GAO-22-104600, COVID-19: Pandemic Lessons Highlight Need for Public Health Situational Awareness Network

Report — GAO-22-104600, COVID-19: Pandemic Lessons Highlight Need for Public Health Situational Awareness Network, dated 2019-12-21, issued by Government Accountability Office.

Full text

COVID-19
Pandemic Lessons
Highlight Need for
Public Health
Situational Awareness
Network

Report to Congressional Addressees
June 2022

GAO-22-104600

United States Government Accountability Office

 United States Government Accountability Office

Highlights of GAO-22-104600, a report to
congressional addressees

June 2022
COVID-19
Pandemic Lessons Highlight Need for Public Health
Situational Awareness Network
What GAO Found
Since 2006, multiple federal laws have mandated that the Department of Health
and Human Services (HHS) take steps to improve the nation’s situational
awareness of threats related to public health emergencies, such as the COVID-
19 pandemic. Specifically, HHS was required to establish a near real-time
electronic nationwide public health situational awareness capability through an
interoperable network of systems. This network was to be used to facilitate early
detection of and rapid response to potentially catastrophic infectious disease
outbreaks.
More than 15 years after the law initially mandated it, the federal government
does not yet have this needed situational awareness network capability. If this
network had been available, it could have been used to provide vital information
to better manage a timely COVID-19 response.
The Pandemic and All-Hazards Preparedness and Advancing Innovation Act of
2019 reiterated the need for HHS to improve situational awareness capabilities.
The following summarizes key requirements in the act and the extent to which
HHS has implemented them as of March 2022.
Summary of statutory requirements related to the improvement of situational awareness for
public health emergencies and the extent to which HHS has implemented them as of March
2022
Summary of requirements
Implementation status
Adopt technical and reporting standards.
●
Provide grants to establish integrated systems.
◑
Develop a plan for sharing and securing information.
○
Establish a near real-time electronic nationwide public health situational
awareness and biosurveillance capability.
○
Facilitate coordination among relevant agencies.
○
Conduct a public meeting with experts in public health by December 21,
2019.
○
Utilize applicable interoperability standards and define minimal data
elements.
○
Develop a strategy and implementation plan by December 24, 2020.
○
Conduct a review of the data and information transmitted by the network by
June 24, 2021 and every 6 years thereafter.
○
Develop a budget plan by June 24, 2021, and on an annual basis
thereafter.
○
Legend:
●  Requirement is fully implemented; ◑   Requirement is partially implemented; ○  Requirement is not implemented
Source: GAO analysis of The Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019 and other related laws,
and Department of Health and Human Services (HHS) data. I GAO-22-104600
The lack of significant progress in implementing the requirements in the act is
due, in part, to the department failing to prioritize the requirements of the act and
not establishing an appropriate management and governance structure. Such a
structure would include a lead operational division with defined roles and
responsibilities for implementation of statutory requirements, and an organization
to provide oversight of these efforts. During GAO’s review, HHS began drafting a
work plan intended to address the requirements of the 2019 act. However, HHS
has not provided a time frame for completing the work plan.
Why GAO Did This Study
The COVID-19 pandemic has drawn
attention to the urgent need for
public health officials to access real-
time information about emerging
threats to enable them to make
timely, responsive decisions. For
over a decade, federal law has
mandated that HHS improve the
nation’s situational awareness of
these threats.
The most recent mandate, enacted
in 2019, included a provision for
GAO to report on HHS’s efforts to
implement these improvements. The
CARES Act also included a
provision for GAO to conduct
monitoring and oversight of the
federal response to the pandemic.
This report examines (1) the extent
to which HHS has made progress
toward implementing the
requirements in the 2019 act; and
(2) the challenges and lessons
learned from COVID-19 that HHS
could incorporate in planning for a
situational awareness and
biosurveillance network.
GAO reviewed HHS documentation,
such as grants provided to states,
technical and reporting standards,
and adoption plans. It also analyzed
documentation and compared it to
requirements in the act.
In addition, GAO surveyed public
health officials from 50 U.S. states,
the District of Columbia, and five
U.S. territories. Thirty-nine states,
the District of Columbia and three
U.S. territories (hereinafter
collectively referred to as states)
responded to the survey, for a
response rate of 77 percent. GAO
assessed these responses to
identify COVID-19 challenges and

View GAO-22-104600. For more
information, contact Jennifer R. Franks at
(404) 679-1831 or franksj@gao.gov.

COVID-19: Pandemic Lessons Highlight Need for Public Health Situational Awareness
Network
In January 2022, GAO designated HHS leadership and coordination of a range of
public health emergencies as high risk. For more than a decade, GAO has
reported on HHS’s execution of its lead role in preparing for, and responding to,
public health emergencies and have found persistent deficiencies in its ability to
perform this role. Similarly, HHS has not provided the leadership necessary to
carry out its required responsibilities in the 2019 act.
Public health entities experienced a variety of challenges and identified lessons
learned from the COVID-19 pandemic that could better inform HHS in developing
and implementing the public health situational awareness and biosurveillance
network. Specifically, state survey respondents identified a number of
information-sharing challenges that they experienced in the management of
public health information. The following summarizes the top four challenges state
survey respondents most often rated as challenging.
State Reported Challenges in Managing Public Health Information during COVID-19
Additional challenges—limitations on data collected, increased reporting
requirements, and impediments to health-related data sharing and
collaboration—were identified by public health organizations at the national,
state, and local levels. Thirty states identified lessons that HHS could use in
planning for the network. The three lessons that states identified most often were
1)
improve public health reporting by, for example, standardizing and
sharing data among federal entities and states to improve surveillance
needs;
2)
collaborate early with stakeholders by, for example, involving state and
local stakeholders throughout the entirety of emergency reponse activities;
and
3)
establish a public health infrastructure to enable data sharing by, for
example, implementing the network required by the 2019 act.
After having over two years of experience in responding to COVID-19, HHS had
not taken steps, as of March 2022, to identify, document, and share all of the
challenges and lessons learned from the pandemic. These challenges and
lessons could be incorporated into the planning and implementation of the public
health situational awareness and biosurveillance network. Until HHS takes steps
to identify, document, share, and incorporate lessons learned from the COVID-19
pandemic, opportunities to improve the response to future and ongoing public
health emergencies by learning from past challenges will likely be missed.
lessons learned. Further, GAO
interviewed representatives from eight
public health organizations
representing state and local levels,
such as the National Governors
Association and National Association
of County and City Health Officials, as
well as HHS officials.
What GAO Recommends
GAO is making 12 recommendations
to HHS to prioritize the development of
the public health situational awareness
and biosurveillance network. Among
these recommendations are that HHS
should:
•
designate a lead operational
division for implementation of
statutory requirements and clearly
define its roles and
responsibilities;
•
identify the office responsible for
overseeing the completion of the
activities performed by the lead
operational division and clearly
define its roles and
responsibilities;
•
commit to a deadline for finalizing
the work plan to implement the
2019 act requirements and ensure
that the work plan is fully
implemented;
•
identify and document information-
sharing challenges and lessons
learned from the COVID-19
pandemic;
•
share the lessons learned from
the COVID-19 pandemic with
relevant stakeholders, such as
state, territorial, and local public
health officials; and
•
incorporate lessons learned from
the COVID-19 pandemic into
plans for implementing the
situational awareness and
biosurveillance network.
HHS concurred with 10 of the 12
recommendations. The department
stated that the remaining two were
under review. The two under review
related to identifying the office
responsible for overseeing the
completion of the activities performed
by the lead operational division and
identifying and documenting
information-sharing challenges and
lessons learned from COVID-19.

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Letter

1
Background
5
HHS Made Minimal Progress toward Establishing a Public Health
Situational Awareness and Biosurveillance Network
14
Public Health Entities Identified Challenges and Lessons Learned
from COVID-19 that Could Help HHS Establish a Situational
Awareness Network
22
Conclusions
33
Recommendations for Executive Action
34
Agency Comments and Our Evaluation
35
Appendix I
Survey Questions Administered to States and Territories and the
Responses for Each Question
39

Appendix II
Objectives, Scope, and Methodology
52

Appendix III
Various State and Federal Entities Use IT to Support Public Health
Situational Awareness and Biosurveillance Activities
55

Appendix IV
Comments from the Department of Health & Human Services
61

Appendix V
GAO Contact and Staff Acknowledgments
66

Tables
Table 1: Statutory Requirements Related to Supporting the
Establishment of Systems of Public Health
Communications and Surveillance and the Extent to
Which HHS Has Implemented Them as of March 2022
15
Table 2: Examples of Public Health Communications and
Surveillance Systems Funded by the Centers for Disease
Control and Prevention (CDC)
17

Contents

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Table 3: PAHPAIA Requirements Related to Modernizing Public
Health Situational Awareness and Biosurveillance and the
Extent to Which HHS Has Implemented Them as of
March 2022
18
Table 4: Examples of Existing Federal Systems Relevant to Public
Health Situational Awareness and Biosurveillance
57

Figures
Figure 1: Illustration of the Types of Entities That Are to Share
Information to Support Nationwide Public Health
Situational Awareness
6
Figure 2: Key Legislation on Public Health Situational Awareness
and Biosurveillance and Health and Human Services
(HHS) Delivered Requirements to Date
12
Figure 3: State Views of Challenges in the Management of Public
Health Information during the COVID-19 Pandemic
24
Figure 4: Types of Information Systems States Reported
Implementing to Support Public Health Situational
Awareness and Biosurveillance
56

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Abbreviations

ASPR
Office of the Assistant Secretary for Preparedness and

  Response
CDC
Centers for Disease Control and Prevention
HHS
Department of Health and Human Services
OCIO
Office of the Chief Information Officer
ONC
Office of the National Coordinator for Health Information

  Technology
PAHPA
Pandemic and All-Hazards Preparedness Act
PAHPAIA
Pandemic and All-Hazards Preparedness and Advancing

  Innovation Act of 2019
PAHPRA
Pandemic and All-Hazards Preparedness Reauthorization

  Act of 2013

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GAO-22-104600  Public Health Network
441 G St. N.W.
Washington, DC 20548
June 23, 2022
Congressional Addressees
Catastrophic public health events—such as the COVID-19 pandemic—
can threaten our national security, weaken our economy, cause hundreds
of thousands of casualties, and damage public morale and confidence.
The pandemic drew attention to the urgent need for public health officials
to access real-time information about emerging threats to enable them to
make timely, responsive decisions.
Public health officials rely on information from a number of key sources to
create the situational awareness they need to prepare for and respond to
a variety of public health emergencies. This information includes critical
response resources, medical care capacity, environmental threats, and
the preparedness status of the many public health jurisdictions across the
country. In addition, public health officials need information about health-
related events from data collection and analysis conducted through
biosurveillance.1 Biosurveillance supports early detection of disease
outbreaks, thus enabling more efficient and effective emergency
preparedness and response.
Since 2006, federal laws have mandated that the Department of Health
and Human Services (HHS) take steps toward improving the nation’s
situational awareness of threats related to public health emergencies.2
Specifically, HHS was required to establish a near real-time electronic
nationwide public health situational awareness capability. This capability
was to be based on an interoperable network of systems to facilitate
sharing data and information to enhance early detection of and rapid
response to potentially catastrophic infectious disease outbreaks and
other public health emergencies. The nationwide public health situational

1Biosurveillance is the process of gathering near real-time biological data that relates to
human and zoonotic disease activity and threats to human or animal health in order to
achieve early warning and identification of such health threats, early detection and prompt
ongoing tracking of health events, and overall situational awareness of disease activity.
2Pandemic and All-Hazards Preparedness Act, Pub. L. No. 109-417, 120 Stat. 2831
(2006); Pandemic and All-Hazards Preparedness Reauthorization Act of 2013, Pub. L. No.
113-5, 127 Stat. 161 (2013); Pandemic and All-Hazards Preparedness and Advancing
Innovation Act of 2019, Pub. L. No. 116-22, 133 Stat. 905 (2019).
Letter

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GAO-22-104600  Public Health Network
awareness network was to be built on existing state situational awareness
systems or enhanced systems that enable such interoperability.
The most recent of these laws—the Pandemic and All-Hazards
Preparedness and Advancing Innovation Act of 2019 (PAHPAIA)—
reiterated the need for HHS to improve situational awareness capabilities
by establishing the near real-time electronic nationwide public health
situational awareness capability, among other things.3 PAHPAIA also
includes a provision for GAO to report on HHS’s efforts to implement the
legal requirements.
In addition, the CARES Act includes a provision for us to report regularly
on the federal response to the pandemic. Specifically, the act requires us
to conduct monitoring and oversight of the federal government’s efforts to
prepare for, respond to, and recover from the COVID-19 pandemic.4
Our specific objectives for this review were to determine (1) the extent to
which HHS has made progress toward establishing systems of public
health communications and surveillance, and modernizing public health
situational awareness and biosurveillance in accordance with the
requirements in PAHPAIA; and (2) the challenges and lessons learned
from the COVID-19 pandemic that states, territories, and HHS could
incorporate in the planning and implementation of the public health
situational awareness and biosurveillance network.
To address the first objective, we identified PAHPAIA requirements aimed
at establishing systems of public health communications and surveillance,
and modernizing public health situational awareness and biosurveillance.
We then reviewed available HHS documentation, such as grants,
contracts, and cooperative agreements provided by the department to
states for the establishment of systems of public health alert
communications and surveillance. We also reviewed HHS’s technical and
reporting standards for interoperability and the department’s plans for the
adoption of the standards. We compared these documents against the
act’s requirements we identified. Further, we reviewed HHS’s draft work

3Pub. L. No. 116-22, § 205(a)(4)(A), 133 Stat. at 919 (2019).
4Pub. L. No. 116-136, § 19010, 134 Stat. at 579–81. We regularly issue government-wide
reports on the federal response to COVID-19. These reports are available on GAO’s
website at https://www.gao.gov/coronavirus.

