RAND Study Finds Gaps in Public Health Agency Responsiveness to Reports of Suspicious Illnesses

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August 30, 2005

Many local public health agencies around the United States are unprepared to quickly learn about and respond to naturally occurring outbreaks of deadly infectious diseases and to acts of bioterrorism, a test conducted by the RAND Corporation found.

A novel effort to test the preparedness of local public health agencies to accept reports of suspicious illnesses found that most fell short of federal guidelines intended to assure a prompt response to potential infectious disease outbreaks. A study reporting the test results was published online today by the journal Health Affairs.

“Despite efforts to strengthen local public health agencies, there is a lot of room for improvement in how these agencies receive and respond to reports that might indicate a disease outbreak,” said Dr. Nicole Lurie,, the Paul O'Neill Alcoa Professor of Public Policy at RAND. “Local public health agencies are one of the nation's first lines of defense against disease outbreaks and they are falling short.”

To conduct the test, RAND Health researchers posed as local physicians who were reporting cases of concern — including fictitious cases of botulism, anthrax, smallpox and bubonic plague — to 19 public health agencies in 18 states that were selected as a sample of public health agencies across the nation.

Agency directors agreed in advance to participate in the tests, but did not inform their staffs. The survey included large and small public health agencies in rural and metropolitan areas. The study does not identify the local agencies participating in the tests because the agencies were promised confidentiality in return for their participation.

Only two of the 19 local public health agencies sampled consistently met federal goals to respond to all calls within 30 minutes, according to the study. Three local public health agencies did not respond to the first five calls they received.

Researchers say the time it took for local public health agencies to return calls varied from one minute to nearly two days. Delays in returning calls were most likely to occur near the end of the workday, during the evening and on weekends.

Some workers who responded to disease reports appeared to have no training in infectious diseases and others provided poor advice to callers, according to the study.

In one case, after listening to a description of the classic symptoms of bubonic plague, a public health worker advised the caller not to worry and to “go back to sleep” because no similar cases had been reported. In another instance, a caller who reported a case with symptoms of botulism was told: “You're right, it does sound like botulism. I wouldn't worry too much if I were you.”

“We found wide variation not only in response time, but also in the way workers handled information about the disease reports,” said David J. Dausey, a RAND researcher and lead author of the report. “There is a strong chance that the early stages of a serious infectious disease outbreak could be missed by local public health officials.”

“Many of the public health agencies had a low level of what we call the index of suspicion,” Dausey added. “They didn't take seriously reports that could signal a serious infectious disease outbreak, even in the face of heightened awareness about bioterrorism.”

The study is part of a larger effort by RAND Health supported by funding by the U.S. Department of Health and Human Services to develop methods to measure the performance of public health agencies.

The public health agencies, operated by local governments, are charged with protecting a region's population from current and future threats such as communicable and infectious diseases, as well as with promoting practices that can improve the health of a region's residents.

Researchers say the methods used in the study provide a way to judge whether local health agencies are prepared to handle infectious disease outbreaks, in addition to the self-reports of the agencies. The researchers developed an operations manual that local public health officials can use to develop tests of their own systems for receiving and responding to reports about infectious disease cases. The manual is available at http://www.rand.org/pubs/technical_reports/TR260/

“The public's expectations for the public health system are much lower than what they expect from the nation's medical system,” Lurie said. “In this new environment — where we face the real risk of bioterror and other novel threats — this should no longer be acceptable.”

After the mock disease outbreaks were called in during the RAND test, researchers told health workers that each call was part of a research project. Agencies were called from six to 10 times with fictitious case reports, depending on the agency's pattern of response.

The other author of the report is Alexis Diamond from the Harvard University Center for Basic Research in the Social Sciences.

RAND Health is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care quality, costs, and delivery, among other topics.

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