emergency Preparedness 
cooperative agreement (PHEP); 
Description: CDC provides funding and technical assistance through the 
PHEP cooperative agreement for the development and strengthening of 
recipients' response capabilities during public-health incidents. PHEP 
awardees include 50 states, 8 territories and freely associated 
states, and 4 localities; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 7 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 7 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Grant or cooperative agreement: Public Health Emergency Response 
funding; 
Description: The Supplemental Appropriations Act, 2009, appropriated 
funding for the "Public Health and Social Services Emergency Fund" to 
prepare for and respond to an influenza pandemic. CDC administered the 
grant to upgrade state and local pandemic-influenza preparedness and 
response capacity. The 62 awardees included 50 states, 8 territories 
and freely associated states, and 4 localities; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7. 

Grant or cooperative agreement: State Homeland Security Grant Program; 
Description: The Department of Homeland Security's (DHS) State 
Homeland Security Grant Program provides funding to support the 
implementation of State Homeland Security Strategies to address the 
identified planning, organization, equipment, training, and exercise 
needs at the state and local levels to prevent, protect against, 
respond to, and recover from acts of terrorism and other catastrophic 
events; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 5 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 5 
of 7. 

Grant or cooperative agreement: Tuberculosis grants; 
Description: CDC provides tuberculosis grants to help state 
laboratories improve their testing ability and to support state 
tuberculosis surveillance and elimination efforts; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 2 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 6 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Grant or cooperative agreement: Urban Areas Security Initiative (UASI); 
Description: UASI provides funding to address the unique planning, 
organization, equipment, training, and exercise needs of high-threat, 
high-density urban areas, and assists them in building an enhanced and 
sustainable capacity to prevent, protect against, respond to, and 
recover from acts of terrorism; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 4 
of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 6 
of 7. 

Source: GAO. 

[End of table] 

Table 13 shows responses from the Agriculture and Wildlife groups to 
the following question concerning Grants & Cooperative Agreements: 
How, if at all, has each of the following items supported 
biosurveillance capabilities in your area of responsibility over the 
last 2 years? (Note: This category--Grants & Cooperative Agreements-- 
refers to federal funding that may support the development and 
maintenance of biosurveillance capabilities.) 

Table 13: Responses from the Agriculture and Wildlife Groups 
Concerning Grants and Cooperative Agreements: 

Grant or cooperative agreement: Animal Health Network funding through 
the National Center for Foreign Animal and Zoonotic Disease Defense 
Center; 
Description: DHS, through the National Center for Foreign Animal and 
Zoonotic Disease Defense, provides funding to states participating in 
the Animal Health Network to help them develop their network. The 
Animal Health Network is a communication conduit for the state 
veterinarian and other officials to get vital animal disease alerts to 
noncommercial livestock and poultry owners; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 6; 
Supports capability enhancement: 1 of 6; 
Not used to support capabilities/Support not received/Do not know: 3 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 7 
of 7. 

Grant or cooperative agreement: Avian influenza cooperative agreement; 
Description: USDA provides funding to states through cooperative 
agreements for expanded bird-monitoring programs, including the 
collection of samples from domesticated and wild birds for avian 
influenza testing; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 6 of 6; 
Supports capability enhancement: 0 of 6; 
Not used to support capabilities/Support not received/Do not know: 0 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7. 

Grant or cooperative agreement: Brucellosis cooperative agreement; 
Description: USDA provides states with funding to conduct continued 
surveillance efforts for brucellosis and to support the cooperative 
federal-state-industry effort to eradicate brucellosis from livestock; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 6; 
Supports capability enhancement: 2 of 6; 
Not used to support capabilities/Support not received/Do not know: 3 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 7 
of 7. 

Grant or cooperative agreement: Chronic wasting disease cooperative 
agreements; 
Description: USDA provides coordination and assistance with research, 
surveillance, disease management, diagnostic testing, technology, 
communications, information dissemination, education, and funding for 
state chronic wasting disease surveillance programs; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 6; 
Supports capability enhancement: 1 of 6; 
Not used to support capabilities/Support not received/Do not know: 2 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 6 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Grant or cooperative agreement: Federal Aid in Wildlife Restoration 
Act funds (Pittman-Robertson Act); 
Description: The act provided that the proceeds of a tax on certain 
ammunition and firearms used for sport hunting be distributed to the 
states and insular areas for wildlife restoration. States use the 
funds to buy, develop, maintain, and operate wildlife-management 
areas--such as conducting passive surveillance and disease-monitoring 
activities; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 6; 
Supports capability enhancement: 0 of 6; 
Not used to support capabilities/Support not received/Do not know: 6 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 6 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 0 
of 7. 

Grant or cooperative agreement: Federal funding passed from public- 
health departments; 
Description: In some instances, state public-health departments 
collaborate with state agriculture or wildlife agencies on specific 
zoonotic disease efforts supported by federal cooperative agreements 
or grants that are received by state public-health departments. State 
public-health departments provide a portion of these funds to support 
the agriculture or wildlife agencies' animal-health monitoring efforts; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 6; 
Supports capability enhancement: 1 of 6; 
Not used to support capabilities/Support not received/Do not know: 4 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 1 of 7; 
Not used to support capabilities/Support not received/Do not know: 6 
of 7. 

Grant or cooperative agreement: Foreign animal disease cooperative 
agreement; 
Description: USDA's Veterinary Services provides states with funding 
and works cooperatively with the state veterinarians in an effort to 
accomplish the goals of the National Animal Health Surveillance 
System--to rapidly detect and conduct surveillance for foreign and 
emerging animal diseases and provide timely and accurate animal-health 
information. The states also quarantine any animals suspected of 
having a foreign animal disease and obtain and submit samples to 
USDA's Animal and Plant Health Inspection Service's NVSL for 
verification; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 5 of 6; 
Supports capability enhancement: 1 of 6; 
Not used to support capabilities/Support not received/Do not know: 0 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 7 
of 7. 