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plan and summarized the progress HHS had made, as of April 2022, in
developing the plan.
We also interviewed relevant HHS officials in the Office of the Assistant
Secretary for Preparedness and Response (ASPR), the Office of the
Chief Information Officer (OCIO), and the Centers for Disease Control
and Prevention (CDC). We interviewed these officials to, among other
things, discuss the actions the department had taken or planned to take
to implement the legal requirements. We also conducted interviews with
officials in the Office of the National Coordinator for Health Information
Technology (ONC) to determine their actions to coordinate with ASPR
and CDC to adopt technical and reporting standards for interoperability.
To address the second objective, we administered a web-based survey to
a relevant public health official in each of the 50 states, the District of
Columbia, and five U.S. territories (hereinafter collectively referred to as
states).5 The survey included questions that solicited state officials’ views
on any COVID-19 challenges they have faced and lessons they have
learned that could inform HHS’s work to develop and implement a
nationwide public health situational awareness and biosurveillance
network. Also included on the survey were questions related to state
systems that support pandemic response. Further, the survey solicited
state officials’ views on HHS coordination and guidance that could help
support states if a near real-time nationwide public health situational
awareness and biosurveillance network was implemented, among other
things.
We administered the survey from September 2021 through December
2021; therefore, the corresponding responses reflected information and
views as of that time period. We received responses from 43 states, for a
77 percent response rate. We assessed the completed or partially
completed responses to the survey questions received from 39 states, the
District of Columbia, and three territories. See appendix I for a copy of the
survey administered to states and the responses for each question.
To supplement the survey information we obtained from the states, we
also interviewed representatives from selected national public health

5The five U.S. territories are Puerto Rico, American Samoa, Guam, the Commonwealth of
the Northern Mariana Islands, and the U.S. Virgin Islands. At times, the public health
officials we administered the survey to forwarded the survey to other officials they felt
were more appropriate to answer the questions. These officials included emergency
preparedness and response and IT staff.

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organizations that collectively represent state and local levels and have
key roles in responding to public health emergencies. We also
interviewed representatives from a selected state association. We used
these interviews to identify common information management challenges
and lessons learned from the COVID-19 pandemic among these
organizations. The organizations we interviewed are the:
•
Association of State and Territorial Health Officials,
•
National Governors Association,
•
Council of State and Territorial Epidemiologists,
•
American Immunization Registry Association,
•
National Rural Health Association,
•
National Association of County and City Health Officials,
•
National Community Pharmacists Association, and
•
Community Health Care Association of New York State.
In addition, we interviewed relevant HHS officials at ASPR, OCIO, and
CDC to discuss any efforts planned or underway to identify, document,
and share challenges and lessons learned from the response to the
COVID-19 pandemic. We compared these efforts against criteria we
identified in a prior GAO report that defined best practices for developing
and disseminating lessons learned for IT investments.6 Lastly, we
reviewed prior GAO reports, such as those issued as part of the CARES
Act provision that requires us to regularly report on the federal response
to the pandemic. We also reviewed relevant reports issued by the HHS
Office of Inspector General. We reviewed these reports to summarize any
lessons learned that we have previously identified. A full description of
our objectives, scope, and methodology can be found in appendix II.
We conducted this performance audit from November 2020 to June 2022
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

6GAO, Information Technology Investment Management: A Framework for Assessing and
Improving Process Maturity, Version 1.1, GAO-04-394G (Washington, D.C.: March 2004).

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the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Public health officials from 59 state and territorial health departments
conduct a variety of public health functions in the United States and its
territories.7 These functions include disease detection, vaccine
administration, and emergency preparedness and response. In addition,
approximately 3,000 county, city, and tribal health departments; about
200,000 public and private clinical laboratories; and multiple federal
agencies also conduct these functions.
Health care providers at the county, city, or tribal level are often the first to
detect a potential public health concern or event. As such, these health
care providers and local public health officials are expected to report
certain events or symptoms of diseases to the state health department
and other designated parties for situational awareness. In many cases,
states may provide supporting personnel, financial resources, laboratory
capacity, and other assistance to local responders when needed. When a
public health event occurs that exceeds or is anticipated to exceed state,
local, or tribal resources, like the COVID-19 pandemic, state governors
may request that the federal government provide resources to assist the
state in its response efforts.
For public health events involving primarily federal jurisdictions or
authorities (e.g., military bases, federal facilities, or federal lands), federal
departments and agencies may be the first responders and first line of
defense in coordinating activities with state, local, and tribal partners.
Along with HHS, several other federal agencies play a role in supporting
public health functions, including the Departments of Agriculture,
Homeland Security, Defense, and Veterans Affairs. Among these, HHS is
the department with primary responsibility for supporting public health
emergency preparedness and response through ASPR, which is to serve
as the federal focal point for coordinating response support for public
health and medical services. Figure 1 provides an illustration of the types
of entities that have a role in sharing information to support nationwide
public health situational awareness.

7These health departments are in the 50 states, District of Columbia, and five U.S.
territories. The remaining three health departments are in three freely associated states:
the Marshall Islands, the Federated States of Micronesia, and Palau.
Background

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Figure 1: Illustration of the Types of Entities That Are to Share Information to Support Nationwide Public Health Situational
Awareness

Because of the many entities involved, the identification and management
of a public health emergency call for effective communication and
collaboration across all levels of government and the public health
community. In this regard, efficient information sharing among these
entities is essential to create and maintain the situational awareness
needed to effectively prepare for, respond to, and manage a public health
emergency.

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Congress has long recognized the importance of HHS’s role in supporting
the nation’s ability to prepare for and respond to health emergencies
through improved situational awareness and biosurveillance. In that
regard, Congress and the President enacted three laws over the last 15
years that required HHS to improve the nation’s public health situational
awareness capability through an interoperable network of systems.8 For
example, the laws require improvements in early detection and rapid
response to potentially catastrophic infectious disease outbreaks, novel
emerging threats, and other public health emergencies that originate
domestically or abroad.
In December 2006, the Pandemic and All-Hazards Preparedness Act
(PAHPA) was enacted, and through provisions of the law, established the
Office of ASPR in HHS.9 Among other things, ASPR is to serve as the
principal advisor to the Secretary of HHS on matters of public health and
medical preparedness and response for public health emergencies. This
official is also responsible for coordinating with state, local, tribal, and
territorial officials to ensure effective management of federal public health
and medical assets in the event of an emergency, among other duties. In
addition, PAHPA established the National Biodefense Science Board.10
This board is to provide expert advice and guidance to the Secretary on
scientific, technical, and other matters regarding current and future
chemical, biological, nuclear, and radiological agents.
Importantly, PAHPA required the Secretary of HHS to develop and submit
a strategic plan to the appropriate committees of Congress by June 16,
2007. The strategic plan was to describe the steps the department would
take to develop, implement, and evaluate an electronic network of
interoperable systems. The network was to be made up of interoperable
systems that would enable the simultaneous sharing of information
needed to enhance situational awareness at the federal, state, local, and
tribal levels of public health. The law required the department to establish
such a network by December 19, 2008. The Secretary subsequently

8Pandemic and All-Hazards Preparedness Act, Pub. L. No. 109-417, 120 Stat. 2831
(2006); Pandemic and All-Hazards Preparedness Reauthorization Act of 2013, Pub. L. No.
113-5, 127 Stat. 161 (2013); Pandemic and All-Hazards Preparedness and Advancing
Innovation Act of 2019, Pub. L. No. 116-22, 133 Stat. 905 (2019). The 2013 act added
biosurveillance activities to the measurable steps that HHS was to include in the
implementation plan required to develop the network.
9Pub. L. No. 109-417, § 102, 120 Stat. at 2832 (2006).
10Pub. L. No. 109-417, § 402, 120 Stat. at 2872 (2006), codified at 42 U.S.C. § 247d-7g.
History of Congressional
Efforts to Improve Public
Health Situational
Awareness and
Biosurveillance
Pandemic and All-Hazards
Preparedness Act

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designated ASPR to be responsible for developing the public health
situational awareness strategy.
However, in December 2010, we reported that the Secretary of HHS had
not met the requirements set forth in PAHPA.11 In particular, we found
that the department had not developed a strategic plan for establishing
the network, among other things.
Thus, we made three recommendations to the Secretary of HHS aimed at
assisting the department in making progress to develop and implement a
comprehensive strategic plan. Specifically, we recommended that the
department develop a strategic plan that (1) defines goals, objectives,
and priorities; (2) includes performance measures for evaluating
capabilities of existing and planned information systems; and
(3) integrates related strategies to achieve unified electronic public health
situational awareness capabilities.
The department neither agreed nor disagreed with the recommendations
but stated that a complete strategy for public health situational awareness
would be developed and incorporated into other relevant strategies within
two years. HHS subsequently implemented two of the three
recommendations by 2015 by developing a strategic plan and
implementation plan for the nationwide public health situational
awareness network. HHS did not implement the third recommendation to
identify within the strategic plan steps and performance measures for
evaluating the capabilities of existing and planned information systems to
establish the network.
PAHPA was reauthorized by the Pandemic and All-Hazards
Preparedness Reauthorization Act of 2013 (PAHPRA). PAHPRA supports
HHS in the awarding of grants, contracts, or cooperative agreements for
establishing integrated systems of public health alert communications and
surveillance between public and private health-related entities.
In addition, the law reiterated the mandate for HHS to develop a strategy
and implementation plan for establishing a near real-time nationwide
public health situational awareness capability through an interoperable
network of systems. The 2013 law added a requirement that HHS include
in its strategy and implementation plan the measurable steps that the

11GAO, Public Health Information Technology: Additional Strategic Planning Needed to
Guide HHS’s Efforts to Establish Electronic Situational Awareness Capabilities,
GAO-11-99 (Washington, D.C.: Dec. 17, 2010).
Pandemic and All-Hazards
Preparedness Reauthorization
Act of 2013

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department will take to modernize and enhance biosurveillance activities.
The strategy was to also identify actions for improving information
sharing, coordination, and communication among disparate
biosurveillance systems supported by HHS. PAHPRA required that the
Secretary of HHS submit the strategy and implementation plan to the
appropriate committees of Congress no later than September 9, 2013.
The act required the nationwide public health situational awareness
network to be established by March 13, 2015.
In May 2014, the Secretary of HHS submitted the Public Health and
Medical Situational Awareness Strategy to Congress. The department
later submitted the accompanying implementation plan in September
2015. In September 2017, we reported that the actions identified in the
implementation plan did not address all of the activities required in
PAHPRA.12 We further reported that HHS did not define the measureable
steps it would take to complete and track the status of activities required
by the law.
We made three recommendations to HHS to (1) task an integrated project
team with including within the implementation plan specific actions for
conducting all activities required to establish and operate the network;
(2) develop a project plan that includes measureable steps that can be
used to guide and monitor HHS’s actions to establish the network; and
(3) conduct oversight of the establishment of the network under the
leadership of the HHS CIO. HHS provided no comment on the report’s
findings or recommendations. All of the recommendations made in 2017
remained unaddressed as of March 2022.
In June 2019, Congress and the President enacted the Pandemic and All-
Hazards Preparedness and Advancing Innovation Act of 2019
(PAHPAIA). The act included statutory requirements for HHS related to
supporting the establishment of systems of public health communications
and surveillance. For example, PAHPAIA requires HHS to develop a plan
to ensure that systems of public health communications and surveillance
allow for the timely sharing and secure dissemination of essential
information concerning bioterrorism or other public health emergencies.
The act further included statutory requirements for HHS related to
modernizing public health situational awareness and biosurveillance.

12GAO, Public Health Information Technology: HHS Has Made Little Progress toward
Implementing Enhanced Situational Awareness Network Capabilities, GAO-17-377
(Washington, D.C.: Sept. 6, 2017).
Pandemic and All-Hazards
Preparedness and Advancing
Innovation Act of 2019

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Notably, HHS was required to establish a near real-time nationwide public
health situational awareness capability through an interoperable network
of systems.
PAHPAIA also includes specific implementation dates for certain
requirements. We discuss HHS’s progress against these requirements
later in this report. Specifically,
•
Conduct Public Meeting by December 21, 2019. HHS was to
conduct a public meeting for the purposes of discussing and providing
input on the goals, functions, and uses of the public health situational
awareness and biosurveillance network. The meeting was to include
relevant federal agencies, as well as state, tribal, territorial, and local
public health officials, and experts in the fields of informatics and data
analytics, among others.
•
Adopt Technical and Reporting Standards by June 24, 2020. HHS
was to adopt technical and reporting standards—such as those for
interoperability—for integrated systems of public health alert
communications and surveillance. The department was to do so in
cooperation with relevant federal agencies, including ONC and the
National Institute for Science and Technology. As part of this
requirement, HHS was to define minimal data elements for the
network; collaborate with state, local, and tribal public health entities
to integrate and build upon existing capabilities for data sharing; and
develop procedures and standards for data collection.
•
Develop Strategy and Implementation Plan by December 24,
2020. HHS was to develop and submit to appropriate congressional
committees a coordinated strategy and implementation plan for
establishing the public health situational awareness and
biosurveillance network.
•
Conduct Network Review by June 24, 2021 and every 6 years
thereafter. HHS was to conduct a review of the elements of the
network, including elements added to advance new technologies that
increase public health situational awareness. HHS was also to provide
the results of the review to its congressional committees of
jurisdiction. Further, the HHS Secretary was to submit a budget plan
for the implementation of the network. The budget plan was to include
(1) a summary of resources previously expended to establish,
improve, and utilize the public health situational awareness and
biosurveillance network; (2) estimates of costs and resources needed
to establish the network; and (3) the identification of gaps in current
capabilities.

