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Volume 10, Number 2—February 2004
2004 SARS Edition
Preparedness and Response

SARS Preparedness Checklist for State and Local Health Officials

Richard S. Hopkins*Comments to Author , Lara Misegades†, James Ransom‡, Leigh Lipson‡, and Edward W. Brink*
Author affiliations: *Centers for Disease Control and Prevention, Atlanta, Georgia, USA; †Association of State and Territorial Health Officials, Washington, DC, USA; and; ‡National Association of County and City Health Officials, Washington, DC, USA

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A planning checklist for widespread severe acute respiratory syndrome, modeled on an Association of State and Territorial Health Officials (ASTHO) pandemic influenza planning checklist, was developed jointly by ASTHO, the National Association of County and City Health Officials, and the Centers for Disease Control and Prevention. This checklist, distributed May, 2003, has been widely used.

In March 2003, the number of cases of severe acute respiratory syndrome (SARS) was increasing daily worldwide, and several cities were having difficulty bringing its transmission under control (1). SARS appeared to have pandemic potential, as all persons worldwide were susceptible and the disease was, under certain conditions, readily spread from person to person. The Centers for Disease Control and Prevention (CDC) developed a multifaceted response to this worldwide and domestic threat, organized in a wide range of investigative and response teams. As part of this response, a team was created and tasked with identifying the types of public health response that would be needed in the United States at various stages if a SARS pandemic occurred, with widespread disease in the United States and with transmission in health care facilities and the community. The team included members with experience in planning for pandemic influenza and for smallpox control, should that disease reappear. Several influenza planning documents had been produced and provided support and encouragement provided to state and local health departments to develop their own influenza pandemic plans (2).

In examining existing influenza planning documents, the team became aware of a pandemic influenza planning checklist designed for state health officials, which had been produced and disseminated as part of a larger influenza planning guidance document by the Association of State and Territorial Health Officials (ASTHO) (3). This document identified a wide range of topics and issues that would need to be considered at the state level in planning for pandemic influenza, ranging from ensuring adequate legal authority and issuing of emergency declarations to organizing volunteer medical assistance, coordinating healthcare services and emergency provision of vaccine and antiviral medications, communicating with healthcare providers and the public, and providing laboratory and epidemiology services. The team believed that this well-received checklist could, with relatively minor modifications, be adapted for SARS planning, at both the state and local levels, to ensure that important preparedness issues were recognized and addressed by SARS planning teams. The checklist might serve as the outline for a SARS plan or be used in review of an existing or developing plan to ensure that key issues were addressed.

A joint workgroup of ASTHO and the National Association of County and City Health Officials (NACCHO) members and staff and CDC representatives convened by telephone in early April 2003. As a result of a series of conference calls, the checklist was modified to address local and district as well as state health officials’ roles; surveillance, epidemiologic investigation, isolation, and quarantine; and transmission in healthcare settings. The material on vaccination and antiviral drug treatment was moved to an appendix.

The revised checklist (Appendix) was reviewed and approved by appropriate committees and managers of ASTHO, NACCHO, and CDC (National Center for Infectious Diseases). It was posted as a joint NACCHO-ASTHO document on the Web sites of both organizations on May 29, 2003 (4). Through electronic newsletters, NACCHO and ASTHO each alerted their members that the document was available. For example, NACCHO emailed approximately 3,000 local health department managers, 1,547 local health department immunization coordinators, and approximately 1,600 local health department bioterrorism coordinators. The checklist was also included in NACCHO’s Public Health Dispatch of July 2003, which is distributed by regular mail to all NACCHO members (5). ASTHO distributed the checklist by email to each state health official, other senior public health staff, and affiliate organizations on May 30, 2003, and notified approximately 1,200 public health personnel through the print version of the ASTHO Report. During June and July 2003, the checklist was accessed approximately 1,600 times on the NACCHO Web site.