Grant or cooperative agreement: Garbage feeder cooperative agreement; 
Description: USDA provides states with funding to conduct surveillance 
for pseudorabies virus and other diseases in garbage feeders--swine 
that eat food waste; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 6; 
Supports capability enhancement: 1 of 6; 
Not used to support capabilities/Support not received/Do not know: 3 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 7 
of 7. 

Grant or cooperative agreement: National Animal Health Laboratory 
Network (NAHLN) funding; 
Description: USDA's National Institute of Food and Agriculture (NIFA) 
provides funding to states that participate in the NAHLN for 
laboratory equipment, training, and staff. USDA's Animal and Plant 
Health Inspection Services provides operational support for the 
network as well as training, proficiency testing, reference materials, 
equipment, and equipment maintenance, and funding for testing. The 
NAHLN is a network of veterinary state and university laboratories 
conducting surveillance and diagnostic testing to protect the U.S. 
animal agricultural industries; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 6; 
Supports capability enhancement: 2 of 6; 
Not used to support capabilities/Support not received/Do not know: 1 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 6 
of 7. 

Grant or cooperative agreement: Scrapie cooperative agreement; 
Description: USDA provides states with funding to conduct continued 
surveillance efforts for scrapie and to support efforts to eradicate 
scrapie from sheep and goats; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 6; 
Supports capability enhancement: 2 of 6; 
Not used to support capabilities/Support not received/Do not know: 3 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 7 
of 7. 

Grant or cooperative agreement: State Homeland Security Grant Program; 
Description: DHS's State Homeland Security Grant Program provides 
funding to support the implementation of State Homeland Security 
Strategies to address the identified planning, organization, 
equipment, training, and exercise needs at the state and local levels 
to prevent, protect against, respond to, and recover from acts of 
terrorism and other catastrophic events; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 6; 
Supports capability enhancement: 1 of 6; 
Not used to support capabilities/Support not received/Do not know: 2 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 7 
of 7. 

Grant or cooperative agreement: Traceability Cooperative Agreement; 
Description: USDA provides funding through the Traceability 
Cooperative Agreement to advance animal disease traceability by 
supporting the search ability of standardized animal disease 
traceability data within and among states, tribes, and territories; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 6; 
Supports capability enhancement: 3 of 6; 
Not used to support capabilities/Support not received/Do not know: 1 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 7 
of 7. 

Grant or cooperative agreement: Tuberculosis cooperative agreement; 
Description: USDA provides states with funding to conduct continued 
surveillance efforts for tuberculosis and to support the cooperative 
federal-state-industry effort to eradicate bovine tuberculosis from 
cattle; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 2 of 6; 
Supports capability enhancement: 0 of 6; 
Not used to support capabilities/Support not received/Do not know: 4 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 7 
of 7. 

Grant or cooperative agreement: U.S. Fish and Wildlife Service's State 
Wildlife Grant Program; 
Description: The State Wildlife Grant Program provides federal grant 
funds that assist states in the development and implementation of 
programs that benefit state-identified species of greatest 
conservation need and their habitats, including species not hunted or 
fished. Grant funds must be used to address conservation needs, such 
as research, surveys, species and habitat management, and monitoring, 
identified within a state's comprehensive wildlife conservation 
plan/strategy; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 6; 
Supports capability enhancement: 1 of 6; 
Not used to support capabilities/Support not received/Do not know: 5 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 3 of 7; 
Supports capability enhancement: 3 of 7; 
Not used to support capabilities/Support not received/Do not know: 1 
of 7. 

Grant or cooperative agreement: USDA's biosecurity cooperative 
agreements; 
Description: Various USDA components provide cooperative agreements 
for enhancing the response capabilities of state and tribal 
governments to foreign animal diseases, developing or improving 
diagnostic tools for animal and plant pathogens, and developing 
diagnostic and reporting networks for plant and animal pathogens; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 1 of 6; 
Supports capability enhancement: 0 of 6; 
Not used to support capabilities/Support not received/Do not know: 5 
of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Supports core capabilities: 0 of 7; 
Supports capability enhancement: 0 of 7; 
Not used to support capabilities/Support not received/Do not know: 7 
of 7. 

Source: GAO. 

[End of table] 

Table 14 shows responses from public-health Epidemiology and 
Laboratory groups to the following question concerning Guidance: How 
useful, if at all, has each of the following items been in supporting 
biosurveillance capabilities in your area of responsibility over the 
last 2 years? (Note: This category--Guidance--refers to federal 
guidance that helps with the design of biosurveillance programs or 
with the implementation of activities that support biosurveillance 
capabilities.) 

Table 14: Responses from the Epidemiology and Laboratory Groups 
Concerning Guidance: 

Type of guidance: Federal guidance concerning industry information and 
privacy protection; 
Description: Federal agencies provide guidance to help states ensure 
the security and privacy of industry information and individuals' 
health information--such as the Health Insurance Portability and 
Accountability Act (HIPAA)--during disease investigations; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Very useful: 3 of 7; 
Moderately useful: 3 of 7; 
Somewhat useful/Not useful: 1 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Very useful: 2 of 7; 
Moderately useful: 5 of 7; 
Somewhat useful/Not useful: 0 of 7. 

Type of guidance: Federal guidance concerning information-systems 
security; 
Description: Federal agencies have provided guidance concerning the 
protection and security of their information infrastructures; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 7; 
Moderately useful: 4 of 7; 
Somewhat useful/Not useful: 2 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 7; 
Moderately useful: 5 of 7; 
Somewhat useful/Not useful: 1 of 7. 