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In developing the network, the Secretary is required to consult with
multiple entities. For example, the National Biodefense Science Board is
to provide expert advice, including recommendations regarding the
measurable steps the HHS Secretary should take to modernize and
enhance biosurveillance activities. PAHPAIA also requires HHS to, on a
periodic basis, meet with the Director of National Intelligence to inform on
the development and capabilities of the network. Figure 2 provides an
overview of the PAHPA, PAHPRA, and PAHPAIA requirement time
frames and actual delivery dates.

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Figure 2: Key Legislation on Public Health Situational Awareness and Biosurveillance and Health and Human Services (HHS)
Delivered Requirements to Date

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Beginning in December 2019, COVID-19 spread rapidly across the United
States and other parts of the world.13 Over time, the impacts of COVID-19
were widespread, including catastrophic loss of life and damage to the
economy, security, and stability of the nation. In response, Congress and
the President enacted the CARES Act, which among other things,
directed GAO to conduct monitoring and oversight of the federal
government’s efforts to prepare for, respond to, and recover from the
COVID-19 pandemic.14 We are also to periodically report on, for example,
the effect of the pandemic on public health and the economy.
In September 2020, we noted the need for federal, state, and local public
health officials to have access to adequate, reliable, and real-time
information about the virus to drive future decisions.15 Access to valuable
information in near-real time can allow officials to make more informed
decisions about public health, safety, and resource allocation.
HHS launched the HHS Protect platform in April 2020 to help integrate
COVID-19 data and other types of health information collected by various
federal, state, and local public health and commercial entities. However,
we reported that some public health and state organizations raised
questions about the completeness and accuracy of some of the HHS
Protect COVID-19 data that were intended to support the federal
government’s response to the pandemic.16 We noted that as HHS further
develops its platform, it would be important to consider prior challenges
the department has faced in developing and implementing information
technology systems and data-sharing networks among federal, state, and
local public health entities.

13The outbreak of COVID-19 was first reported on December 31, 2019, in Wuhan, China.
In the weeks that followed, the virus quickly spread around the globe. On January 31,
2020, the Secretary of Health and Human Services declared a public health emergency
for the United States, retroactive to January 27. On March 11, 2020, the World Health
Organization characterized COVID-19 as a pandemic.
14Pub. L. No. 116-136, § 19010(b), 134 Stat. at 580 (2020).
15GAO, COVID-19: Federal Efforts Could be Strengthened by Timely and Concerted
Actions, GAO-20-701 (Washington, D.C.: Sept. 21, 2020).
16GAO-20-701.
Impact of COVID-19 on
Public Health Situational
Awareness

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In January 2021, we reported on the need for more complete and
consistent COVID-19 data to inform health care indicators.17 We noted
that the lack of complete and consistent data limited the ability to monitor
trends in the pandemic and assess the impact of public health actions to
prevent and mitigate the spread of COVID-19. Additionally, we noted that
incomplete and inconsistent data had limited the ability to prioritize the
allocation of health resources in specific geographic areas or among
certain populations most affected by the pandemic.
We recommended, among other things, that HHS immediately establish
an expert committee comprised of knowledgeable health care
professionals from the public and private sectors, academia, and
nonprofits to systematically review and inform the alignment of ongoing
data collection and reporting standards for key health indicators. HHS
partially agreed with our recommendation and stated that it plans to
consider ways to establish more permanent work groups to incorporate
best practices for ongoing interagency data needs and to scale up as
necessary during future public health emergencies. However, we
maintained that immediately establishing an expert committee—not
limited to federal agency officials—is an important and worthwhile effort to
help improve the federal government’s response to COVID-19 and its
preparedness for future pandemics. We continue to monitor HHS’s
progress in implementing this recommendation.
As of March 2022, HHS had not fully implemented most of the statutory
requirements related to supporting the establishment of systems of public
health communications and surveillance. Further, HHS had not
implemented any of the PAHPAIA requirements related to modernizing
public health situational awareness and biosurveillance. Consequently,
more than 15 years after the law initially mandated it, the federal
government does not yet have an interoperable network of systems for
near real-time public health situational awareness.18 Had the network
been available, it could have been used to provide vital information to
public health officials to better manage a timely COVID-19 response.

17GAO, COVID-19: Critical Vaccine Distribution, Supply Chain, Program Integrity, and
Other Challenges Require Focused Federal Attention, GAO-21-265 (Washington, D.C.:
Jan. 28, 2021).
18Pandemic and All-Hazards Preparedness Act, Pub. L. No. 109-417, 120 Stat. 2831
(2006); Pandemic and All-Hazards Preparedness Reauthorization Act of 2013, Pub. L. No.
113-5, 127 Stat. 161 (2013); Pandemic and All-Hazards Preparedness and Advancing
Innovation Act of 2019, Pub. L. No. 116-22, 133 Stat. 905 (2019).
HHS Made Minimal
Progress toward
Establishing a Public
Health Situational
Awareness and
Biosurveillance
Network

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As of March 2022, HHS had taken action to fulfill some, but not all, of the
statutory requirements related to supporting the establishment of systems
of public health communications and surveillance. Specifically, HHS
implemented the requirement to adopt technical and reporting standards,
but did not fully implement the remaining requirements related to
providing for the establishment of systems of public health
communications and surveillance. Table 1 summarizes the statutory
requirements related to supporting the establishment of systems of public
health communications and surveillance and the extent to which HHS has
implemented them.
Table 1: Statutory Requirements Related to Supporting the Establishment of Systems of Public Health Communications and
Surveillance and the Extent to Which HHS Has Implemented Them as of March 2022
Summary of requirements
Implementation
status
Provide for the establishment of systems of public health communications and surveillance
Adopt technical and reporting standards, including standards for interoperability, for integrated systems of
public health alert communications and surveillance, and update such standards as necessary.
●
Provide grants, contracts, or cooperative agreements for establishing integrated systems of public health alert
communications and surveillance.
◑
Develop a plan to, and ensure that integrated systems of public health alert communications and surveillance
allow for the timely sharing and secure discussion of essential information.
○
Legend:
● Requirement is fully implemented
◑ Requirement is partially implemented
○ Requirement is not implemented
Source: GAO analysis of The Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019 (PAHPAIA) and Department of Health and Human Services (HHS) data. I GAO-22-104600

Adopt technical and reporting standards. PAHPAIA requires that HHS
adopt technical and reporting standards, including standards for
interoperability, for integrated systems of public health alert
communications and surveillance, and update the standards as
necessary.19 To that end, ONC has adopted various standards to promote
public health system interoperability and health information exchange.
According to ONC officials, the standards are developed through a
consensus-based process by nationally recognized standards
development organizations. In 2017, ONC established the Interoperability
Standards Advisory. The Advisory includes all of the standards and

19According to the National Institute of Standards and Technology, interoperability is the
ability of one entity to communicate with another entity, whether the entities are people,
devices, or processes.
HHS Made Partial
Progress toward Fulfilling
Public Health
Communications and
Surveillance
Requirements

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implementation specifications that can be used by the U.S. health care
industry to address specific interoperability needs for clinical, public
health, and research purposes.
To illustrate, in February 2020, ONC released the United States Core
Data for Interoperability—a standardized set of data elements intended
for nationwide, interoperable health information exchange. According to
ONC officials, the standards included in the Interoperability Standards
Advisory are frequently updated to include improvements made based on
recommendations received from public comments and feedback from
subject matter experts. Version 3 of the United States Core Data for
Interoperability is planned for July 2022. Other interoperability standards
ONC has adopted relate to patient allergic reaction, COVID-19
vaccination, and patient medication data, among other things.
Provide grants to establish integrated systems. PAHPAIA supports
HHS in the awarding of grants, contracts, or cooperative agreements for
establishing integrated systems of public health alert communications and
surveillance between various entities. These entities include federal,
state, and local public health entities. CDC, a component of HHS, has
provided funding to states for the establishment of various public health
alert communications and surveillance systems.
According to CDC officials, the agency invests in a broad range of public
health data and surveillance systems and capabilities, many of which play
a role in the surveillance of public health threats at the federal, state, and
local levels. However, according to these officials, there is not a clear way
to define and distinguish CDC grants, contracts, or cooperative
agreements to provide for, as required by law, the establishment of
integrated systems of public health communications and surveillance.
CDC officials stated that the agency does not categorize its surveillance
activities and funding lines with specific situational awareness and
biosurveillance objectives.
According to CDC, the agency supports activities related to situational
awareness and biosurveillance by investing in individual system-specific
investments through other funding mechanisms.20 However, the funding
CDC provided for these systems was not contingent on them being

20According to CDC officials, the other funding mechanisms include, for example, CARES
Act funding.

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GAO-22-104600  Public Health Network
integrated between public health entities, as required by PAHPAIA and
other related laws. Table 2 shows examples of the funding that CDC has
provided for various systems using funds appropriated for the last 2 fiscal
years, as well as through the CARES Act to support public health
communications and surveillance activities.21
Table 2: Examples of Public Health Communications and Surveillance Systems Funded by the Centers for Disease Control
and Prevention (CDC)

Fiscal year 2020
Fiscal year 2021a
CARES Act fundingb
National Syndromic Surveillance
Programc
$23,000,000
$23,000,000
$11,000,000
National Respiratory and Enteric
Virus Surveillance System
$1,320,000
$400,000
$11,300,000d
Flu Vaccine Effectiveness Network
$7,600,000
$5,335,572
$10,149,551
COVID-19 – Associated
Hospitalization Surveillance
Network
$20,000,000
$5,600,000
Not applicable for
this funding source
New Vaccine Surveillance Network
$5,999,994
$2,500,000
$11,900,000e
National Healthcare Safety Network
$21,000,000
$21,000,000
$17,505,379
Source: Department of Health and Human Services data. I GAO-22-104600
Note: For a description of these systems, see appendix III.
aFiscal year 2021 column notes funds from fiscal year 2021 appropriations that are not funds
appropriated by the CARES Act.
bCARES Act column shows funding that was appropriated through the CARES Act, which was
separate from other appropriations in fiscal years 2021 and 2022.
cThe National Syndromic Surveillance Program is supported by CDC’s BioSense platform that allows
for the analysis of public health data gathered from hospitals, urgent care facilities, and laboratories.
This program also involves collaboration among federal, state, local, academic, and private partners
who share and analyze data to identify and monitor health events.
dThis amount represents broader funding to build a Pan-Respiratory Surveillance System for tracking
and assessing multiple respiratory pathogens. The Pan-Respiratory Surveillance System is intended
to integrate existing CDC respiratory surveillance systems and modernize specific State Public Health
Laboratory data messaging systems.
eThis amount represents broader funding to electronically incorporate vaccine information from the
immunization information systems into the integrated disease surveillance system, and support
enhancement of a centralized hub for the exchange of vaccine and immunity data with state, tribal,
local, and territorial immunization information systems.

Develop a plan for sharing and securing information. PAHPAIA
requires that HHS develop a plan to ensure that integrated systems of
public health alert communications and surveillance allow for the timely

21CDC officials stated that the six systems listed in the table are examples of systems that
CDC has provided funding for regarding public health communications and surveillance
activities.

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sharing and secure discussion of essential information among federal,
state, and local health entities. However, HHS had not taken steps to
develop such a plan.
As of March 2022, HHS had not taken any action to fulfill the
requirements in PAHPAIA related to modernizing public health situational
awareness and biosurveillance, including those mandating that HHS plan
for the public health situational awareness and biosurveillance network.
Table 3 summarizes the PAHPAIA requirements related to modernizing
public health situational awareness and biosurveillance and the extent to
which HHS has implemented them.
Table 3: PAHPAIA Requirements Related to Modernizing Public Health Situational Awareness and Biosurveillance and the
Extent to Which HHS Has Implemented Them as of March 2022
Summary of requirements
Implementation
status
Modernize public health situational awareness and biosurveillance
Establish a near real-time electronic nationwide public health situational awareness and biosurveillance
capability through an interoperable network of systems to share data and information.
○
Facilitate coordination among relevant agencies and consult with the Secretaries of Agriculture, Commerce
(and the Director of the National Institute of Standards and Technology), Defense, Homeland Security,
Veterans Affairs, and the heads of other Federal agencies, as appropriate.
○
Conduct a public meeting with experts in public health, biosurveillance, and situational awareness by
December 21, 2019 to discuss and provide input on the potential goals, functions, uses, and elements of a
near real-time electronic nationwide public health situational awareness capability through an interoperable
network of systems.
○
In establishing and operating a public health situational awareness and biosurveillance network, utilize
applicable interoperability standards; define minimal data elements; integrate and build upon existing state,
local, and tribal capabilities; and develop procedures and standards for the collection, analysis, and
interpretation of data, among other things.
○
Submit to Congress a coordinated strategy and implementation plan by December 24, 2020 that includes a
review and assessment of existing capabilities; measurable steps the department will carry out to develop
and implement the network; and performance measures and target implementation dates for each
measurable step.
○
Conduct a review of the data and information transmitted by the network by June 24, 2021 and every 6
years thereafter. The review is to include a discussion of any additional data sources and any challenges in
the incorporation of standardized data from various sources.
○
Develop a budget plan by June 24, 2021, and on an annual basis thereafter, that includes resources
previously expended to establish, improve, and utilize the public health situational awareness and
biosurveillance network; estimates of costs and resources needed to establish the network; and the
identification of gaps in current capabilities.
○
Consult with the National Biodefense Science Board in carrying out the requirements for the network. The
board is to identify the steps needed to achieve a national biosurveillance system for human health, and
identify any duplicative surveillance programs and gaps in the programs, among other things.
○
HHS Took No Actions to
Fulfill PAHPAIA
Modernization
Requirements

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Summary of requirements
Implementation
status
Periodically meet with the Director of National Intelligence to inform the development and capabilities of the
public health situational awareness and biosurveillance network.
○
Legend:
● Requirement is fully implemented
◑ Requirement is partially implemented
○ Requirement is not implemented
Source: GAO analysis of The Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019 (PAHPAIA) and Department of Health and Human Services (HHS) data. I GAO-22-104600

