United States Government Accountability Office

GAO Report to the Committee on Government 

Reform, House of Representatives 

INFLUENZA 

PANDEMIC 

DOD Has Taken 

Important Actions to 

Prepare, but 

Accountability, 

Funding, and 

Communications Need 

to be Clearer and 

Focused 

Departmentwide 

September 2006 

 

GAO-06-1042 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

September 2006

INFLUENZA PANDEMIC

DOD Has Taken Important Actions to 

Prepare, but Accountability, Funding, and 

Communications Need to be Clearer and 

Focused Departmentwide 

Highlights of GAO-06-1042, a report to the 

Chairman and Ranking Minority Member, 

Committee on Government Reform, 

House of Representatives

An influenza pandemic would be of

global and national significance

and could affect large numbers of 

Department of Defense (DOD) 

personnel, seriously challenging 

DOD’s readiness. 

GAO was asked to examine DOD’s 

pandemic influenza preparedness 

efforts. This report focuses on 

DOD’s planning for its workforce, 

specifically (1) actions DOD has 

taken to prepare and (2) challenges

DOD faces going forward. GAO

analyzed guidance, contracts, and 

plans, and met with DOD officials.

What GAO Recommends

GAO recommends that DOD 

(1) define and communicate roles 

and responsibilities, oversight 

mechanisms, and goals and

performance measures for DOD’s 

efforts, (2) establish a framework 

to request funding, tied to its goals, 

(3) define and communicate 

departmentwide which types of 

personnel DOD plans to include in

its vaccine and antiviral

distribution, and (4) implement a 

comprehensive and effective 

departmentwide communications 

strategy. DOD generally concurred 

with four recommendations, and 

did not address one in its written

comments. Based on DOD’s 

comments and additional

information provided showing

DOD designated a lead authority

for its efforts, GAO combined two 

recommendations. GAO clarified 

another recommendation to focus 

on requesting funding tied to the 

department’s goals. 

DOD had taken a number of actions since September 2004 to prepare for an 

influenza pandemic, and its planning efforts continue to evolve. The 

Implementation Plan for the National Strategy for Pandemic Influenza, 

released in May 2006, tasked each federal department to develop its own 

implementation plan that details how it will carry out its responsibilities as 

outlined in the national plan and how it will prepare its workforce. DOD 

established working groups for its pandemic influenza planning efforts, 

including the Pandemic Influenza Task Force, which included 

representatives from across the department, including the Offices of the 

Assistant Secretary of Defense (ASD) for Homeland Defense, ASD for Health 

Affairs, ASD for Special Operations and Low Intensity Conflict, and the Joint 

Chiefs of Staff. In addition, the Office of the ASD for Health Affairs 

developed guidance that provided tasks for the Office of the Secretary of 

Defense, military departments, installation commanders, and others to 

complete to prepare for a pandemic. Further, several entities within DOD 

drafted plans and guidance, and DOD had taken other important steps, such 

as establishing Web sites, stockpiling vaccines and antivirals, and initiating 

projects to assist other nations with their preparedness efforts. 

Going forward, DOD faces four management challenges that it needs to 

address as it shifts its focus to the department as a whole. First, at the time

of GAO’s review, neither the Secretary of Defense nor the Deputy Secretary 

of Defense had yet issued guidance defining lead and supporting roles and 

responsibilities with clear lines of authority, oversight mechanisms, and 

goals and performance measures for DOD’s influenza pandemic planning 

efforts. The lack of these accountability mechanisms over time may hamper 

the leadership’s ability to ensure that planning efforts across the department 

are progressing as intended. Second, DOD had not yet requested funding for 

its pandemic influenza preparedness efforts linked to departmentwide goals. 

Therefore, it is unclear whether DOD can address the tasks assigned to it in 

the national implementation plan and pursue its own preparedness efforts 

for its workforce departmentwide within current resources. Third, DOD had 

not yet fully defined or communicated departmentwide which types of 

personnel—military and civilian personnel, contractors, beneficiaries, and 

dependents—it plans to include in its distribution of vaccines and antivirals. 

Fourth, DOD had not yet fully developed its communications strategy or 

communicated information to its personnel departmentwide on what actions 

to take in the event of an influenza pandemic. Also, DOD had not yet 

developed a plan to communicate information on the safety and efficacy of 

vaccines and antivirals, if DOD decides to dispense them. While DOD 

established Web sites with some information on pandemic influenza, GAO 

identified some unevenness across the department in terms of the 

information personnel received. A comprehensive and effective 

communications strategy could ensure that DOD’s personnel 

departmentwide are aware of actions they should take in the event of an 

influenza pandemic. 

www.gao.gov/cgi-bin/getrpt?GAO-06-1042.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Davi M. 