Type of guidance: Federal guidance for assessing capabilities; 
Description: Federal agencies may provide guidance to states and 
localities for assessing capabilities. For example, CDC's Public 
Health Preparedness Capabilities: National Standards for State and 
Local Planning includes performance metrics for some of the 
capabilities CDC expects states and localities to develop. The 
national standards for public-health preparedness help state and local 
public-health departments assess capabilities, identify gaps, 
determine specific jurisdictional priorities, and develop plans for 
building and sustaining capabilities; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Very useful: 0 of 7; 
Moderately useful: 5 of 7; 
Somewhat useful/Not useful: 2 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Very useful: 2 of 7; 
Moderately useful: 2 of 7; 
Somewhat useful/Not useful: 3 of 7. 

Type of guidance: Federal guidance for best practices for laboratory 
testing protocols; 
Description: Federal agencies provide states and localities with 
guides outlining the best practices for laboratory testing protocols; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Very useful: 3 of 7; 
Moderately useful: 1 of 7; 
Somewhat useful/Not useful: 3 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Very useful: 6 of 7; 
Moderately useful: 1 of 7; 
Somewhat useful/Not useful: 0 of 7. 

Type of guidance: Federal guidance for disease-reporting requirements; 
Description: Federal agencies develop disease-reporting requirements 
for state and local jurisdictions for those diseases posing a serious 
public-health, animal-health, or economic risk for which case reports 
would help inform prevention and control efforts; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Very useful: 5 of 7; 
Moderately useful: 1 of 7; 
Somewhat useful/Not useful: 1 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Very useful: 2 of 7; 
Moderately useful: 3 of 7; 
Somewhat useful/Not useful: 2 of 7. 

Type of guidance: Federal guidance for sampling procedures for unusual 
or emerging disease agents; 
Description: Federal agencies provide states with guidance on the 
appropriate methods for collecting and shipping samples for unusual or 
emerging diseases; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Very useful: 4 of 7; 
Moderately useful: 1 of 7; 
Somewhat useful/Not useful: 2 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Very useful: 3 of 7; 
Moderately useful: 3 of 7; 
Somewhat useful/Not useful: 1 of 7. 

Type of guidance: Federal guidance for standardized case definitions; 
Description: Federal agencies provide guidance for standardizing case 
definitions to improve disease reporting and information sharing. For 
example, CDC published the Case Definitions for Infectious Conditions 
Under Public Health Surveillance, which provides uniform criteria for 
state health department personnel to use when reporting notifiable 
diseases to CDC; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Very useful: 5 of 7; 
Moderately useful: 1 of 7; 
Somewhat useful/Not useful: 1 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Very useful: 4 of 7; 
Moderately useful: 2 of 7; 
Somewhat useful/Not useful: 1 of 7. 

Type of guidance: Federal guidance on how to execute projects that use 
federal funding; 
Description: Federal grants and cooperative agreements may contain 
guidance that outlines specifically how certain funds should be used. 
For example, funding for specific surveillance efforts may contain 
sampling protocols or reporting requirements that states are expected 
to follow; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 7; 
Moderately useful: 3 of 7; 
Somewhat useful/Not useful: 3 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Very useful: 4 of 7; 
Moderately useful: 3 of 7; 
Somewhat useful/Not useful: 0 of 7. 

Type of guidance: Federal guidance regarding methods and mechanisms 
for enhancing timely detection and situational awareness; 
Description: Federal agencies may provide guidance regarding methods 
and mechanisms for enhancing timely detection and situational 
awareness, for example, designing electronic reporting or syndromic 
surveillance systems; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Very useful: 2 of 7; 
Moderately useful: 1 of 7; 
Somewhat useful/Not useful: 4 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 7; 
Moderately useful: 3 of 7; 
Somewhat useful/Not useful: 3 of 7. 

Type of guidance: Federal guidance regarding safety and security 
measures for specimen handling; 
Description: Federal agencies provide states and localities with 
guidance concerning the appropriate methods for handling, storing, and 
shipping specimens; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Very useful: 5 of 7; 
Moderately useful: 0 of 7; 
Somewhat useful/Not useful: 2 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Very useful: 5 of 7; 
Moderately useful: 2 of 7; 
Somewhat useful/Not useful: 0 of 7. 

Type of guidance: Federal priorities, goals, and objectives 
communicated through grant and cooperative agreement guidance; 
Description: Federal grant and cooperative agreement guidance 
generally provides instructions to state agencies about applying for 
and executing federal projects with funding, including federal 
priorities, goals, and objectives for the use of the funding; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Very useful: 2 of 7; 
Moderately useful: 4 of 7; 
Somewhat useful/Not useful: 1 of 7; 
Group: Laboratory; 
Number of respondents who selected each of the following options: 
Very useful: 4 of 7; 
Moderately useful: 3 of 7; 
Somewhat useful/Not useful: 0 of 7. 

Source: GAO. 

[End of table] 

Table 15 shows responses from the Agriculture and Wildlife groups to 
the following question concerning Guidance: How useful, if at all, has 
each of the following items been in supporting biosurveillance 
capabilities in your area of responsibility over the last 2 years? 
(Note: This category--Guidance--refers to federal guidance that helps 
with the design of biosurveillance programs or with the implementation 
of activities that support biosurveillance capabilities.) 

Table 15: Table15: Responses from the Agriculture and Wildlife Groups 
Concerning Guidance: 

Type of guidance: Federal guidance concerning industry information and 
privacy protection; 
Description: Federal agencies provide guidance to help states ensure 
the security and privacy of industry information and individuals' 
health information--such as the Health Insurance Portability and 
Accountability Act (HIPAA)--during disease investigations; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Very useful: 0 of 6; 
Moderately useful: 3 of 6; 
Somewhat useful/Not useful: 3 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 7; 
Moderately useful: 2 of 7; 
Somewhat useful/Not useful: 4 of 7. 