In particular, HHS did not meet the four requirements that had specific
delivery dates. For example, HHS was required to conduct a public
meeting with stakeholders and experts on the potential goals and uses of
a nationwide public health situational awareness and biosurveillance
network by December 21, 2019. As of March 2022, HHS had not
conducted the meeting. In another example, HHS was required to submit
to Congress a coordinated strategy and implementation plan by
December 24, 2020 that discussed the functions of the network, among
other things. HHS had developed a strategy in 2014 and an
implementation plan in 2015 in response to PAHPRA—the predecessor
to PAHPAIA. However, ASPR officials stated in May 2021 that those
plans were no longer valid. As of March 2022 and over a year after they
were due to Congress, HHS had not developed a new strategy and
implementation plan. Further, HHS had not defined how it would use
applicable interoperability standards when establishing and operating the
public health situational awareness and biosurveillance network.
It is important for HHS to define how new or existing standards for
interoperability will be used for the network because many states reported
that they are planning to modernize their systems. Specifically, 33 of 43
states responding to the survey reported that they planned on
modernizing their systems that support public health situational
awareness and biosurveillance activities. The states noted that their
modernization plans include the capability to interface with federal and
other state systems to share data for common reporting or analysis to
effectively respond to pandemics. As many states prepare for system
modernization, a federal plan that demonstrates how new or existing
standards for interoperability will be used for the network once
implemented would better prepare states for future needs.
HHS officials stated that while the various implemented medical and
public health surveillance systems may not yet be the fully integrated

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capability that PAHPAIA requires, the process of creating an
interoperable, real-time system is iterative. For example, CDC stated that
the Data Modernization Initiative and HHS Protect are examples of efforts
that had been initiated. CDC believes that these efforts at least partially
satisfy the requirement to establish a near real-time electronic nationwide
public health situational awareness and biosurveillance network. The
officials added that HHS Protect aimed to integrate health information
collected by different entities to support the COVID-19 response. They
further added that the systems implemented for COVID-19 could be used
for a broader scope if budgeted.
We agree that HHS has implemented several systems related to public
health situational awareness and biosurveillance, as discussed in
appendix III. However, the law called for a near real-time electronic
nationwide public health situational awareness and biosurveillance
capability through an interoperable network of systems to share data and
information. This capability was to be made up of interoperable systems
that would enable the simultaneous sharing of information needed to
enhance situational awareness at the federal, state, local, and tribal levels
of public health. This capability does not exist today.
The minimal progress in establishing systems of public health
communications and surveillance and modernizing public health
situational awareness and biosurveillance is due, in part, to HHS not
prioritizing the development and implementation of the network. To
demonstrate, HHS had not established a management and governance
structure. Specifically, HHS did not have a lead operational division with
defined roles and responsibilities, or an organization to provide oversight
of the implementation of the activities required by PAHPAIA and other
related laws. According to CDC officials, ASPR facilitates the coordination
and strategy for medical situational awareness activities, and shares
responsibility with HHS OCIO, CDC, and other agencies for the
implementation of those capabilities. However, HHS officials were often
unsure who was responsible for answering specific questions we asked
related to the progress they had made in meeting the requirements in
PAHPAIA and other related laws—indicative of the lack of clear roles and
responsibilities.
The Lack of a
Management and
Governance Structure for
Oversight of PAHPAIA
Implementation Has
Hindered Progress

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We have previously reported that clear roles and responsibilities during a
pandemic have been a longstanding concern.22 For more than a decade,
we have reported on HHS’s execution of its lead role in preparing for, and
responding to, a range of public health emergencies and have found
persistent deficiencies in its ability to perform this role. These deficiencies
have hindered the nation’s response to the current COVID-19 pandemic
and a variety of past threats, including other infectious diseases—such as
the H1N1 influenza pandemic, Zika, and Ebola—and extreme weather
events, such as hurricanes. We have also reported that lessons from the
initial COVID-19 response, as well as experience from past economic
crises, disasters, and emergencies highlight the importance of having
clear goals and defining roles and responsibilities among those
responding to a crises.23
We have also reported that federal leadership roles and responsibilities,
including those at HHS, need to be robust and rigorously tested as they
evolve to ensure clarity in how relationships should work during
emergencies. In January 2022, we added HHS’s leadership and
coordination of a range of public health emergencies to our High-Risk List
to help ensure sustained executive branch and Congressional attention
so that our nation is adequately prepared for future threats.24 Without a
management and governance structure, including defined roles and
responsibilities, to oversee the activities required by PAHPAIA and other
related laws, HHS and the federal government will continue to lack the
comprehensive capabilities needed to allow for the timely and secure
sharing of information to detect, manage, and respond to infectious
disease outbreaks like COVID-19.
During our review, ASPR, CDC, and the OCIO began drafting a work plan
that is intended to address PAHPAIA requirements. At the time of our

22GAO, COVID-19: Significant Improvements Are Needed for Overseeing Relief Funds
and Leading Responses to Public Health Emergencies, GAO-22-105291 (Washington,
D.C.: Jan. 27, 2022).
23GAO, COVID-19: Opportunities to Improve Federal Response and Recovery Efforts,
GAO-20-625 (Washington, D.C.: June 25, 2020).
24GAO-22-105291. We designate federal programs and operations as “high risk” due to
their vulnerabilities to fraud, waste, abuse, and mismanagement, or because they need
transformation. We consider qualitative factors, such as whether the risk involves public
health or safety. For information on how we determine which federal government
programs and functions should be designated high risk, see GAO, Determining
Performance and Accountability Challenges and High Risks, GAO-01-159SP
(Washington, D.C.: November 2000). For more information on programs and operations
on our High-Risk List, see https://www.gao.gov/high-risk-list.

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review, ASPR did not have a time frame for completing and finalizing the
work plan.
The draft work plan includes proposed roles and responsibilities for the
governing and decision-making body, federal lead entity, and participating
entities— including federal departments and agencies—for the public
health situational awareness and biosurveillance network. According to
HHS officials, the work plan will include an update of the 2014 strategy
and 2015 implementation plan. They added that the work plan will also
include measurable steps, a timeline of tasks, resource requirements,
estimated costs, and performance metrics to guide and monitor HHS’s
actions to establish the public health situational awareness and
biosurveillance network. Officials further stated that ASPR has recently
hired a Chief Health Informatics Officer responsible for managing and
coordinating health informatics strategies, and will focus on improving
interoperability and innovation for ASPR.
Until HHS finalizes and implements the work plan, it will continue to lack
any significant progress in implementing the various statutory
requirements enacted over the last 15 years, including the establishment
of a public health situational awareness and biosurveillance network.
States and public health organizations experienced a variety of
challenges and identified lessons learned from the COVID-19 pandemic
that could be incorporated in the planning and implementation of a public
health situational awareness and biosurveillance network. Specifically,
states most often reported that the lack of human capital-related IT
resources, interoperability among systems, technology resources, and
clarity of guidance from the federal government were their top challenges
related to the management of public health information during the
pandemic. Public health organizations identified additional challenges,
such as limitations on data collected, increased reporting requirements,
and impediments to health-related data sharing and collaboration.
Furthermore, states and public health organizations identified lessons
learned related to improving public health reporting, collaborating early
with stakeholders, establishing a public health infrastructure, establishing
a data management framework, and investing in an IT health-related
workforce. However, as of March 2022, HHS had not identified,
documented, shared, and incorporated its challenges or lessons learned
from the COVID-19 pandemic into the planning and implementation of the
public health situational awareness and biosurveillance network.
Public Health Entities
Identified Challenges
and Lessons Learned
from COVID-19 that
Could Help HHS
Establish a
Situational Awareness
Network

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States responding to our survey identified a number of challenges that
they experienced in the management of public health information during
the pandemic.25 States varied in their views on the extent of each
challenge. Figure 3 provides the views of the states for each reported
challenge.

25We administered a web-based survey to public health officials within the 50 states, the
District of Columbia, and five U.S. territories. The territories are Puerto Rico, American
Samoa, Guam, the Commonwealth of the Northern Mariana Islands, and the U.S. Virgin
Islands. At times, the public health officials we administered the survey to forwarded the
survey to other officials they felt were more appropriate to answer the questions. These
officials included emergency preparedness and response and IT staff.
States Identified
Challenges in Responding
to COVID-19

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Figure 3: State Views of Challenges in the Management of Public Health Information during the COVID-19 Pandemic

aOther constraints include managing communications in light of complex information resources and
addressing an abundance of misinformation regarding pandemic response.

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The following summarizes the challenges state survey respondents most
often rated as challenging with regard to the management of public health
information during the COVID-19 pandemic. In addition, representatives
from public health organizations identified similar challenges.
•
Human capital-related IT resources. Forty of 43 states rated human
capital-related IT resources as challenging during the pandemic.26 For
example, one state reported that there were not enough trained IT
staff across the state to support various public health IT initiatives due
to funding and hiring limitations. Another state lacked staff with
experience in public health and informatics to support needed
improvements in electronic laboratory and case reporting.
Additionally, representatives from a public health organization
reiterated that a lack of human capital-related IT resources was a
challenge. Specifically, the representatives stated that they have had
difficulty in recruiting people with the right skill sets to manage health
IT systems because of limited compensation and competition for
similar skills within the federal and private sectors.
•
Interoperability among systems. Thirty-nine of 41 states rated
interoperability among systems as challenging. For example, in
describing the challenge, one state noted that interoperability between
its immunization information system and its surveillance system has
yet to be achieved. Another state reported that because of the lack of
interoperability among its health department systems, public health
officials and stakeholders (e.g., hospitals, vaccination partners, and
other state agencies) are required to manually input data into different
systems.
Additionally, representatives from public health organizations stated
that interoperability was also a challenge. The representatives
reported difficulty in sharing data between states due to disparate,
legacy systems, such as immunization information systems, that are
not interoperable and in urgent need of an upgrade. The public health
organization representatives also stated that many local health
departments had to report data manually because their systems
lacked interoperability. In contrast, laboratory and hospital emergency
room data were more automated and complete based on systems and
reporting processes already in place prior to the pandemic.

26Examples of human capital-related IT resources include inadequate staffing, training,
and technical competence.

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•
Technology resources. Thirty-eight of 43 states rated technology
resources as challenging. For example, one state described that its
existing technologies and infrastructure were inadequate to address
the response demands brought on by the pandemic. More specifically,
this state noted that its disease surveillance system could only handle
an average of a hundred concurrent users at any given time. As a
result, the state had to rapidly adapt to handle the exponential
increase in electronic laboratory reports by making system
enhancements and increasing data storage and processing
capabilities. Another state described the lengthy time frames and high
costs for procuring vendors as a challenge when significant
enhancements to health IT systems are needed quickly.
Additionally, a report from a public health organization estimated that
it would take approximately $7.8 billion over 5 years to modernize
state, territorial, local, and tribal public health data, including
modernizing public health systems. According to representatives from
this organization, the state and local public health data infrastructure
is severely underfunded, fractured, and outdated. The representatives
also stated that the investments made as part of the Data
Modernization Initiative at CDC was a positive step—$50 million in
fiscal year 2020, $50 million in fiscal year 2021, $500 million in the
CARES Act, and approximately $300 million in the American Rescue
Plan Act of 2021.27 However, the representatives added that
additional funding is needed at the state, local, tribal, and territorial
levels to fully modernize a public health infrastructure, and to attract
and retain a supporting workforce.
•
Clarity of guidance. Thirty-eight of 43 states rated clarity of guidance
also as challenging. For example, several states noted that federal
guidance changed multiple times over the course of the early stages
of the pandemic. Another state noted that in the initial stages of the
COVID-19 pandemic, guidance from CDC, the White House, and
HHS concerning personal protective equipment levels, effective
treatment options, and masking were not always clear and easily
understood, which led to confusion. Additionally, a representative from
a public health organization agreed that this was a challenge and
stated that guidance from HHS on data standards was needed to

27Launched in 2020, CDC’s Data Modernization Initiative is a multi-year effort to
modernize core data and surveillance infrastructure across the federal and state public
health landscape. Section 2404 of the American Rescue Plan Act of 2021, Pub. L. No.
117-2, § 2404, 135 Stat. 4, 42 (2021) provides $500 million to CDC, available until
expended, for activities to support public health data surveillance and analytics
infrastructure modernization initiatives.

