Report No. 2007-73
November 2007

Complete Audit Report

The following report is our audit of the Department of Health and Senior Services, Bioterrorism Program.

The Department of Health and Senior Services (DHSS) has not established adequate tracking procedures to monitor improvements made by local health entities to address problems/weaknesses identified during bioterrorism exercises.

The DHSS uses grant funding to develop and conduct exercises at a statewide level while Local Public Health Agencies (LPHAs) use grant funding provided by the department to participate in local and regional exercises and training. The federal government requires the state and LPHAs to complete a variety of exercises/training annually to work towards and help ensure compliance with National Incident Management System standards. Meeting these standards is necessary to ensure the receipt of future federal preparedness funding assistance.

Upon completion of an exercise, response entities submit to the DHSS after-action reports (AARs) documenting an evaluation of the exercise. While the DHSS receives and reviews the AARs, corrective actions noted in the AARs are not tracked by the DHSS and followed up on in a timely manner. The lack of proactive, ongoing monitoring procedures could result in weaknesses in local response plans to bioterrorism incidents not being addressed and corrected in a timely manner.

The Strategic National Stockpile (SNS) Program was established to aid state and local entities in the development of local distribution and dispensing plans of a massive stockpile of pharmaceuticals, vaccines, medical supplies, equipment, and other items to augment local supplies of critical medical items in case of a terrorist attack. The DHSS, through the activities of its Center for Emergency Response and Terrorism, is responsible for ensuring the department has a SNS Receiving, Distribution and Dispensing Plan.

The federal Centers for Disease Control and Prevention (CDC) conducts annual assessments of Missouri's SNS Program. Since 2003, Missouri’s overall SNS preparedness rating has risen from Amber minus to Green minus. Green is the highest rating given by the CDC, followed by Amber, with Red being the lowest possible rating. The CDC's latest assessment of the state's SNS program, dated October 2006, indicated that Missouri has made excellent progress in strengthening the state’s readiness to manage SNS material.

While the CDC's October 2006 assessment was generally positive, the report included various recommendations to further improve the readiness, efficiency, and effectiveness of response efforts. In that assessment the CDC recommended, among other things, that the DHSS: refine and restructure the SNS Plan operationally; schedule an annual review of the Emergency Communications Plan; include written facility security and vulnerability assessments in the Plan for each receiving, staging, and storage site; ensure that all local SNS dispensing plans meet the guidelines identified by the DHSS; and work with the State Emergency Management Agency to improve communications between the State Emergency Operations Center and the DHSS's Department Situation Room.

During 2004, the federal CDC established the Cities Readiness Initiative (CRI) to increase and enhance readiness over a larger geographic area, instead of just at a state and local level. A CRI pilot program provided funding to 21 selected metropolitan areas. St. Louis (including the city and county) was one of the cities/areas initially selected by the CDC to participate in the CRI pilot program. In the following year, Kansas City and its metropolitan area was selected to join in the CRI program. Also, in that year, St. Charles County began participating in the CRI program.

The CDC and the DHSS are responsible for conducting annual assessments of the local CRI programs in Missouri and working with local CRI staff to aid and help direct their efforts. During the annual assessments, the local entities receive an overall rating or score, and a rating in various individual categories, such as: Command and Controls, Management of SNS operations, Tactical Communications, Public Information, Controlling SNS Inventory, Security, Dispensing Oral Medications, and Training, Exercise, and Evaluation.

The city of St. Louis/St. Louis County was first assessed by the CDC in September 2004. At that time, the CDC's overall assessment rating for the city of St. Louis/St. Louis County was Red, meaning major improvements were needed. In the latest assessment by the CDC in April 2006, some improvement had been made as the City/County had achieved an overall assessment rating of Amber. Within the Kansas City metropolitan area, the CDC conducted Jackson County's only CRI-related assessment to date in May 2006. That county was given an overall readiness rating of Red, or major improvement needed. In that assessment report, the CDC indicated that Jackson County did not have a reliable or consistent SNS Preparedness plan in Kansas City or its surrounding counties, and no documentation was present to reflect that its current plan was incorporated into the city’s Comprehensive Emergency Management Plan. The CDC conducted St. Charles County's only CRI-related assessment to date in January 2007. At that time, the CDC's overall assessment rating for St. Charles County was 55 out of 100 (based on a new rating system established in 2007), indicating major improvement was needed.

The DHSS is working with these entities in an effort to improve their CRI programs and the related ratings on future annual assessments. Although the assessments conducted of the CRI plans of local entities in the state's two largest metropolitan areas reflect some progress, much improvement is still needed. The low assessment ratings can reflect weaknesses with the CRI plans in Missouri and may increase the risk for the citizens those plans are intended to protect.

Complete Audit Report