Type of guidance: Federal guidance concerning information-systems 
security; 
Description: Federal agencies have provided guidance concerning the 
protection and security of their information infrastructures; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Very useful: 0 of 6; 
Moderately useful: 4 of 6; 
Somewhat useful/Not useful: 2 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 7; 
Moderately useful: 1 of 7; 
Somewhat useful/Not useful: 5 of 7. 

Type of guidance: Federal guidance for assessing capabilities; 
Description: Federal agencies may provide guidance to states and 
localities for assessing capabilities. For example, CDC's Public 
Health Preparedness Capabilities: National Standards for State and 
Local Planning includes performance metrics for some of the 
capabilities CDC expects states and localities to develop. The 
national standards for public-health preparedness help state and local 
public-health departments assess capabilities, identify gaps, 
determine specific jurisdictional priorities, and develop plans for 
building and sustaining capabilities; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Very useful: 0 of 6; 
Moderately useful: 2 of 6; 
Somewhat useful/Not useful: 4 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 7; 
Moderately useful: 2 of 7; 
Somewhat useful/Not useful: 4 of 7. 

Type of guidance: Federal guidance for best practices for laboratory 
testing protocols; 
Description: Federal agencies provide states and localities with 
guides outlining the best practices for laboratory testing protocols; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Very useful: 2 of 6; 
Moderately useful: 2 of 6; 
Somewhat useful/Not useful: 2 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Very useful: 2 of 7; 
Moderately useful: 3 of 7; 
Somewhat useful/Not useful: 2 of 7. 

Type of guidance: Federal guidance for disease-reporting requirements; 
Description: Federal agencies develop disease reporting requirements 
for state and local jurisdictions for those diseases posing a serious 
public-health, animal-health, or economic risk for which case reports 
would help inform prevention and control efforts; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Very useful: 2 of 6; 
Moderately useful: 4 of 6; 
Somewhat useful/Not useful: 0 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 7; 
Moderately useful: 5 of 7; 
Somewhat useful/Not useful: 1 of 7. 

Type of guidance: Federal guidance for sampling procedures for unusual 
or emerging disease agents; 
Description: Federal agencies provide states with guidance on the 
appropriate methods for collecting and shipping samples for unusual or 
emerging diseases; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Very useful: 3 of 6; 
Moderately useful: 2 of 6; 
Somewhat useful/Not useful: 1 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Very useful: 2 of 7; 
Moderately useful: 4 of 7; 
Somewhat useful/Not useful: 1 of 7. 

Type of guidance: Federal guidance for standardized case definitions; 
Description: Federal agencies provide guidance for standardizing case 
definitions to improve disease reporting and information sharing. For 
example, CDC published the Case Definitions for Infectious Conditions 
Under Public Health Surveillance, which provides uniform criteria for 
state health-department personnel to use when reporting notifiable 
diseases to CDC; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 6; 
Moderately useful: 5 of 6; 
Somewhat useful/Not useful: 0 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 7; 
Moderately useful: 4 of 7; 
Somewhat useful/Not useful: 2 of 7. 

Type of guidance: Federal guidance on how to execute projects that use 
federal funding; 
Description: Federal grants and cooperative agreements may contain 
guidance that outlines specifically how certain funds should be used. 
For example, funding for specific surveillance efforts may contain 
sampling protocols or reporting requirements that states are expected 
to follow; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Very useful: 3 of 6; 
Moderately useful: 2 of 6; 
Somewhat useful/Not useful: 1 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Very useful: 2 of 7; 
Moderately useful: 2 of 7; 
Somewhat useful/Not useful: 3 of 7. 

Type of guidance: Federal guidance regarding methods and mechanisms 
for enhancing timely detection and situational awareness; 
Description: Federal agencies may provide guidance regarding methods 
and mechanisms for enhancing timely detection and situational 
awareness, for example, designing electronic reporting or syndromic-
surveillance systems; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 6; 
Moderately useful: 3 of 6; 
Somewhat useful/Not useful: 2 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 7; 
Moderately useful: 3 of 7; 
Somewhat useful/Not useful: 3 of 7. 

Type of guidance: Federal guidance regarding safety and security 
measures for specimen handling; 
Description: Federal agencies provide states and localities with 
guidance concerning the appropriate methods for handling, storing, and 
shipping specimens; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Very useful: 1 of 6; 
Moderately useful: 2 of 6; 
Somewhat useful/Not useful: 3 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Very useful: 2 of 7; 
Moderately useful: 4 of 7; 
Somewhat useful/Not useful: 1 of 7. 

Type of guidance: Federal priorities, goals, and objectives 
communicated through grant and cooperative agreement guidance; 
Description: Federal grant and cooperative agreement guidance 
generally provides instructions to state agencies about applying for 
and executing federal projects with funding, including federal 
priorities, goals, and objectives for the use of the funding; 
Group: Agriculture; 
Number of respondents who selected each of the following options: 
Very useful: 4 of 6; 
Moderately useful: 1 of 6; 
Somewhat useful/Not useful: 1 of 6; 
Group: Wildlife; 
Number of respondents who selected each of the following options: 
Very useful: 3 of 7; 
Moderately useful: 2 of 7; 
Somewhat useful/Not useful: 2 of 7. 

Source: GAO. 

[End of table] 

[End of section] 

Appendix IV: Responses to Follow-Up Questionnaire Concerning 
Challenges State and Local Officials May Face in Building and 
Maintaining Biosurveillance Capabilities: 

[Side bar: Response options on follow-up questionnaire for challenges: 

Challenge that is not being adequately addressed: This is a current 
challenge, and the combination of resources, leadership, and 
organization is not currently adequate to address the challenge. 