On May 28 and 29, 2003, NACCHO used the checklist as the organizing document for a 2-day working meeting in Chicago, Illinois, of representatives of more than 20 large city health departments, held to develop recommendations for managing possible epidemic SARS in metropolitan areas. The checklist was presented and discussed in a plenary session of the July 9–11 ASTHO meeting of senior deputies in Park City, Utah. The checklist was favorably cited July 29, 2003 by Dr. Marjorie Kanof of the U.S. General Accounting Office in congressional testimony about national readiness for a resurgence of SARS (6).

The checklist has been used by state public health agencies as a guiding document for SARS preparedness planning and has been included as an appendix in some state SARS public health emergency response plans. In addition, the Chicago Department of Health is using the checklist to make plans for dealing with SARS control in its pediatric population through pediatric providers. The Santa Clara (California) County Health Department has used the checklist to work with its hospitals and clinical laboratories in coordinating their SARS plans. The Dallas County Health Department has used it to review legal authority issues and to work with hospitals and law enforcement on isolation and quarantine issues (J. Ransom, unpub. data). As experience accumulates from using the checklist as a framework for local and statewide SARS planning, the document may be revised. As of December 2003, SARS transmission is not known to be occurring anywhere in the world (7). The quick development and widespread acceptance of this checklist suggest that with periodic updating and modification such a planning document can be a useful tool for managing serious infectious disease threats. The value of plans developed using this checklist should be assessed in each community by carrying out realistic table-top and field exercises that involve all partners identified in the plan.



We acknowledge the assistance of numerous members and staff of the Association of State and Territorial Health Officials and the National Association of County and City Health Officials; the leadership roles of Nancy Cox, Keiji Fukuda, and Raymond Strikas as co-chairs of the team preparing the checklist; and the assistance of Pascale Wortley as a working group member.

Dr. Hopkins is associate director for science, Division of Public Health Surveillance and Informatics, Epidemiology Program Office, Centers for Disease Control and Prevention. He has been state epidemiologist in several states, most recently in Florida, and is interested in the design and evaluation of surveillance systems.



  1. Outbreak of severe acute respiratory syndrome—worldwide, 2003. [Erratum in: MMWR Morb Mortal Wkly Rep 2003;52:284]. MMWR Morb Mortal Wkly Rep. 2003;52:2268.PubMedGoogle Scholar
  2. National Vaccine Program Office, Centers for Disease Control and Prevention. Pandemic influenza: a planning guide for state and local officials (draft 2.1), 2003. [cited 2003 Dec 9]. Available from: URL:
  3. Misegades  L. Preparedness planning for state health officials: nature’s terrorist attack, pandemic influenza [monograph on the Internet]. Washington: Association of State and Territorial Health Officials; 2002. [cited 2003 Dec 9]. Available from: URL:
  4. State and local health official epidemic SARS checklist. Washington: Association of State and Territorial Health Officials; 2003. [cited 2003 Dec 9]. Available from: URL:
  5. State and local health official SARS epidemic checklist. Public health dispatch. Washington: National Association of City and County Health Officials; 2003 July. [cited 2003 Dec 9]. Available from: URL:
  6. Testimony before the Permanent Subcommittee on Investigations, Committee on Governmental Affairs, U.S. Senate on July 30, 2003, by Marjorie E. Kanof, Government Accounting Agency Director for Health Care—Clinical and Military Health Care Issues. Severe acute respiratory syndrome: established infectious disease control measures helped contain spread, but a large-scale resurgence may pose challenges. GAO-03-1058T. [cited 2003 Dec 9]. Available from: URL:
  7. World Health Organization. Features, July 5, 2003. SARS: breaking the chains of transmission. [cited 2003 Dec 9]. Available from: URL:


Cite This Article

DOI: 10.3201/eid1002.030729

Table of Contents – Volume 10, Number 2—February 2004

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Please use the form below to submit correspondence to the authors or contact them at the following address:

Richard S. Hopkins, Associate Director for Science, Division of Public Health Surveillance and Informatics, Epidemiology Program Office, Centers for Disease Control and Prevention, Mailstop K74; fax: 770-488-8445

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The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.