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GAO-22-104600  Public Health Network
support states’ efforts to build their technological infrastructure and
provide for system interoperability.
Representatives from public health organizations identified similar
challenges that the states faced during the COVID-19 pandemic
response.28 In addition, representatives from these organizations
identified other common challenges. The following summarizes these
challenges.
•
Limitations on data collected. Representatives reported challenges
with collecting complete demographic data for use in identifying trends
in COVID-19 vaccinations and the number of COVID-19 vaccine
doses administered. Similar challenges were experienced in a prior
public health emergency. For example, we reported in January 2021
that due to variations in states’ immunization tracking systems and
capabilities, limited information was available nationally on the
number of H1N1 vaccine doses administered.29 We further reported
that according to a state immunization official, just one-quarter of
states required patient-level reporting on H1N1 vaccine administration
to state registries.
•
Increased reporting requirements. Representatives described
difficulty in managing the increasing demand for reporting health data
to relevant authorities. Specifically, they stated that it was difficult for
state and local health officials to manage the increase in the
information that was expected to be reported to governors, legislators,
health officials, and to the federal government during the rollout of
COVID-19 vaccines by new providers and partners (e.g., medical
clinics, hospitals, and pharmacies) to address the pandemic.
•
Impediments to health-related data sharing and collaboration.
Representatives stated that data sharing and collaboration is
challenging because states and local jurisdictions have separate
vaccination management systems and have limited visibility into other

28We interviewed representatives from selected public health organizations at the
national, state, and local level that have key roles in responding to public health
emergencies. These organizations were the Association of State and Territorial Health
Officials, National Governors Association, Council of State and Territorial Epidemiologists,
American Immunization Registry Association, National Rural Health Association, National
Association of County and City Health Officials, National Community Pharmacists
Association, and Community Health Care Association of New York State.
29GAO-21-265. In the spring of 2009, H1N1, a novel influenza A virus emerged and was
detected first in the United States. Subsequently, this virus spread quickly across the
United States and the world.
Public Health
Organizations Identified
Challenges in Responding
to COVID-19

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GAO-22-104600  Public Health Network
states’ data and no visibility into vaccination data at the federal level.
The representatives further added that they were not aware of the
HHS Protect system and wished it had been promoted more as a tool
states could use. Other representatives noted that improved
collaboration is needed with external entities to better understand how
rural health facilities are managed and how state and local public
health entities coordinate with them.
Thirty of 43 states noted that they had identified lessons learned from the
COVID-19 pandemic related to the management of public health
information. The following summarizes three lessons learned that states
identified most often. In addition, representatives from public health
organizations also identified similar lessons learned.
•
Improve public health reporting. Sixteen of 30 states identified
improving public health reporting as a lesson learned during the
pandemic. For example, one state reported that data sharing should
be established with surrounding states to ensure that early detection
surveillance and planning needs are identified prior to a surge in local
communities. This state noted that data sharing on bed capacity,
ventilator usage, and hospitalization statistics in real-time would have
been helpful in determining surveillance needs. Additionally, this state
noted that specific state surveillance details that demonstrate, for
example, how different age groups and health care workers are
impacted by COVID-19 could have helped with pandemic response.
Another state reported that standardized HHS reporting of data, such
as in the reporting of COVID-19 cases, tests, or deaths, would be
more beneficial for its needs. The state further noted that HHS
developed various reports through the gathering of web-based health
data from a university, which is not standardized, rather than from
state health department data.
•
Collaborate early with stakeholders. Seven of 30 states reported
collaborating early with stakeholders as a lesson learned during the
pandemic. For example, one state reported that state, territory, local,
and tribal jurisdictions should be involved in the initial planning phase
with federal public health officials before decisions are made that may
impact them. Another state reported that public health stakeholders,
including those at the state and local level, should be engaged not
only at the beginning, but throughout the entirety of public health
emergency response activities.
A representative from a public health organization agreed with the
need for stakeholder collaboration, stating that rural health partners, in
States and Public Health
Organizations Identified
Lessons Learned That
HHS Could Use in
Planning for the Network

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GAO-22-104600  Public Health Network
particular, need to be included as stakeholders and collaborate more
with federal and state public health officials in order to more effectively
support a public health situational awareness system. One state noted
a positive experience with collaboration and stated that various
departments within the state collaborated to understand how COVID-
19 was being spread in order to respond to it. This state also reported
sharing resources including workers and volunteers, as well as
equipment, vehicles, and supplies from different departments during
the COVID-19 response.
Representatives from public health organizations also noted that
during the implementation of HHS Protect, states, territories, and local
and tribal entities were often not involved as stakeholders. This
resulted in challenges associated with duplicative and inefficient
processes. For example, the representatives stated that some of the
data HHS requested be reported from hospitals were already being
reported as part of electronic case reporting at the state and local
level.30 However, those already established reporting mechanisms
were not being used. The representatives also cited an example of a
hospital staff member being solely responsible for reporting HHS
Protect data to CDC when the data was easily available through
electronic case reporting.31
•
Establish a public health infrastructure. Five of 30 states reported
establishing a public health infrastructure as a lesson learned during
the pandemic. For example, a state reported that a technological
infrastructure or backbone is needed to enable data sharing with state
agencies and departments, including private and federal partners.
Such a technological infrastructure or backbone could be achieved by
establishing the network required by PAHPAIA and other relevant
laws. The official explained that during the COVID-19 pandemic, the
state was manually collecting, processing, and transferring data from
one place to another. More specifically, the official described having to
fax documents, make copies, and transport documents via vehicles to
get information where it was needed. The state added that by
establishing this infrastructure, errors would be reduced from
manually inputting data and the loss of documents from manually

30Electronic case reporting is the automatic submission of disease reports directly from
electronic health records at clinical care organizations to state, local, tribal, and territorial
public health departments.
31We examined HHS Protect hospital capacity reporting requirements and the challenges
experienced by reporting entities, among other things. See GAO, COVID-19: HHS’s
Collection of Hospital Capacity Data, GAO-21-600 (Washington, D.C.: Aug. 5, 2021).

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GAO-22-104600  Public Health Network
transporting them would be avoided. The state further added that
establishing a redundant network connection would also provide
continuity of operations when a portion of the network fails. In another
example, a state highlighted the importance of having a well-built,
comprehensive, and integrated disease surveillance system.
In addition to the lessons learned identified by the states through the
survey, representatives from public health organizations described
lessons learned from the COVID-19 pandemic. The following summarizes
these lessons learned.
•
Establish a data management framework. Representatives from
public health organizations said that COVID-19 has demonstrated the
need for a national data management framework. They stated that
HHS needed to engage with state and local public health entities to
define and agree on common terminology and data elements. One
example they cited was that core data elements for an HIV
surveillance system should be the same core data elements, or use
the same terminology, as the system used for tracking Hepatitis, as
these diseases have common characteristics that are tracked for
public health surveillance. However, data for tracking HIV and
Hepatitis diseases are collected in different surveillance systems,
creating redundancy.
Representatives from public health organizations reiterated the need
for HHS to define the purpose of the public health situational
awareness and biosurveillance network required by PAHPAIA and
other relevant laws. In addition, they added that HHS should
coordinate with state, local, and territorial public health entities to
define common data elements, a data strategy, the type of data that
will be required for the network, and the ownership of the data.
•
Invest in an IT health-related workforce. A representative from a
public health organization described the need for greater investments
in the IT health-related workforce because health departments do not
have all the technical and health care-related skillsets necessary to
address their needs. More specifically, the representative stated that
there needs to be a better understanding of public health by the IT
workforce because they may not have a full understanding of the
specific IT needs of public health practitioners.

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GAO-22-104600  Public Health Network
GAO’s IT Investment Management Framework stresses the importance of
identifying lessons learned to support future investment decisions.32
Lessons learned can be leveraged from an event to inform future efforts
and limit the chance of recurring challenges. We have previously reported
that mechanisms for documenting, sharing, and disseminating lessons
learned serve to communicate acquired knowledge more effectively and
ensure that beneficial information is incorporated into planning, work
processes, and activities. Lessons learned provide a powerful method of
sharing good ideas for improving work processes, quality, safety, and
cost-effectiveness. They can be based on positive experiences or on
negative experiences that result in undesirable outcomes. The framework
notes that gathering lessons learned should be ongoing because
stakeholders’ perspectives can be lost or forgotten over time. Additionally,
it is important to disseminate lessons learned since lessons are of little
benefit unless they are distributed and used by people who will benefit
from them.
In July 2021, the Public Health Data Systems Task Force provided ONC
a set of recommendations to help inform HHS’s response to an executive
order on ensuring a data-driven response to COVID-19 and future high-
consequence public health threats.33 The task force’s recommendations
focused on the challenges, gaps, and the ideal future state for data
sharing between public health systems and clinical data sources (such as
electronic health records, laboratory systems, immunization information
systems, syndromic surveillance, and case reporting). The task force
provided ONC with 52 recommendations including those related to public
health data systems infrastructure. The recommendations were also
related to situational awareness data; standards development and
adoption; and improving engagement between public health authorities,
healthcare organizations, practitioners, and governing bodies at the
federal, state, and local levels. According to ONC, the White House will
determine whether the recommendations should be implemented.
While these recommendations are a positive step toward recognizing
improvements are needed in public health situational awareness, it is
unclear whether HHS is taking action to implement them. Further, the

32GAO-04-394G.
33The White House, Executive Order 13994, Ensuring a Data-Driven Response to COVID-
⁠19 and Future High-Consequence Public Health Threats,” (January 21, 2021). Among
other things, the order tasked HHS with reviewing the effectiveness, interoperability, and
connectivity of public health data systems supporting the detection of and response to
high-consequence public health threats, such as the COVID-19 pandemic.
HHS Did Not Identify and
Document Challenges and
Lessons Learned from
COVID-19 for the
Situational Awareness and
Biosurveillance Network

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GAO-22-104600  Public Health Network
scope of the review was narrowly focused. At the time of our review, HHS
had not taken steps to identify, document, and share challenges and
lessons learned in the management of public health information that it,
states, and public health organizations experienced as a result of the
pandemic. These challenges and lessons learned could be incorporated
into the planning and implementation of the public health situational
awareness and biosurveillance network required by PAHPAIA and other
related laws. We reported in November 2021 that CDC officials planned
to develop an agency-wide COVID-19 after action review that included a
formal process for identifying lessons learned within HHS.34 However, this
after action review had not taken place as of March 2022 and would not
include lessons learned from other federal, state, and local public health
agencies.
According to HHS officials in ASPR and CDC, the department had not
taken steps to identify and document lessons learned from COVID-19—
including those related to IT and system challenges—because they
viewed the lessons learned process as ongoing. ASPR officials also
stated that HHS is still responding to the pandemic and has been
integrating lessons learned during real-time response throughout this time
period. The officials added that they were working to establish a COVID
lessons learned portal but did not provide a timeframe for completing that
activity. However, HHS officials could not demonstrate that they had
integrated lessons learned during the COVID-19 response.
While we agree that an ongoing, iterative lessons learned process can be
beneficial, important lessons can be identified and documented from over
two years of continual COVID-19 response activities. For example,
representatives from public health organizations told us that they were not
able to access HHS Protect information at a useful, granular level
because it was summarized. As a result, these officials stated that they
were not able to obtain, for example, all the necessary data from HHS
regarding COVID-19 vaccination dose allocations in their jurisdictions to
assist them in determining what additional vaccination supplies may be
needed.
Given the state challenges we identified earlier, obtaining stakeholder
perspectives on lessons learned and sharing these lessons with other
stakeholders could provide invaluable information for future pandemic

34GAO, COVID-19: HHS Agencies’ Planned Reviews of Vaccine Distribution and
Communication Efforts Should Include Stakeholder Perspectives, GAO-22-104457
(Washington, D.C.: Nov. 4, 2021).

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GAO-22-104600  Public Health Network
system implementation efforts. Also, incorporating these lessons learned
into future plans for developing the network would increase its chances
for successful implementation. Until HHS takes steps to identify,
document, share, and incorporate lessons learned from the COVID-19
pandemic, opportunities to improve the response to future and ongoing
public health emergencies by learning from past challenges will likely be
missed.
In commenting on a draft of this report, HHS stated that the department
continues to incorporate lessons learned early in the current response
efforts. For example, officials stated that HHS responded to stakeholder
input about the burden of COVID-19 hospital data reporting in its COVID-
19 hospital reporting requirement guidance updates by decreasing the
number or required data elements and flexibility in reporting data from
weekends and holidays to the next business day. While this is a positive
step, as discussed earlier, HHS had not taken steps, at the time of our
review to identify and document lessons learned from COVID-19 and
could not provide information related to lessons learned.
In the over 15 years since the enactment of the first of three laws aimed
at improving pandemic-related information sharing, the federal
government remains without a near real-time electronic nationwide public
health situational awareness and biosurveillance network. By March
2022, HHS completed minimal actions required by PAHPAIA. While it
provided grants to states for situational awareness and biosurveillance
systems and adopted standards for interoperability, it is not clear how
these efforts directly contribute to establishing the public health situational
awareness and biosurveillance network required by law. The department
has also not taken any action to complete the remaining requirements in
PAHPAIA, including establishing the network. While HHS has begun
drafting a work plan that is intended to address PAHPAIA requirements,
the department could not provide a time frame for when the plan would be
completed and finalized. The minimal progress that HHS has made in
fulfilling PAHPAIA requirements is due, in part, to the lack of an
established management and governance structure, such as a lead
operational division, to oversee the activities required by PAHPAIA and
other related laws. Without a management and governance structure to
oversee the activities required by law, HHS and the federal government
will likely continue to lack the comprehensive capabilities needed to allow
for the timely response to infectious disease outbreaks like COVID-19.
While HHS had over 2 years of experience in responding to COVID-19,
the department had not taken steps to identify, document, and share
Conclusions

Page 34
GAO-22-104600  Public Health Network
challenges and lessons learned from the pandemic that could be
incorporated into the planning and implementation of the public health
situational awareness and biosurveillance network. Further, while officials
planned to develop an agency-wide COVID-19 after action review that
included challenges and lessons learned, as of March 2022, HHS had not
done so. Until the department takes these steps, it will likely miss
opportunities to improve the response to the ongoing and future public
health emergencies.
We are making the following 12 recommendations to HHS:
The Secretary of HHS should prioritize the development of the public
health situational awareness and biosurveillance network by designating
a lead operational division for PAHPAIA implementation.
(Recommendation 1)
The Secretary of HHS should clearly define the roles and responsibilities
for the lead operational division responsible for PAHPAIA implementation.
The roles and responsibilities should include the specific activities
required in PAHPAIA. (Recommendation 2)
The Secretary of HHS should identify the office responsible for
overseeing the completion of the activities performed by the lead
operational division and clearly define its roles and responsibilities.
(Recommendation 3)
The Secretary of HHS should ensure that the lead operational division, in
developing the PAHPAIA work plan, includes the steps to be taken to
address all of the required actions in PAHPAIA. (Recommendation 4)
The Secretary of HHS should ensure that the lead operational division, in
developing the PAHPAIA work plan, includes specific near-term and long-
term actions that can be completed to show progress in developing the
network. (Recommendation 5)
The Secretary of HHS should ensure that the lead operational division, in
developing the PAHPAIA work plan, includes time frames for
implementing the near-term and long-term actions. (Recommendation 6)
The Secretary of HHS should ensure that the PAHPAIA work plan
includes specific steps the department will take to oversee the progress of
the actions the lead operational division takes to implement PAHPAIA
requirements. (Recommendation 7)
Recommendations for
Executive Action