Challenge that is being adequately addressed: 

This is an ongoing challenge, but the current combination of 
resources, leadership, and organization is currently adequate to 
address the challenge. 

Not a challenge: This is not a challenge. 

Do Not Know/No response: Either you do not know if this item is a 
challenge in your area of responsibility or you decline to respond.
Source: GAO. End of side bar] 

Table 16 shows the results of our follow-up questionnaire for the 
question concerning challenges that state and local officials may face 
in building and maintaining biosurveillance capabilities. Presented 
below are the question and response totals to the follow-up 
questionnaires we sent to (1) state and city public-health 
epidemiology officials, (2) state and city public-health laboratory 
officials, (3) state agriculture officials, and (4) state wildlife 
officials by group, and descriptions for the challenges identified. 

Question: How do you classify the following challenges as they 
currently pertain to your area of responsibility? 

Table 16: Results of Responses to Questions Concerning Challenges: 

Challenge: Competing federal priorities; 
Description: Working with multiple different federal agencies may be a 
challenge, because they do not always have the same priorities, and 
conflict manifests in federal guidance, funding, or technical 
assistance; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 5 of 7; 
Challenge that is being adequately addressed: 0 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 1 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 2 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 2 of 7; 
Do not know/No Response: 1 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 4 of 6; 
Challenge that is being adequately addressed: 2 of 6; 
Not a challenge: 0 of 6; 
Do not know/No Response: 0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 3 of 7; 
Challenge that is being adequately addressed: 3 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 0 of 7. 

Challenge: Federalism challenges; 
Description: The division of roles and responsibilities across 
federal, state, and local jurisdictions may be a challenge, because 
federal, state, and local departments do not always share priorities, 
philosophies, or approaches to conducting biosurveillance; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 3 of 7; 
Challenge that is being adequately addressed: 3 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 0 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 2 of 7; 
Challenge that is being adequately addressed: 1 of 7; 
Not a challenge: 3 of 7; 
Do not know/No Response: 1 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 5 of 6; 
Challenge that is being adequately addressed: 1 of 6; 
Not a challenge: 0 of 6; 
Do not know/No Response: 0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 2 of 7; 
Challenge that is being adequately addressed: 1 of 7; 
Not a challenge: 3 of 7; 
Do not know/No Response: 1 of 7. 

Challenge: Funding stability/security; 
Description: The stability of funding may be a challenge, because 
state officials are uncertain whether, for what purpose, and how much 
funding will be available to build and maintain capabilities from year 
to year; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 6 of 7; 
Challenge that is being adequately addressed: 1 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 7 of 7; 
Challenge that is being adequately addressed: 0 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 6 of 6; 
Challenge that is being adequately addressed: 0 of 6; 
Not a challenge: 0 of 6; 
Do not know/No Response: 0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 6 of 7; 
Challenge that is being adequately addressed: 1 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Challenge: Funding structure/stovepiping; 
Description: The structure of available funding may be a challenge 
because it tends to target specific diseases and does not allow for 
building and maintaining core capabilities for emerging disease 
threats; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 4 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 0 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 6 of 7; 
Challenge that is being adequately addressed: 1 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 5 of 6; 
Challenge that is being adequately addressed: 1 of 6; 
Not a challenge: 0 of 6; 
Do not know/No Response: 0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 6 of 7; 
Challenge that is being adequately addressed: 1 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Challenge: Guidance for planning and developing biosurveillance 
capabilities; 
Description: Assimilating existing knowledge to help plan and develop 
capabilities may be a challenge because guidance lacks specificity or 
there is no place to find best practices; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 4 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 0 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 3 of 7; 
Challenge that is being adequately addressed: 0 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 3 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 3 of 6; 
Challenge that is being adequately addressed: 1 of 6; 
Not a challenge: 1 of 6; 
Do not know/No Response: 1 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 2 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 2 of 7. 

Challenge: Laboratory capacity; 

Description: Maintaining adequate laboratory capacity for 
biosurveillance purposes may be a challenge because it is difficult to 
maintain certifications or sufficient resources; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 4 of 7; 
Challenge that is being adequately addressed: 1 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 2 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 5 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 4 of 6; 
Challenge that is being adequately addressed: 2 of 6; 
Not a challenge: 0 of 6; 
Do not know/No Response: 0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 0 of 7; 
Challenge that is being adequately addressed: 1 of 7; 
Not a challenge: 4 of 7; 
Do not know/No Response: 2 of 7. 

Challenge: State policies; 
Description: Using federal resources to build biosurveillance 
capabilities may be a challenge because state policies, rules or 
regulations create barriers for hiring personnel, attending national 
conferences and trainings, and/or participating in online training and 
discussions; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 2 of 7; 
Challenge that is being adequately addressed: 4 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 0 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 6 of 7; 
Challenge that is being adequately addressed: 0 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 0 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 5 of 6; 
Challenge that is being adequately addressed: 1 of 6; 
Not a challenge: 0 of 6; 
Do not know/No Response: 0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 7 of 7; 
Challenge that is being adequately addressed: 0 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Challenge: Support for integrating human and animal surveillance 
information; 
Description: Integrating information across disease domains may be a 
challenge because of a lack of leadership and mechanisms to facilitate 
information sharing and data integration among public health, 
agriculture, and wildlife infectious disease control functions; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 3 of 7; 
Challenge that is being adequately addressed: 3 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 1 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 4 of 7; 
Challenge that is being adequately addressed: 0 of 7; 
Not a challenge: 2 of 7; 
Do not know/No Response: 1 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 5 of 6; 
Challenge that is being adequately addressed: 1 of 6; 
Not a challenge: 0 of 6; 
Do not know/No Response: 0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 5 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Challenge: Support for regional approaches to surveillance; 
Description: Sharing information and resources across state or other 
jurisdictional boundaries may be a challenge because leadership and 
mechanisms to facilitate regional approaches are inadequate; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 5 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 4 of 7; 
Challenge that is being adequately addressed: 1 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 1 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 3 of 6; 
Challenge that is being adequately addressed: 3 of 6; 
Not a challenge: 0 of 6; 
Do not know/No Response: 0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 4 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 0 of 7. 

