HHS’s and DHS’s Lack of Comprehensive Procedures for Information Sharing and Coordination and CBP Inspection Deficiencies Hindered the Response to the TB Incidents

Various factors—a lack of comprehensive procedures for information  sharing and coordination as well as border inspection shortfalls—hindered  the federal response to the two TB incidents. They had established  a memorandum of understanding in October 2005 creating a broad  agreement to communicate and coordinate during public health  emergencies. HHS and DHS Lacked Comprehensive Procedures to Share Information and Coordinate Their Responses and Resources in the Two TB Incidents

Despite the memorandum of understanding between HHS and DHS in  place at the time of the incidents, the departments lacked comprehensive  procedures needed to share information with each other and coordinate  resources to deter cross-border travel of nonadherent individuals with  infectious disease, such as TB. Additionally, Standards for Internal Control in the Federal  Government calls for (1) management to ensure that there are adequate  means of communicating with, and obtaining information from, external  stakeholders that may have a significant impact on the agency achieving  its goals and (2) effective communication flowing down, across, and up  the organization to enable managers to carry out their internal control  responsibilities. CDC Lacked Procedures to Coordinate with State and Local Health Officials to Determine Use of Federal Isolation and Quarantine Authorities

CDC had not developed procedures to inform state and local health  officials about the process for coordinating with CDC to determine  whether federal isolation and quarantine authorities should be used to  deter the travel of an individual with TB, causing the initial delay in the  federal response. CBP Inspection Deficiencies Contributed to Delays in Locating the Individuals with TB

Deficiencies in CBP’s traveler inspection operations further contributed to  the delay in federal efforts to locate the two individuals with TB and direct  them to treatment. When responding to HHS’s request for assistance to  deter the U.S. citizen from traveling, CBP issued a TECS alert to determine  when the U.S. citizen planned to return to the United States. HHS and DHS Implemented Procedures and Tools to Address Response Deficiencies, but Could Take Further Steps to Complete Actions Identified as a Result of the 2007 TB Incidents

HHS and DHS have implemented various procedures and tools intended to  address deficiencies identified by the 2007 TB incidents. Finally, HHS and DHS have identified additional actions  that need to be taken to further strengthen the departments’ ability to  respond to incidents involving individuals with TB who intend to travel. HHS and DHS Implemented New Procedures and Tools Intended to Address Information Sharing, Coordination, and Public Health Screening and Border Inspection Deficiencies Identified by the TB Incidents

HHS and DHS officials—including officials from CDC, CBP, and TSA—met  in June 2007 to develop new procedures and tools to determine how DHS  might be able to help HHS respond to public health incidents, develop a  framework for coordinating with each other during responses to public  health incidents, and ensure the appropriate level of agency involvement  and use of agency resources. To help promote enhanced information  sharing across and within both departments, HHS and DHS developed new  procedures for HHS to request assistance from DHS. These new  procedures are consistent with practices identified in our past work for  enhancing and sustaining agency collaboration and for establishing  leadership, capabilities, and accountability for preparedness and  response. CDC Has Made Some Efforts to Inform State and Local Health Officials of New Procedures and Tools, but Has Not Completed All Actions

Although CDC has made some efforts to educate health officials,  according to CDC officials the agency has not yet completed all actions to  provide information to health officials who work with individuals with TB  about the new procedures and tools, or about the criteria for adding  individuals to or removing them from the Do Not Board list or TECS. HHS and DHS Have Activities Under Way to Assess Their Ability to Respond to TB Incidents

According to CDC officials, both departments have activities under way to  assess the effectiveness of the new procedures and tools. Additionally, HHS and DHS have more opportunities to improve their  information-sharing efforts in responding to future TB incidents. At that time, we will send copies to the Secretary of Health  and Human Services and the Secretary of Homeland Security.
Why GAO Did This Study

In spring 2007, the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS), and state and local health officials worked together to interdict two individuals with drug-resistant infectious tuberculosis (TB) from crossing U.S. borders and direct them to treatment. Concerns arose that HHS's and DHS's responses to the incidents were delayed and ineffective. GAO was asked to examine (1) the factors that affected HHS's and DHS's responses to the incidents, (2) the extent to which HHS and DHS made changes to response procedures as a result of the incidents, and (3) HHS's and DHS's efforts to assess the effectiveness of changes made as a result of the incidents. GAO reviewed agency documents and interviewed officials about the procedures in place at the time of the incidents and changes made since.

What GAO Found

Various factors--a lack of comprehensive procedures for information sharing and coordination and border inspection shortfalls--hindered the federal response to the two TB incidents. GAO's past work and federal internal control standards call for collaborative communication and coordination across agencies; communication flowing down, across, and up agencies to help managers carry out their internal control responsibilities; and effective leadership, capabilities, and accountability to ensure effective preparedness and response to hazardous situations. HHS and DHS finalized a memorandum of understanding in October 2005 intended to promote communication and coordination in response to public health incidents, but they had not fully developed operational procedures to share information and coordinate their efforts. Thus, HHS and DHS lost time locating or identifying the individuals to interdict them at the U.S. border. Also, HHS lacked procedures to coordinate with state and local health officials to determine when to use federal isolation and quarantine authorities, which further contributed to the delay in the federal response to one of the incidents. Finally, DHS had deficiencies in its process for inspecting individuals at the border, which caused delays in locating the individuals with TB. HHS and DHS have subsequently implemented procedures and tools intended to address deficiencies identified by the incidents, consistent with GAO's past work and internal control standards, but the departments could take additional steps to enhance their ability to respond to future TB incidents. Since the 2007 incidents, HHS and DHS have developed formal procedures for HHS to request DHS's assistance, and DHS has (1) developed a watch list for airlines to identify individuals with TB and other infectious diseases who are to be stopped from traveling and (2) revised its border inspection process to include a requirement that individuals with TB identified by HHS be subject to further inspection. DHS has also enhanced its process for creating public health alerts based on some variations of biographic information (e.g., name, date of birth, or travel document information), but has not explored the benefits of creating these alerts based on other variations, which impeded DHS's ability to interdict one of the individuals at the border. In addition, HHS has not yet completed efforts to provide information on changes in procedures to state and local health officials, who typically originate requests for assistance, to help mitigate delays in accessing federal assistance. HHS and DHS identified additional actions that need to be taken to further strengthen their response, but have not developed plans for completing them. HHS and DHS have activities under way to assess the effectiveness of the new procedures and tools, including performance monitoring and cross-agency meetings to discuss and revise the new procedures and tools based on actual experiences. HHS and DHS have coordinated on more than 70 requests for assistance since the 2007 incidents through February 2008; officials said they view each incident as a test of the efficacy of their responses.