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GAO-22-104600  Public Health Network
The Secretary of HHS should commit to a deadline for finalizing the work
plan to implement PAHPAIA requirements and ensure that the work plan
is fully implemented. (Recommendation 8)
The Secretary of HHS should ensure that the lead operational division for
PAHPAIA implementation identifies and documents the IT- and
information sharing-related challenges and lessons learned from the
COVID-19 pandemic. (Recommendation 9)
The Secretary of HHS should ensure that the lead operational division for
PAHPAIA implementation shares the lessons learned from the COVID-19
pandemic with relevant stakeholders, such as state, territorial, and local
public health officials. (Recommendation 10)
The Secretary of HHS should ensure that the lead operational division for
PAHPAIA implementation request that state, territory, and local public
health officials share their lessons learned from the COVID-19 pandemic
with HHS. (Recommendation 11)
The Secretary of HHS should ensure that the lead operational division for
PAHPAIA implementation incorporates lessons learned from the COVID-
19 pandemic into its plans for implementing the situational awareness
and biosurveillance network. (Recommendation 12)
HHS provided written comments on a draft of this report, which are
reproduced in appendix IV. In its comments, the department concurred
with 10 of the 12 recommendations and stated that the remaining two
were under review. The department stated that it remains committed to
the full implementation of PAHPAIA. HHS added that our report provides
important information that can assist the department’s ongoing efforts to
fulfill their PAHPAIA responsibilities. For example, according to HHS, it is
currently working to enhance its public health situational awareness
network by defining roles and responsibilities for PAHPAIA
implementation, and sharing lessons learned from the COVID-19
pandemic with relevant stakeholders. The department added that HHS is
making strides and working toward improving the U.S. government’s
medical countermeasures enterprise, building early warning systems with
improved data analytics and forecasting capability, strengthening the U.S.
public health system, and addressing health disparities. HHS also
provided technical comments, which we incorporated as appropriate.

Agency Comments
and Our Evaluation

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GAO-22-104600  Public Health Network
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Health and Human Services, the Assistant
Secretary for Preparedness and Response, Director of CDC, HHS OCIO,
and interested congressional parties. In addition, the report is available at
no charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact
Jennifer R. Franks at (404) 679-1831 or franksj@gao.gov. GAO staff who
made key contributions to this report are listed in appendix V.

Jennifer R. Franks
Director, Information Technology and Cybersecurity

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GAO-22-104600  Public Health Network
List of Addressees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chair
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chair
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Frank Pallone Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives

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GAO-22-104600  Public Health Network
The Honorable Bennie G. Thompson
Chairman
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Richard Neal
Chairman
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives
The Honorable Mitt Romney
United States Senate

Appendix I: Survey Questions Administered to
States and Territories and the Responses for
Each Question

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GAO-22-104600  Public Health Network
We administered a web-based survey to 50 states, the District of
Columbia, and five U.S. territories (hereinafter collectively referred to as
states).1 The survey was administered to solicit state officials’ views on
any COVID-19 challenges that they faced and lessons they have learned
that could inform HHS’s work to develop and implement a nationwide
public health situational awareness and biosurveillance network. The
following identifies the survey questions that we administered and the
aggregated results from the responses under each question. Forty-three
of 56 states responded to the survey. Not all 43 respondents to the
survey answered each question. Some questions were only asked of a
subset of respondents giving a qualifying answer to an earlier question. In
addition, not all qualifying respondents may have answered a particular
question. Narrative answers to open-ended text questions are not
displayed below for brevity and to limit the possibility of identification of
individual states.
Survey on the Pandemic and All-Hazards Preparedness and
Advancing Innovation Act of 2019, Public Health Situational
Awareness Capability

U.S. Government Accountability Office

Introduction

The Pandemic and All-Hazards Preparedness and Advancing Innovation
Act of 2019 (PAHPAIA) reauthorized the mandate that the Department of
Health and Human Services (HHS) develop a near real-time, electronic,
nationwide public health situational awareness and biosurveillance
capability through an interoperable network of systems based on
information from various entities, including states and territories.
According to the law, the purpose of the situational awareness capability
is to allow sharing of information and data among health partners to
enhance the early detection of and rapid response to catastrophic
infectious disease outbreaks, novel emerging threats, and other public
health emergencies. In accordance with the law, HHS is required to
develop a plan to ensure that the network allows for the timely sharing of
secure information concerning public health emergencies. PAHPAIA

1The U.S. territories are Puerto Rico, American Samoa, Guam, the Commonwealth of the
Northern Mariana Islands, and the U.S. Virgin Islands. At times, the public health officials
we administered the survey to forwarded the survey to other officials they felt were more
appropriate to answer the questions. These officials included emergency preparedness
and response and IT staff.
Appendix I: Survey Questions Administered
to States and Territories and the Responses
for Each Question

Appendix I: Survey Questions Administered to
States and Territories and the Responses for
Each Question

Page 40
GAO-22-104600  Public Health Network
requires the network capability to include data and information from the
following entities:

•
state, local, and tribal public health entities, including public health
laboratories;
•
federal health agencies;
•
zoonotic disease monitoring systems; and
•
public and private sector health care entities, including hospitals,
pharmacies, poison control centers or professional organizations
in the field of poison control, immunization information systems,
community health centers, clinical laboratories, and public
environmental health agencies.

According to PAHPAIA, the network capability should be built on existing
state situational awareness systems or enhanced systems that enable
interoperability. The law also included a provision for GAO to report on
the progress of HHS efforts to implement the network capability.

To learn more about completing the questionnaire or printing your
responses click here for help.

Thank you for your time and assistance.

Situational Awareness and Biosurveillance Capability
The following questions ask about your state’s or territory’s capabilities,
as well as your state’s or territory’s involvement, if any, in HHS’s efforts to
implement a nationwide public health situational awareness and
biosurveillance capability for public health emergencies.

1. Does your state or territory have any information system(s) in place to
collect data from health care or local public health entities (ex: local
health departments, hospitals, laboratories, private health care
facilities, pharmacies, federal installations, etc.) that support or has
the potential to support the early detection and response to
pandemics, novel emerging threats, or other public health
emergencies?

 Number of Responses
Yes
41
No
1

Appendix I: Survey Questions Administered to
States and Territories and the Responses for
Each Question

Page 41
GAO-22-104600  Public Health Network
Don't know
1

2. (Part 1) Please indicate if your state or territory has implemented one
or more of the following types of information systems.

Number of Responses
State Implemented Information System
Does your state have this system?

Yes
No
Don’t Know
Immunization Information System(s)
41
0
0
Infectious Disease Surveillance System(s)
40
0
1
Syndromic Surveillance System(s)
39
2
0
Zoonotic Disease Monitoring System(s)
21
13
6
Other System(s)
14
9
9

2. (Part 2) Then, for each system that has been implemented, select
each type of entity that reports any amount of data to that system or
systems. (For example, if some hospitals report data to an
Immunization Information System and some do not, please check the
box for hospitals for that system type.) If your state does not have this
system or if you don't know whether your state has this system,
please select Not Applicable for the reporting entity.

Number of Responses

Immunization
Information
System(s)
Infectious
Disease
Surveillance
System(s)
Syndromic
Surveillance
System(s)
Zoonotic
Disease
Monitoring
System(s)
Other
System(s)
Local Health
Departments
(including state or
locally funded
clinics)
37
35
8
18
7
Hospitals
(including federal,
state, and local
hospitals)
39
37
38
16
8
Laboratories
11
37
8
19
5
Private Sector
Health Care
Entities (other
than hospitals)
41
31
18
15
6
Pharmacies
38
16
7
3
2

Appendix I: Survey Questions Administered to
States and Territories and the Responses for
Each Question

Page 42
GAO-22-104600  Public Health Network
Federal Agencies
9
13
4
7
1
State
Agencies/Entities
23
24
6
15
3
Other
6
6
8
5
4
Not Applicable
0
0
0
1
1

2a. If you selected "Other" for one or more of the reporting entity, please
explain below. (Note – open ended text responses deliberately omitted)

2b. If you selected "Yes" for Other system, please describe the other
type(s) of system(s) that the above entities report data to. (Note – open
ended text responses deliberately omitted)

3. If you indicated in question 2 that your state or territory has a
syndromic surveillance system(s), does the system track symptoms
and/or signs of disease in animals?

Number of Responses
Yes
2
No
33
Don't know
5

4. Please describe what your state or territory currently does in practice,
in the absence of a system. (Note – open ended text responses
deliberately omitted)

5. Aside from any required reporting through state and federal mandates,
are any data from your state's or territory's system(s) that support or
could support early detection and response to pandemics, novel
emerging threats, or other public health emergencies voluntarily reported
to any federal entity(ies)?

Number of Responses
Yes
23
No
10
Don't know
10

Appendix I: Survey Questions Administered to
States and Territories and the Responses for
Each Question

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5a. Please provide an example(s) in the space below, including the
federal entities and systems that your state or territory is voluntarily
reporting the data to. (Note – open ended text responses deliberately
omitted)

6. Does your state or territory have access to all the federal systems that
house the data you have shared with federal entities?

Number of Responses
Yes
17
No
12
Don't know
14

6a. Please provide an example of a federal system you share data with
but do not have access to. (Note – responses deliberately omitted)

7. Does your state or territory share any reported data with other states or
territories?

Number of Responses
Yes
27
No
9
Don't know
7

7b. Please explain if data is being shared formally (e.g., data sharing
agreements, memorandums of understanding, etc.), informally (e.g.,
periodic meetings), both formally and informally, or don’t know. (Note –
open ended text responses deliberately omitted)

8. Does your state or territory have plans to implement or modernize a
system(s) that supports early detection and response to pandemics, novel
emerging threats, or other public health emergencies?
Number of Responses
Yes
33
No
3
Don't know
7

Appendix I: Survey Questions Administered to
States and Territories and the Responses for
Each Question

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8a. Please describe your state or territory’s plans to implement or
modernize a system(s) and include approximate timeframes for
implementation. (Note – open ended text responses deliberately omitted)

8b. Will the plans to modernize the system(s) include the ability for the
system to interact or be interoperable with other state or territorial
systems to share data for common reporting or analysis?

Number of Responses
Yes
23
No
2
Don't know
7

8c. Will the plans to modernize the system(s) include the ability for the
system to interact with federal systems to share data for common
reporting or analysis?

Number of Responses
Yes
23
No
1
Don't know
8

Coordination
The Pandemic and All-Hazards Preparedness and Advancing Innovation
Act of 2019 (PAHPAIA) requires HHS to coordinate with states and
territories when developing the situational awareness and biosurveillance
network capability required by the law.

9. Has HHS (e.g., Office of the Assistant Secretary for Preparedness and
Response (ASPR), the Centers for Disease Control and Prevention
(CDC), Office of the Chief Information Officer (OCIO)) or any other federal
entity coordinated with your state or territory regarding providing
information and data that could support a situational awareness and
biosurveillance network capability for public health emergencies? This
would include information that supports the early detection of and
response to pandemics and public health emergencies, including COVID-
19.

Appendix I: Survey Questions Administered to
States and Territories and the Responses for
Each Question

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GAO-22-104600  Public Health Network
Number of Responses
Yes
31
No
0
Don't know
11

10. Which of the following federal entities or their component agencies
coordinate with your state or territory? Please select "other" if the specific
agency or component is not listed.

Number of Responses

Yes
No
Don’t Know
10a. HHS Office of the Assistant
Secretary for Preparedness and
Response
25
3
1
10b. HHS Centers for Disease Control
and Prevention
29
0
1
10c.  HHS Office of the Chief
Information Officer
4
6
17
10d.  Food and Drug Administration
17
7
6
10e.  Department of Defense
12
9
8
10f.  Department of Homeland Security
(e.g., Federal Emergency Management
Agency (FEMA) and National
Biosurveillance Integration Center)
20
4
5
10g.  Department of Agriculture
13
8
8
10h.  Environmental Protection Agency
13
6
9
10i.  White House
17
7
5
10j.  Other entity
1
5
13

10k. If you selected "Yes" to Other entity, please name the other
entity/entities that apply. (Note – open ended text responses deliberately
omitted)

10l. If you selected "Yes" to any of the items above, please provide
examples of the coordination that took place. (Note – open ended text
responses deliberately omitted)

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States and Territories and the Responses for
Each Question

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11. Would your state or territory benefit from the types of coordination
described below regarding HHS’s (e.g., ASPR, CDC, OCIO) efforts to
develop a network capability? If yes, please provide an example of how
your state or territory would benefit. If no, please write N/A in the box.
(Note – Examples deliberately omitted)

Number of Responses
Coordination Type
Benefit from this Type of Coordination

Yes
No
Don’t Know
Integrating and building upon any
existing system capabilities
35
3
5
Using a standardized data set
and/or creating common data
elements
34
5
4
Sharing of data and information
36
2
5
Developing procedures and
standards for the collection and
analyses of data that states,
territories, regions, or other entities
collect and report to HHS, ASPR,
CDC, or other HHS entities
33
6
4
Piloting test standards and
implementation specifications for
the network capability
26
2
14
Other types of coordination
9
7
25

11a. If you selected "Yes" for Other types of coordination, please
describe. (Note – open ended text responses deliberately omitted)

11b. If you selected "No" for all types of coordination, please explain why
none of these types of coordination efforts would be beneficial to your
state or territory. (Note – open ended text responses deliberately omitted)

Challenges and Lessons Learned
These questions ask about challenges and lessons learned from the
COVID-19 pandemic that could be helpful to HHS in planning for the
implementation of the public health situational awareness and
biosurveillance network capability.

