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What the GAO found

Since 2006, several federal laws have required the Department of Health and Human Services (HHS) to take steps to increase the nation’s situational awareness of the threats associated with public health emergencies such as the COVID-19 pandemic. Specifically, HHS needed to build a nationwide real-time electronic public health situational awareness system through a functional network of systems. This network was to be used to facilitate early detection and rapid response to potentially catastrophic infectious disease outbreaks.

More than 15 years after the law originally mandated it, the federal government still lacks that much-needed situational awareness networking capability. If this network were available, it could be used to provide vital information to better manage the timely response to COVID-19.

The Pandemic and Hazard Preparedness and Innovation Advancement Act of 2019 reaffirms the need for HHS to improve situational awareness capabilities. Below are the main requirements of the law and the extent to which HHS complies with them as of March 2022.

Summary of legislative requirements related to raising situational awareness of public health emergencies and HHS implementation status as of March 2022

Summary of requirements

Implementation status

Adopt technical and reporting standards.

Provide grants to build integrated systems.

Develop a plan for sharing and protecting information.

Creation of a nationwide electronic real-time situational awareness system for public health and biosurveillance.

Facilitate coordination between relevant agencies.

Hold a public meeting with public health experts by December 21, 2019.

Use applicable interoperability standards and define minimum data elements.

Develop a strategy and implementation plan by December 24, 2020.

Verify the data and information transmitted by the network by June 24, 2021. and then every 6 years.

Develop a budget plan by June 24, 2021 and annually thereafter.

Legend: ● Requirement fully met; ◑ The requirement is partially met; ○ Requirement not met Source: GAO analysis of the Pandemic and Hazard Preparedness and Innovation Promotion Act of 2019 and other relevant laws, and data from the Department of Health and Human Services (HHS). I GAO-22-104600

The lack of significant progress in implementing the requirements of the law is partly due to the fact that the department failed to prioritize the requirements of the law and did not create an appropriate governance and leadership structure. Such a structure would include a lead operational unit with defined roles and responsibilities for complying with legal requirements, as well as an organization providing oversight for these efforts. During the GAO review, HHS began developing a work plan to meet the requirements of the 2019 law. However, HHS has not provided a timeline for completion of the work plan.

In January 2022, the GAO identified HHS leadership and coordination of a number of public health emergencies as high risk. For more than a decade, the GAO has reported HHS’s leadership role in preparing for and responding to public health emergencies and has found persistent shortcomings in its ability to fulfill this role. Similarly, HHS has not provided the guidance needed to fulfill its responsibilities under the 2019 law.

Public health agencies have faced many challenges and identified lessons learned from the COVID-19 pandemic that could better inform HHS in developing and implementing a public health situational awareness and biosurveillance network. In particular, state survey respondents identified a number of communication challenges they faced in managing public health information. Below is a summary of the top four issues most commonly rated as difficult by state survey respondents.

Stated Challenges in Managing Public Health Information During COVID-19

Summary of legislative requirements related to raising situational awareness of public health emergencies and HHS implementation status as of March 2022

Additional challenges—limitations on data being collected, increased reporting requirements, and barriers to health sharing and collaboration—have been identified by public health organizations at the national, state, and local levels. Thirty states have identified lessons that HHS can use in network planning. The three lessons most frequently highlighted by states were:

  1. improve public health reporting for example, by standardizing and exchanging data between federal and state entities to improve surveillance needs;
  2. start cooperation with stakeholders early for example, by involving state and local stakeholders in all emergency response activities; as well as
  3. build a public health infrastructure to enable data sharing for example, by implementing the network required by the 2019 law.

With over two years of experience in responding to COVID-19, as of March 2022, HHS has taken no steps to identify, document, and disseminate all of the concerns and lessons learned from the pandemic. These challenges and lessons can be taken into account when planning and implementing a situational awareness and biosurveillance network in public health. Until HHS takes steps to identify, document, share and build on lessons learned from the COVID-19 pandemic, opportunities to improve response to future and current public health emergencies by learning from past challenges are likely to be missed.

Why the GAO did this study

The COVID-19 pandemic has highlighted the critical need for public health officials to access real-time information about emerging threats so they can make timely and prompt decisions. For more than a decade, federal law has required HHS to improve the nation’s situational awareness of these threats.

The most recent mandate, passed in 2019, included a provision requiring the GAO to report on HHS’s efforts to implement these improvements. The CARES Act also included a provision for the GAO to monitor and oversee the federal pandemic response.

This report looks at (1) the extent of HHS progress in meeting the requirements of the 2019 law; and (2) challenges and lessons learned from COVID-19 that HHS can take into account when planning a situational awareness and biosurveillance network.

The GAO reviewed HHS documentation such as grants made to states, technical and reporting standards, and implementation plans. He also analyzed the documentation and compared it with the requirements of the law.

In addition, the GAO interviewed health officials from 50 US states, the District of Columbia, and five US territories. Thirty-nine states, the District of Columbia, and three US territories (collectively referred to as states) responded to the questionnaire, with a response rate of 77 percent. The GAO has evaluated these responses to identify issues related to COVID-19 and learn lessons. In addition, the GAO interviewed representatives from eight state and local public health organizations such as the National Association of Governors and the National Association of County and City Health Officials, as well as HHS officials.

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