Challenge: Systems maintenance or enhancement; 
Description: Maintaining or enhancing systems to support 
biosurveillance may be a challenge because of the fast rate of change 
and ongoing upkeep associated with information technology; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 5 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 4 of 7; 
Challenge that is being adequately addressed: 3 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 5 of 6; 
Challenge that is being adequately addressed: 1 of 6; 
Not a challenge: 0 of 6; 
Do not know/No Response: 0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 1 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 3 of 7. 

ChallengeTraining availability; 
Description: Ensuring adequate ongoing training and education for 
staff with biosurveillance responsibilities may be a challenge because 
training opportunities are limited; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 4 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 1 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 3 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 2 of 7; 
Do not know/No Response: 0 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 3 of 6; 
Challenge that is being adequately addressed: 2 of 6; 
Not a challenge: 1 of 6; 
Do not know/No Response: 0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 6 of 7; 
Challenge that is being adequately addressed: 1 of 7; 
Not a challenge: 0 of 7; 
Do not know/No Response: 0 of 7. 

Challenge: Workforce competency; 
Description: Maintaining the workforce may be a challenge, because 
staff lacks sufficient training and education; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 3 of 7; 
Challenge that is being adequately addressed: 3 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 0 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 4 of 7; 
Challenge that is being adequately addressed: 2 of 7; 
Not a challenge: 1 of 7; 
Do not know/No Response: 0 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 2 of 6; 
Challenge that is being adequately addressed: 4 of 6; 
Not a challenge: 0 of 6; 
Do not know/No Response: 0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed: 5 of 7; 
Challenge that is being adequately addressed: 0 of 7; 
Not a challenge: 2 of 7; 
Do not know/No Response: 0 of 7. 

Challenge: Workforce sufficiency; 
Description: Maintaining the workforce may be a challenge, because 
skilled professionals--i.e., epidemiologists, informaticians, 
statisticians, laboratory staff, animal health staff, or animal 
disease specialists - are not available in sufficient numbers; 
Group: Epidemiology; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed:5 of 7; 
Challenge that is being adequately addressed:1 of 7; 
Not a challenge:1 of 7; 
Do not know/No Response:0 of 7. 

Group: Public Health Laboratory; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed6 of 7; 
Challenge that is being adequately addressed1 of 7; 
Not a challenge0 of 7; 
Do not know/No Response0 of 7. 

Group: Agriculture; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed:3 of 6; 
Challenge that is being adequately addressed:3 of 6; 
Not a challenge:0 of 6; 
Do not know/No Response:0 of 6. 

Group: Wildlife; 
Number of respondents who selected each of the following options: 
Challenge that is not being adequately addressed:5 of 7; 
Challenge that is being adequately addressed:0 of 7; 
Not a challenge:2 of 7; 
Do not know/No Response: 0 of 7. 

Source: GAO. 

[End of table] 

[End of section] 

Appendix V: Comments from the Department of Homeland Security: 

U.S. Department of Homeland Security: 
Washington, DC 20528: 

October 19, 2011: 

William 0. Jenkins, Jr. 
Director, Homeland Security and Justice: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Re: Draft Report GAO-12-55, "Biosurveillance: Nonfederal Capabilities 
Should be Considered in Creating a National Biosurveillance Strategy" 

Dear Mr. Jenkins: 

Thank you for the opportunity to review and comment on this draft 
report. The U.S. Department of Homeland Security (DHS) appreciates the 
U.S. Government Accountability Office's work in planning and 
conducting its review and issuing of this report. Within DHS, the 
National Biosurveillance Integration Center's primary mission includes 
enhancing the capability of the Federal Government to: 

* rapidly identify, characterize, localize, and track a biological 
event of national concern by integrating and analyzing data relating 
to human health, animal, plant, food, and environmental monitoring 
systems (both national and international); and; 

* disseminate alerts and other information to Member Agencies and, in 
coordination with Member Agencies, to agencies of state, local, and 
tribal governments, as appropriate, to enhance the ability of such 
agencies to respond to a biological event of national concern. 

To effectively support this mission area, DHS is working in 
coordination with the National Security Staffs efforts to finalize the 
National Biosurveillance Strategy through its participation on the sub-
Interagency Policy Committee on Biosurveillance. DHS understands the 
importance and supports the inclusion of nonfederal biosurveillance in 
the National Biosurveillance Strategy currently being developed. 

Again, thank you for the opportunity to review and comment on this 
draft report. We note the report does not contain any recommendations 
for DHS. Technical comments were submitted under separate cover. We 
look forward to working with you on future homeland security issues. 

Sincerely, 

Signed by: 

Jim H. Crumpacker: 
Director: 
Departmental GAO-OIG Liaison Office: 

[End of section] 

Appendix VI: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

William O. Jenkins, Jr., (202) 512-8777 or jenkinswo@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Edward George, Assistant 
Director; Amanda Jones Bartine; Michelle Cooper; Kathryn Godfrey; 
Susanna Kuebler; and Heather Romani made significant contributions to 
the work. Tina Cheng assisted with graphic design. Amanda Miller and 
Russ Burnett assisted with design, methodology, and analysis. Stuart 
Kaufman assisted with design and administration of the follow-up 
questionnaire. Tracey King provided legal support. Linda Miller 
provided communications expertise. 