Appendix I: Survey Questions Administered to
States and Territories and the Responses for
Each Question

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12. Overall, how challenging, if at all, were the following activities during
the COVID-19 pandemic regarding the management of public health
information, such as the data collected for monitoring the pandemic?

Number of Responses

Very
Challenging
Moderately
Challenging
Not at all
Challenging
Don’t
Know
12a.  Clarity of guidance from the
federal government on public
health information management
(e.g., inconsistent guidance,
conflicting guidance, lack of
definitions on the data necessary
and the use of the data, lack of
definitions of situational
awareness or biosurveillance)
19
19
4
1
12b. Clarity in roles and
responsibilities of federal entities
and agencies such as the White
House, ASPR, CDC, HHS OCIO,
and FEMA (e.g., duplicative,
overlapping, fragmented roles
and responsibilities)
22
13
6
2
12c. Support of key stakeholders
or public health localities. For
example, this would include
ineffective collaboration amongst
stakeholders to implement a
system (e.g., obtaining
inadequate stakeholder
requirements/input for systems)
7
27
5
4
12d. Manual processing of data
and data collection for federal
reporting
29
8
4
2
12e. Interoperability among
systems (e.g., non-standardized
data, incompatible systems, or
legacy systems)
26
13
2
0
12f. Access to specific types of
data for reporting and decision-
making (e.g., not having access
to local-level or other granular
data in systems, such as
Tiberius, HHS Community Profile
Reports, or CDC COVID Data
Tracker)
10
22
7
4

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States and Territories and the Responses for
Each Question

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12g.  Bidirectional sharing of data
between state, territorial, federal,
and public or private health care
entities—such as hospitals or
pharmacies—across multiple
systems (e.g., sharing of
immunization systems’ data
across states, territories, etc.)
19
18
3
3
12h. Public health information
messaging (e.g., informing
stakeholders on the importance
of reporting COVID-19 data)
8
24
11
0
12i. Human capital-related IT
resources (e.g., inadequate
staffing, training, technical
competence/skill set, etc.)
25
15
1
2
12j. Technology resources (e.g.,
funding or availability of systems
and/or data warehouses, network
connectivity)
15
23
3
2
12k. Legal constraints (e.g.,
privacy constraints)
9
25
5
4
12l. Organizational and/or cultural
constraints
12
21
7
3
12m. Political constraints
18
17
5
3
12n. Other constraints
2
1
3
23

12o. Please describe the other constraint. (Note – open ended text
responses deliberately omitted)

13. The following questions ask you to identify your state's or territory's
top three challenges from question 12. After each selection, please
provide an example of that challenge. (Note – open ended text responses
deliberately omitted)

Number of Responses

1st Top
Challenge
2nd Top
Challenge
3rd Top
Challenge
Sum of the
Top 3
Challenges
a. Clarity of guidance from
the federal government on
public health information
management
8
1
2
11

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States and Territories and the Responses for
Each Question

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GAO-22-104600  Public Health Network
b. Clarity in roles and
responsibilities of federal
entities and agencies such
as the White House, ASPR,
CDC, HHS OCIO, and
FEMA
7
3
5
15
c. Support of key
stakeholders or public
health localities
2
2
0
4
d. Manual processing of
data and data collection for
federal reporting
0
11
5
16
e. Interoperability among
systems
8
6
1
15
f. Access to specific types
of data for reporting and
decision-making
1
0
3
4
g. Public health information
messaging
1
1
2
4
h. Human capital-related IT
resources
9
5
7
21
i. Bidirectional sharing of
data between state,
territorial, federal, and
public or private health care
entities—such as hospitals
or pharmacies—across
multiple systems
1
4
4
9
j. Technology resources
3
5
7
15
k. Legal constraints
0
0
1
1
l. Organizational and/or
cultural constraints
0
0
1
1
m. Political constraints
2
3
3
8
n. Other challenge
1
2
2
5

14. Have you identified any lessons learned, positive or negative, from
your experience with the COVID-19 pandemic that could be helpful to
HHS in planning for the implementation of the public health situational
awareness and biosurveillance network capability?

Number of Responses
Yes
30
No
4
Don't know
9

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States and Territories and the Responses for
Each Question

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14a.  Please describe any lessons learned, including successes that
could be emulated or challenges that could be or were mitigated, which
might assist HHS in planning for a situational awareness and
biosurveillance network capability for public health emergencies. (Note –
open ended text responses deliberately omitted)

HHS Guidance Related to General PAHPAIA Requirements
In establishing the public health situational awareness and biosurveillance
network capability, PAHPAIA requires HHS to conduct activities, including
utilizing interoperability standards, defining minimal data elements for the
network, and collaborating with state and local public health officials to
integrate and build upon existing state and local system capabilities to
ensure the simultaneous sharing of data and information. These
questions ask about general PAHPAIA requirements and any guidance
HHS has provided to your state or territory regarding the systems that
could potentially help support the public health situational awareness and
biosurveillance network capability for public health emergencies.
15. As HHS plans for the development and implementation of the public
health situational awareness and biosurveillance network capability,
would the following guidance from HHS (e.g., ASPR, CDC, or OCIO) be
helpful to your state or territory for supporting the capability?

Number of Responses

Yes
No
Don’t
Know
15a. Technical specifications
39
2
2
15b. Functional specifications or requirements
39
2
2
15c. Standards for interoperability
41
1
1
15d.  Common operating picture
41
1
1
15e.  Guidance on the development of the public health
situational awareness and biosurveillance network
capability
34
5
4
15f.  Guidance on the type of information and data required
by HHS from states and territories for the network capability
38
3
2
15g.  Plans and guidance for integration of existing systems
with the network capability
35
4
4
15h.  Guidance on performance measures and metrics to
assess the performance of the network capability
33
5
4
15i.  Other guidance
4
3
24

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States and Territories and the Responses for
Each Question

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15j. Please describe the other guidance. (Note – open ended text
responses deliberately omitted)

16. If you selected "Yes" to any of the above types of guidance, please
identify the top 3 that would be most helpful to your state or territory and
explain how the guidance will be helpful. (Note – explanations deliberately
omitted)
Number of Responses

Most
Helpful
2nd
Most
Helpful
3rd
Most
Helpful
Total
Helpful
16a. Technical specifications
7
5
6
18
16b. Functional specifications or requirements
5
11
5
21
16c. Standards for interoperability
12
6
7
25
16d.  Common operating picture
7
5
6
18
16e.  Guidance on the development of the public
health situational awareness and biosurveillance
network capability
0
4
2
6
16f.  Guidance on the type of information and data
required by HHS from states and territories for the
network capability
1
7
4
12
16g.  Plans and guidance for integration of existing
systems with the network capability
6
2
6
14
16h.  Guidance on performance measures and
metrics to assess the performance of the network
capability
3
1
3
7
16i.  Other guidance
1
0
2
3

17. If you have any additional comments on any of the topics included in
this questionnaire, please write them in the box below. (Note – open
ended text responses deliberately omitted)

Appendix II: Objectives, Scope, and
Methodology

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Our objectives were to determine (1) the extent to which the Department
of Health and Human Services (HHS) has made progress toward
establishing systems of public health communications and surveillance,
and modernizing public health situational awareness and biosurveillance
in accordance with the requirements in the Pandemic and All-Hazards
Preparedness and Advancing Innovation Act of 2019 (PAHPAIA); and
(2) the challenges and lessons learned from the COVID-19 pandemic that
states, territories, and HHS could incorporate in the planning and
implementation of the public health situational awareness and
biosurveillance network.
For the first objective, we reviewed 42 U.S.C. § 247d-4 (b) and (c) to
identify and summarize requirements for establishing systems of public
health communications and surveillance, and modernizing public health
situational awareness and biosurveillance. We then assessed any actions
HHS had taken against these requirements. Specifically, we reviewed
available department documentation, such as grants, contracts, and
cooperative agreements provided by HHS to states for the establishment
of systems of public health alert communications and surveillance. We
also reviewed HHS’s technical and reporting standards for
interoperability, including the United States Core Data for Interoperability.
We compared these documents against the PAHPAIA requirements
aimed at establishing systems of public health communications and
surveillance. Further, we reviewed HHS’s draft work plan and
summarized the progress HHS had made, as of April 2022, in developing
the plan.
We also interviewed relevant officials in the HHS Office of the Assistant
Secretary for Preparedness and Response (ASPR), the Office of the
Chief Information Officer (OCIO), and the Centers for Disease Control
and Prevention (CDC). We interviewed these officials to discuss the
actions the department had taken or planned to take to implement the
legal requirements related to establishing systems of public health
communications and surveillance and modernizing public health
situational awareness and biosurveillance. We also interviewed the
officials to understand each office’s roles and responsibilities for
establishing the public health situational awareness and biosurveillance
network. In addition, we conducted interviews with officials in the Office of
the National Coordinator for Health Information Technology (ONC) to
determine whether they had taken action to coordinate with ASPR and
CDC to adopt technical and reporting standards for interoperability.
Appendix II: Objectives, Scope, and
Methodology

Appendix II: Objectives, Scope, and
Methodology

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For the second objective, we administered a web-based survey to a
public health official in each of the 50 states, the District of Columbia, and
five territories (hereinafter collectively referred to as states).1 We
identified these contacts in a variety of ways, including our ongoing
CARES Act public health-related work, emails to state public health
entities, and state websites. The survey included questions that solicited
state officials’ views on the COVID-19 challenges they have faced and
lessons they have learned that could inform HHS’s work to develop and
implement a nationwide public health situational awareness and
biosurveillance network. The questions also related to state systems that
support pandemic response. Further, the survey also solicited state
officials’ views on HHS coordination and guidance that could help support
states if a network was implemented, among other things.
Before administering the survey, we pretested it with representatives from
the Association of State and Territorial Health Officials and public health
officials from the states of Oklahoma and New Mexico. The pretests were
conducted to ensure that our survey questions were appropriate, skip
patterns were clear and logical, and that the respondents could answer
the questions without undue burden. We received survey responses from
September 2021 through December 2021; therefore, the responses
reflect information and views as of that time period. We received
responses from 43 states, for a 77 percent response rate. We analyzed
states’ survey responses to summarize their views on challenges and
lessons learned from the COVID-19 pandemic that HHS could consider in
the planning and implementation of the public health situational
awareness and biosurveillance network. See appendix I for a copy of the
survey administered to states and responses for each question.
To supplement the survey information we obtained from the states, we
also interviewed representatives from selected national public health
organizations that collectively represent state and local levels and have
key roles in responding to public health emergencies. We also
interviewed representatives from a selected state association. We used
these interviews to identify common information management challenges

1The U.S. territories are Puerto Rico, American Samoa, Guam, the Commonwealth of the
Northern Mariana Islands, and the U.S. Virgin Islands. At times, the public health officials
we administered the survey to forwarded the survey to other officials they felt were more
appropriate to answer the questions. These officials included emergency preparedness
and response and IT staff.

Appendix II: Objectives, Scope, and
Methodology

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and lessons learned from the COVID-19 pandemic among these
organizations. The organizations we interviewed are the:
•
Association of State and Territorial Health Officials,
•
National Governors Association,
•
Council of State and Territorial Epidemiologists,
•
American Immunization Registry Association,
•
National Rural Health Association,
•
National Association of County and City Health Officials,
•
National Community Pharmacists Association, and
•
Community Health Care Association of New York State.
In addition, we interviewed relevant officials at HHS—ASPR, OCIO, and
CDC—to discuss any efforts planned or underway to identify, document,
and share challenges and lessons learned from the response to the
COVID-19 pandemic. We compared these efforts against criteria we
identified in a prior GAO report that defined best practices for developing
and disseminating lessons learned for IT investments.2 Lastly, we
reviewed prior GAO reports, such as those issued as part of the CARES
Act provision that requires us to regularly report on the federal response
to the pandemic. We also reviewed prior HHS Office of Inspector General
reports that identify the department’s information management
challenges. We reviewed these reports to summarize any lessons learned
that we have previously identified.
We conducted this performance audit from November 2020 to June 2022
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.

2GAO, Information Technology Investment Management: A Framework for Assessing and
Improving Process Maturity, Version 1.1, GAO-04-394G (Washington, D.C.: March 2004).

Appendix III: Various State and Federal Entities
Use IT to Support Public Health Situational
Awareness and Biosurveillance Activities

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Maintaining a situational awareness capability involves an active,
continuous, and timely exchange of information that enhances the ability
of public health officials to make decisions related to emergency
preparedness and response. Public health officials at state, local, tribal,
territorial, and federal, levels rely on IT systems and tools to collect and
share information in their day-to-day functions, such as tracking
vaccinations and outbreaks of seasonal influenza. These officials also
use IT systems to create the situational awareness needed to enable
early detection of, and effective response to, emerging diseases and
other public health events.
We administered a web-based survey to the 50 states, the District of
Columbia, and five U.S. territories (hereinafter collectively referred to as
states).1 The survey included questions related to the systems the states
have implemented to support public health situational awareness and
biosurveillance, among other things. The responding states reported that
they have implemented a number of systems, including immunization
information systems, infectious disease surveillance systems, syndromic
surveillance systems, and zoonotic disease monitoring systems, among
others. Figure 4 identifies and describes the various types of systems that
states reported that they have implemented to support public health
situational awareness and biosurveillance activities.

1The U.S. territories are Puerto Rico, American Samoa, Guam, the Commonwealth of the
Northern Mariana Islands, and the U.S. Virgin Islands. At times, the public health officials
we administered the survey to forwarded the survey to other officials they felt were more
appropriate to answer the questions. These officials included emergency preparedness
and response and IT staff.
Appendix III: Various State and Federal
Entities Use IT to Support Public Health
Situational Awareness and Biosurveillance
Activities

Appendix III: Various State and Federal Entities
Use IT to Support Public Health Situational
Awareness and Biosurveillance Activities

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Figure 4: Types of Information Systems States Reported Implementing to Support
Public Health Situational Awareness and Biosurveillance

aImmunization information systems are confidential, population-based, computerized databases that
record immunization doses administered by participating providers to persons residing within a given
geopolitical area.
bInfectious disease surveillance systems monitor information about cases or a person diagnosed with
a disease or condition to understand diseases and their spread and determine appropriate actions to
control outbreaks.
cSyndromic surveillance systems use health-related data to identify patterns of disease symptoms
prior to confirmed diagnoses. These systems may include real-time data from emergency
departments, urgent and ambulatory care centers, inpatient health care settings, and laboratories.
dZoonotic disease monitoring systems are intended to monitor diseases in humans or animals that
are caused by germs that spread between animals and people.
eOther systems that were reported by states include prescription drug monitoring, infectious disease
outbreak reporting, wastewater surveillance, and molecular surveillance.

Most of the states that responded to our survey indicated that various
health entities, such as federal and state agencies, local health
departments, and hospitals reported health-related data to the states’
immunization information systems and infectious disease surveillance
systems. In particular, at least 30 of the 43 states indicated that local
health departments, hospitals, and private sector health entities reported
data to these two types of state systems. Additionally, a large majority of
state respondents indicated that laboratories also report data to infectious

Appendix III: Various State and Federal Entities
Use IT to Support Public Health Situational
Awareness and Biosurveillance Activities

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disease surveillance systems; hospitals report to syndromic surveillance
systems; and pharmacies report to immunization information systems
(see appendix I, question 2 for more detailed information).
At the federal level, multiple agencies use numerous IT systems and tools
as part of their efforts to collect, integrate, and share critical public health
and medical information. For example, the Center for Disease Control
and Prevention’s (CDC) Red Sky tool is used to manage and share public
health data about global events that may require CDC assistance or
resources. CDC’s BioSense platform supports the National Syndromic
Surveillance Program and features the analysis of public health data
gathered from hospitals, urgent care facilities, and pharmacies.
In response to COVID-19, in April 2020, the Department of Health and
Human Services (HHS) created a data ecosystem—HHS Protect—to
collect and share public health data related to the pandemic.2 Following
the Anthrax attacks of 2001, the Department of Homeland Security
developed the BioWatch program to provide early indication of an
aerosolized biological weapon attack.3 Table 4 includes these and other
examples of federal systems that provide information relevant to public
health situational awareness and biosurveillance.
Table 4: Examples of Existing Federal Systems Relevant to Public Health Situational Awareness and Biosurveillance
Department
Subcomponent
System name
Description
Surveillance Systems and Dashboards Used to Monitor COVID-19
Health and Human
Services (HHS)
Centers for Disease
Control and Prevention
(CDC)
HHS Protect
Serves as the common operating picture and central hub
to receive, integrate, and share COVID-19 data in near-
real time for the U.S. government. HHS Protect also
receives national and state data on COVID-19 cases,
laboratory testing, COVID-19 deaths, hospital capacity,
personal protective equipment, COVID-19 treatment, and
COVID-19 vaccine administration in the U.S.

2HHS Protect includes the number of COVID-19 cases from more than 200 data sources
(e.g. federal, state, and local governments and health care entities), supply chain data,
inpatient bed utilization, intensive care unit bed utilization, percentage of inpatient beds
occupied by COVID-19 patients, laboratory testing, COVID-19 deaths, COVID-19
vaccinations, and therapeutics.
3For more information on BioWatch and the Department of Homeland Security’s efforts to
replace the system, see GAO, Biodefense: DHS Exploring New Methods to Replace
BioWatch and Could Benefit from Additional Guidance, GAO-21-292 (Washington, D.C.:
May 20, 2021).

Appendix III: Various State and Federal Entities
Use IT to Support Public Health Situational
Awareness and Biosurveillance Activities

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Department
Subcomponent
System name
Description
HHS
CDC/HHS
Coordination
Operations Response
Element
Tiberius
Situational awareness platform that aggregates COVID-19
data, including vaccine data therapeutics data, and
logistics data, from various U.S. stakeholders in support of
Operation Warp Speed and later the HHS
Countermeasures Acceleration Group and the HHS
Coordination Operations Response Element.a
HHS
CDC
COVID-19 Vaccine Data
Systems
System of systems used to track COVID-19 vaccine
distribution and administration in the U.S.
HHS
CDC/Food and Drug
Administration
Vaccine Adverse Event
Reporting Systems
National system for health care professionals, vaccine
manufacturers, and the public to report possible side
effects or health problems after vaccination for
investigation by scientists.
HHS
CDC
V-Safe COVID-19 Vaccine
Pregnancy Registry
Smartphone-based, after-vaccination health checker for
people receiving COVID-19 vaccines with additional data
collection on pregnant vaccine recipients.
HHS
CDC
COVID-19-Associated
Hospitalization Surveillance
Network (commonly
referred to as COVID-NET)
Collects demographic, clinical, and outcome data on
laboratory-confirmed COVID-19 hospitalization data for
children and adults through a network of acute-care
hospitals in 14 states in the U.S.
HHS
CDC
Vaccine Administration
Management System
Application used by vaccination clinics to register patients
and record vaccination dose data.
HHS
CDC
National Wastewater
Surveillance System
Tracks COVID-19 through wastewater testing data.
HHS
Multiple HHS
subcomponents
Unified Hospital Data
Surveillance System
Collects facility-level aggregated data from all hospitals in
the U.S. on capacity and occupancy, pediatric and adult
COVID-19 hospitalization, personal protective equipment
inventory, and COVID-19 therapeutics inventory and
utilization.
Public Health Surveillance Systems and Dashboards (Not COVID-19 Specific)
HHS
CDC
Epidemic Information
Exchange
The Epidemic Information Exchange provides 24/7 bi-
directional electronic data and public health reporting
between CDC, federal, state, and international public
health agencies.
HHS
CDC
BioSense Platform
Platform that supports the National Syndromic Surveillance
Program and allows for the analysis of public health data
gathered from hospitals, urgent care facilities, and
laboratories.b
HHS
CDC
Red Sky
Tool that gathers data and information about public health
events and displays the data in a real-time dashboard and
global map that is intended to track active health events
and improve situational awareness.
HHS
CDC
National Notifiable
Diseases Surveillance
System
System that tracks data on nationally notifiable diseases
from approximately 3,000 health departments across the
U.S.
HHS
CDC
New Vaccine Surveillance
Network
Network that conducts surveillance and data collection on
use and impact of vaccines at seven U.S. study sites that
collect population-based surveillance data.c

Appendix III: Various State and Federal Entities
Use IT to Support Public Health Situational
Awareness and Biosurveillance Activities

Page 59
GAO-22-104600  Public Health Network
Department
Subcomponent
System name
Description
HHS
CDC
Flu Vaccine Effectiveness
Network
Network that provides estimates of clinical influenza
vaccines’ effectiveness based on data from seven state
study sites spread across the U.S.d
HHS
CDC
National Respiratory and
Enteric Virus Surveillance
System
Laboratory-based system that monitors circulation patterns
of respiratory and enteric viruses.e
HHS
CDC
Laboratory Response
Network
Integrated network of laboratories that can detect and
respond to bioterrorism, emerging infectious diseases,
chemical terrorism, and other public health emergencies.
HHS
CDC
National Outbreak
Reporting System
Tracks U.S. reports of waterborne and foodborne disease
outbreaks.
HHS
CDC
Chronic Disease Center
Surveillance Systems
System of systems that monitors chronic diseases to
understand the extent of risk behaviors, preventative
practices, and the burden of chronic diseases.
HHS
CDC
Drug Overdose
Surveillance and
Epidemiology System
Analyzes data from other syndromic surveillance systems
to identify outbreaks of drug overdoses.
HHS
CDC
National Vital Statistics
System
Collects and analyzes data on vital events like births and
deaths from all 50 states, two cities, and five territories.f
HHS
CDC
National Healthcare Safety
Network
System that tracks health care-associated infections,
antibiotic resistant infections, and antibiotic use across
health care settings. Examples of these data include
catheter-associated urinary tract infections, central-line
associated bloodstream infections, and Methicillin-resistant
Staphylococcus aureus.g This network was leveraged
during the COVID-19 pandemic to collect and analyze
COVID-19 data from all of the nation’s nursing homes and
dialysis clinics. Until HHS Protect was available, this
system also collected COVID-19 hospitalization data.h
HHS
Office of the Assistant
Secretary for
Preparedness and
Response (ASPR)
EMPortal Emergency
Management Application
Knowledge management tool that provides all-hazards
information, materials, and knowledge sharing to support
emergency operations.
HHS
ASPR
GeoHEALTH
Interactive mapping application that collects public health
incident and federal disaster information from open
sources to create a visual environment for situational
awareness capabilities.
HHS
ASPR
National Special Pathogen
System
Nationwide systems-based network approach that builds
on existing infrastructure and investments in preparing for
infectious disease outbreaks. The system supports the
urgent preparedness and response needs of hospitals,
health systems, and health care providers related to
treating patients with special pathogens.
HHS
ASPR
ASPR Ready
An ecosystem that is to streamline agency collaboration,
information and data management, and provide the
common operating picture for ASPR’s preparedness and
response missions.

Appendix III: Various State and Federal Entities
Use IT to Support Public Health Situational
Awareness and Biosurveillance Activities

Page 60
GAO-22-104600  Public Health Network
Department
Subcomponent
System name
Description
Department of
Homeland Security
(DHS)
Countering Weapons
of Mass Destruction
Office
National Biosurveillance
Integration System
Aggregates the collection and analysis of biosurveillance
data, such as media reports, government agency websites,
professional association reports, and data provided by
National Biosurveillance Integration System partners.i
DHS
Countering Weapons
of Mass Destruction
Office
BioWatch
System that tracks pathogens in the air to identify early
indications of aerosolized biological attacks. As of March
2022, this system was still in development.
DHS
Countering Weapons
of Mass Destruction
Office
Biological Detection for the
21st Century
System of sensor nodes that captures environmental data,
camera images, and video to detect airborne bio-threats.
As of March 2022, this system is still in development.
Department of
Defense
Defense Applied
Research Projects
Agency
SIGMA+
Network of sensors that detects chemical, biological,
radiological, nuclear, and high-yield explosive attacks.
Department of
Defense
Defense Health
Agency
Electronic Surveillance
System for the Early
Notification of Community-
based Epidemics
Global military health system monitoring capability that
detects imminent health threats impacting force readiness
for active duty service members. The system is intended to
monitor and provide alerts for rapid or unusual increases in
the occurrence of infectious diseases and biological
outbreaks.
Source: GAO analysis of Department of Health and Human Services, Department of Homeland Security, and Department of Defense data. I GAO-22-104600
aOperation Warp Speed—a partnership between the Departments of Health and Human Services
(HHS) and Defense—aimed to help accelerate the development of a COVID-19 vaccine. In 2021, the
Department of Defense transferred its responsibilities for Operation Warp Speed to HHS, and the
operation was renamed to the Countermeasures Acceleration Group.
bThe National Syndromic Surveillance program involves collaboration between federal, state, local,
academic, and private partners who share and analyze data to identify and monitor health events.
cThe seven study sites are Vanderbilt University Medical Center, Nashville, Tennessee; University of
Rochester School of Medicine and Dentistry, Rochester, New York; Cincinnati Children’s Hospital
Medical Center, Cincinnati, Ohio; Texas Children’s Hospital. Houston, Texas; Seattle Children’s
Hospital, Seattle, Washington; Children’s Mercy Hospital, Kansas City, Missouri; and Children’s
Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
dThe seven study sites are located in California, Washington, Wisconsin, Michigan, Tennessee,
Pennsylvania, and Texas in order to provide a representative sample of flu vaccine conditions across
the U.S.
eEnteric viruses are a wide spectrum of viruses that invade and replicate in the mucosa of the
intestinal tract and spread through fecal transmission.
fThe two cities are Washington, DC and New York City and the five territories are Puerto Rico, the
U.S. Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana
Islands.
gMethicillin-resistant Staphylococcus aureus is a type of staph infection, typically of the skin, that is
resistant to certain types of antibiotics.
hThe National Healthcare Safety Network also allows health care facilities to track blood safety errors
and important health care process measures such as health care personnel influenza and COVID-19
vaccination status and infection control adherence rates.
iThe National Biosurveillance Integration System represents the federal departments and agencies
with mission and resources that can contribute to earlier detection and situational awareness for
nationally significant biological events.

Appendix IV: Comments from the Department
of Health & Human Services

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GAO-22-104600  Public Health Network

Appendix IV: Comments from the
Department of Health & Human Services

Appendix IV: Comments from the Department
of Health & Human Services

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GAO-22-104600  Public Health Network

Appendix IV: Comments from the Department
of Health & Human Services

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GAO-22-104600  Public Health Network

Appendix IV: Comments from the Department
of Health & Human Services

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GAO-22-104600  Public Health Network

Appendix IV: Comments from the Department
of Health & Human Services

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GAO-22-104600  Public Health Network

Appendix V: GAO Contact and Staff
Acknowledgments

Page 66
GAO-22-104600  Public Health Network
Jennifer R. Franks at (404) 679-1831 or franksj@gao.gov
In addition to the contact named above, Nicole Jarvis (Assistant Director),
Freda Paintsil (Analyst-in-Charge), Gerard Aflague, Chris Businsky,
Donna Epler, Christopher Gyra, Franklin Jackson, Grant Mallie, Kelly
Rubin, Amber Sinclair, Andrew Stavisky, Walter Vance, Adam Vodraska,
and AJ Yohn made key contributions to this report.

Appendix V: GAO Contact and Staff
Acknowledgments
GAO Contact
Staff
Acknowledgments
(104600)

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