[End of section] 

Footnotes: 

[1] GAO, Biosurveillance: Efforts to Develop a National 
Biosurveillance Capability Need a National Strategy and a Designated 
Leader, [hyperlink, http://www.gao.gov/products/GAO-10-645] 
(Washington, D.C.: June 30, 2010). 

[2] The White House, Homeland Security Presidential Directive 21: 
Public Health and Medical Preparedness (Washington, D.C.: Oct. 18, 
2007). 

[3] [hyperlink, http://www.gao.gov/products/GAO-10-645]. 

[4] Pub. L. No. 110-53, § 1102, 121 Stat. 266, 379 (2007). 

[5] In consultation with congressional staff, we expanded the scope of 
this work to include insular areas, in addition to the state, local, 
and tribal levels specified in the mandate. According to the 
Department of the Interior's definition, an insular area is a 
jurisdiction that is neither a part of one of the several states nor a 
federal district. This is the current term to refer to any U.S. 
commonwealth, freely associated state, possession, or territory. 

[6] Pub. L. No. 107-296, 116 Stat. 2135 (2002). 

[7] Pub. L. No. 107-188, 116 Stat. 594 (2002). 

[8] Pub. L. No. 109-417, 120 Stat. 2831 (2006). 

[9] The White House, Homeland Security Presidential Directive 9: 
Defense of United States Agriculture and Food (Washington, D.C.: 
February 3, 2004). 

[10] The White House, Homeland Security Presidential Directive 10: 
Biodefense for the 21st Century (Washington, D.C.: Apr. 28, 2004). 

[11] Our June 2010 work on biosurveillance efforts at the federal 
level explored surveillance for the following biosurveillance domains: 
human health, animal health, plant health, food, and the environment 
(specifically, air and water). Given further complexity arising from 
the number of and variation among states, localities, tribes, and 
insular areas, we narrowed the disease scope for this report. We 
focused on zoonotic disease agents because of the particular threats 
associated with them--detailed later in this report--and because 
threats from zoonotic disease agents clearly illustrate the potential 
benefits of an integrated biosurveillance capability. Given the focus 
on surveillance for zoonoses and other emerging infectious diseases in 
humans, certain federal efforts--for example, DHS's air monitoring 
system, BioWatch--are not discussed. Similarly, certain types of 
waterborne, foodborne, plant, or animal diseases--for example Foot and 
Mouth Disease--that could have devastating economic consequences or 
dire human health effects are not the focus of this report. 

[12] The biosurveillance enterprise is the whole combination of 
systems and resources at every level of government and the private 
sector that can contribute to timely detection and situational 
awareness of potentially catastrophic biological events. 

[13] The findings in this report about insular areas focus on the U.S.-
Affiliated Pacific Islands. With the exception of Puerto Rico and the 
U.S. Virgin Islands, all commonwealths, territories, possessions, and 
freely associated states of the United States fall within the U.S.- 
Affiliated Pacific Islands. 

[14] HSPD-10 states that the United States requires a periodic 
assessment that identifies gaps or vulnerabilities in our biodefense 
capabilities--of which surveillance and detection is a key part--to 
guide prioritization of federal investments. Because nonfederal 
entities play a critical role in biosurveillance, such an assessment 
would necessarily include the capability of nonfederal entities to 
support a biosurveillance capability. 

[15] In response to HSPD-21's charge for HHS to enhance 
biosurveillance for human health, CDC created the National 
Biosurveillance Strategy for Human Health with input from federal and 
other partners. The strategy states that an assessment is needed of 
the current workforce and the assets invested. 

[16] In January and April 2011, we briefed congressional staff on our 
preliminary findings. 

[17] [hyperlink, http://www.gao.gov/products/GAO-10-645]. 

[18] This allocation of responsibility reflects the fact that 
protection of public health is primarily a state responsibility. 
However, the federal government has acquired certain public-health 
responsibilities over the years, including acting in support of state 
and local public-health agencies. This kind of distribution of power 
between the central government and the states is called federalism, a 
term we use later in this report. 

[19] See GAO, Emerging Infectious Diseases: Review of State and 
Federal Disease Surveillance Efforts, [hyperlink, 
http://www.gao.gov/products/GAO-04-877] (Washington, D.C.: Sept. 30, 
2004) and Health Information Technology: More Detailed Plans Needed 
for the Centers for Disease Control and Prevention's Redesigned 
BioSense Program, [hyperlink, http://www.gao.gov/products/GAO-09-100] 
(Washington, D.C.: Nov. 20, 2008). 

[20] 75 Fed. Reg. 60,810 (Oct. 1, 2010); 75 Fed. Reg. 66,124 (Oct. 27, 
2010). 

[21] The federal government recognizes Indian tribes as distinct, 
independent political communities that possess certain powers of self- 
government. Federal recognition confers specific legal status on a 
particular Native American group, establishes a government-to- 
government relationship between the United States and the tribe, 
imposes on the federal government a fiduciary trust relationship to 
the tribe and its members, and imposes specific obligations on the 
federal government to provide benefits and services to the tribe and 
its members. 

[22] Pub. L. No. 93-638, 88 Stat. 2203 (1975) (codified as amended at 
25 U.S.C. § 450-458ddd-2). 

[23] IHS defines an Indian tribe as any Indian tribe, band, nation, 
group, Pueblo, or community, including any Alaska Native village or 
Native group, which is federally recognized as eligible for the 
programs and services provided by the United States to Indians because 
of their status as Indians. 

[24] [hyperlink, http://www.gao.gov/products/GAO-10-645]. 

[25] We calculated an overall rank for the importance of federal 
support categories, as identified by respondents to our questionnaire. 
We assigned numerical value to each observation, a value of 4 each 
time a respondent identified a type of federal assistance as most 
important, 3 for second-most important, 2 for third-most important, 
and 1 for fourth-most important. 

[26] Active surveillance involves actively looking for signs or 
seeking clinical diagnoses for specific disease agents in specific 
populations. In contrast, passive surveillance relies on astute 
clinicians and other existing systems to detect signs or symptoms of 
disease outbreaks, which often trigger further investigation to 
identify and characterize disease outbreaks. The federally-supported 
avian influenza and chronic wasting disease programs are active 
surveillance programs because wildlife officials collect samples from 
birds and cervids, and laboratories diagnose the presence or absence 
of the target diseases in those samples. Without active surveillance 
programs, wildlife officials generally rely on the public or 
biologists in the field to notify them of animal die-offs and other 
signs of disease outbreaks. 

[27] The NVSL is a federal laboratory that serves as in international 
reference laboratory and conducts tests and confirms tests for other 
laboratories. See also appendix II. 

[28] Some federal information is available only to the state where the 
data were collected; in other cases regional or state-by-state 
information is available. For example, according to officials, USDA's 
Veterinary Service Laboratory Submissions website provides data about 
other states' wild bird avian influenza activity, but for most of its 
disease modules the data are restricted to officials in the state 
where they were collected. 

[29] [hyperlink, http://www.gao.gov/products/GAO-10-645]. 

[30] CDC's Advisory Committee to the Director is to advise the CDC 
Director on policy issues and broad strategies in pursuit of CDC's 
mission of protecting health through health promotion, prevention, and 
preparedness. The committee recommends ways to prioritize CDC's 
activities, improve results, and address health disparities. It also 
provides guidance to help CDC work more effectively with its various 
private-and public-sector constituents. The State, Tribal, Local, and 
Territorial Workgroup was created to provide input to the advisory 
committee on state, tribal, local, and territorial public-health 
policies and priorities; to provide input as requested regarding other 
CDC programs; and to provide public-health practice input from the 
state, tribal, local, and territorial public-health community. 

[31] Pub. L. No. 111-148, § 4304, 124 Stat. 119, 584 (2010) (codified 
at 42 U.S.C. § 300hh-31). 

[32] HHS's Office of the Assistant Secretary for Preparedness and 
Response issued the National Health Security Strategy in December 
2009. The strategy is designed to achieve two goals: build community 
resilience and strengthen and sustain health and emergency-response 
systems. One of the strategy's 10 strategic objectives is to ensure 
the nation has a situational awareness capability. Under this 
objective, the strategy and its accompanying interim implementation 
plan emphasize the need for situational awareness obtained through 
epidemiological and animal-disease surveillance as well as monitoring 
agricultural and food supplies for contamination. 

[33] The objective of the BioSense program is to collect electronic 
data that are voluntarily shared by participating state, local, and 
other federal public-health entities, including data related to 
infections, injuries, and chronic diseases, to provide a more-complete 
picture of potential and actual health events both locally and across 
jurisdictional boundaries. According to CDC officials, they have been 
actively working over the past year to redesign BioSense. Officials 
say the redesigned BioSense--known as BioSense 2.0 is the focal point 
of their efforts to provide support and guidance to states in 
preparation for receipt of additional data that will be available to 
them as a result of certain provisions in PPACA. They say they have 
been working with the International Society for Disease Surveillance, 
Council of State and Territorial Epidemiologists, the Association of 
State and Territorial Health Officials, and the National Association 
of County and City Health Officials, among others, to help reach out 
to their state partners about the rollout of BioSense 2.0, which is 
scheduled for November 2011. 

[34] [hyperlink, http://www.gao.gov/products/GAO-10-645]. 

[35] [hyperlink, http://www.gao.gov/products/GAO-10-645]. 

[36] A necropsy is one of the basic tools used to determine why an 
animal dies. It involves the thorough examination of a carcass 
externally and internally for any indications of causes of death. 

[37] Pub. L. No. 104-191, 110 Stat. 1936 (1996). 

[38] Pub. L. No. 111-148, § 10221(a), 124 Stat. 119, 935 (codified at 
25 U.S.C. § 1621m(e)). 

[39] Homeland Security Presidential Directive 10: Biodefense for the 
21ST Century. 

[40] [hyperlink, http://www.gao.gov/products/GAO-10-645]. 

[41] In August 2011, the National Security Staff reported that it had 
created a biosurveillance sub-Interagency Policy Committee, under the 
guidance of the Domestic Resilience Group, to serve as a focal point 
in order to coordinate the development of a National Strategy for 
Biosurveillance. They said the strategy, and the implementation 
guidance to it, will define the overall purpose of the U.S. government 
biosurveillance effort, and will pay particular attention to the 
assignment of roles and responsibilities. 

[42] Pub. L. No. 107-296, 116 Stat. 2135 (2002). 

[43] Pub. L. No. 107-188, 116 Stat. 594 (2002). 

[44] Pub. L. No. 109-417, 120 Stat. 2831 (2006). 

[45] In response to HSPD-21's charge for the Department of Health and 
Human Services to enhance biosurveillance for human health, CDC has 
created the National Biosurveillance Strategy for Human Health with 
input from federal and other partners. 

[46] See GAO, Biosurveillance: Efforts to Develop a National 
Biosurveillance Capability Need a National Strategy and a Designated 
Leader, [hyperlink, http://www.gao.gov/products/GAO-10-645] 
(Washington, D.C.: June 30, 2010) and GAO, Combating Terrorism: 
Evaluation of Selected Characteristics in National Strategies Related 
to Terrorism, [hyperlink, http://www.gao.gov/products/GAO-04-408T] 
(Washington, D.C.: Feb. 3, 2004). 

[End of section] 

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