D'Agostino at (202) 512-5431 or 

DAgostinoD@gao.gov. 
Contents 

Letter 1

Results in Brief 6 

Background 11

DOD Had Taken Actions to Prepare for an Influenza Pandemic 13 

Going Forward, DOD Faces Four Key Management Challenges in 

Its Pandemic Influenza Planning and Preparedness Efforts for Its 

Workforce Departmentwide 22 

Conclusions 33

Recommendations for Executive Action 34 

Agency Comments and Our Evaluation 35 

Appendix I Scope and Methodology 39 

Appendix II Summary of DOD’s Guidance for Pandemic 

Influenza and Related Force Health Protection 

Policies 41 

Appendix III Comments from the Department of Defense 43 

Appendix IV GAO Contact and Staff Acknowledgments 47 

Related GAO Products 48 

Table 

Table 1: DOD’s Current Priorities for Vaccine and Antiviral 

Distribution 17

Figures 

Figure 1: Issues to Be Addressed in DOD’s Pandemic Influenza 

Implementation Plan 3 

Page i GAO-06-1042 Influenza Pandemic
Figure 2: Comparison of WHO Pandemic Phases and U.S. 

Government Stages 4 

Figure 3: Timeline of Actions DOD Has Taken to Prepare for an 

Influenza Pandemic Compared to Key Homeland Security 

Council Plans 14 

Abbreviations 

ASD Assistant Secretary of Defense 

DOD Department of Defense 

HHS Department of Health and Human Services 

WHO World Health Organization 

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Page ii GAO-06-1042 Influenza Pandemic
United States Government Accountability Office

Washington, DC 20548 

September 21, 2006 

The Honorable Tom Davis 

Chairman 

The Honorable Henry A. Waxman 

Ranking Minority Member 

Committee on Government Reform 

House of Representatives 

The Honorable Tom Davis 

Chairman 

The Honorable Henry A. Waxman 

Ranking Minority Member 

Committee on Government Reform 

House of Representatives 

An influenza pandemic—a novel strain of influenza virus to which humans 

have little or no immunity that has the ability to infect and be passed 

efficiently between humans worldwide—would be of global and national

significance. A large number of Department of Defense (DOD) personnel 

potentially could be affected by an influenza pandemic, which could 

adversely affect the military’s readiness, jeopardize ongoing military 

operations overseas, and threaten the day-to-day functioning of the 

department and maintenance of its critical infrastructure. For example, 

approximately one-half of all of the deaths of U.S. servicemembers from 

World War I, at least 43,000 deaths, were due to influenza or influenzarelated complications, and another 1 million servicemembers were 

hospitalized, limiting the military’s resources to continue ongoing 

missions. An influenza pandemic outbreak not only would be a medical 

problem, but also a human capital and national security problem. The 

federal government anticipates an influenza pandemic would occur in 

multiple waves over a period of time, rather than as a discrete event. 

During the peak weeks of an outbreak of a severe influenza pandemic, an 

estimated 40 percent of the U.S. workforce may not be at work due to 

illness, the need to care for family members, or fear of infection. 

An influenza pandemic—a novel strain of influenza virus to which humans 

have little or no immunity that has the ability to infect and be passed 

efficiently between humans worldwide—would be of global and national

significance. A large number of Department of Defense (DOD) personnel 

potentially could be affected by an influenza pandemic, which could 

adversely affect the military’s readiness, jeopardize ongoing military 

operations overseas, and threaten the day-to-day functioning of the 

department and maintenance of its critical infrastructure. For example, 

approximately one-half of all of the deaths of U.S. servicemembers from 

World War I, at least 43,000 deaths, were due to influenza or influenzarelated complications, and another 1 million servicemembers were 

hospitalized, limiting the military’s resources to continue ongoing 

missions. An influenza pandemic outbreak not only would be a medical 

problem, but also a human capital and national security problem. The 

federal government anticipates an influenza pandemic would occur in 

multiple waves over a period of time, rather than as a discrete event. 

During the peak weeks of an outbreak of a severe influenza pandemic, an 

estimated 40 percent of the U.S. workforce may not be at work due to 

illness, the need to care for family members, or fear of infection. 

Planning for an influenza pandemic is a difficult and daunting task, 

particularly because so much is currently unknown about a potential 

pandemic. While some scientists and public health experts believe that the 

next influenza pandemic could be spawned by the H5N1 strain of avian 

influenza (also known as “bird flu”) that is currently circulating in parts of 

Asia, the Middle East, Europe, and Africa, it is unknown when an influenza 

pandemic will occur, where it will begin, or whether a variant of the H5N1 

strain or some other strain would be the cause. Moreover, the severity of

an influenza pandemic, as well as the groups of people most at risk for 

infection, cannot be accurately predicted. Additionally, responding to an

influenza pandemic would be more challenging than dealing with annual 

influenza in several ways. Each year, annual influenza causes 

Planning for an influenza pandemic is a difficult and daunting task, 

particularly because so much is currently unknown about a potential 

pandemic. While some scientists and public health experts believe that the 

next influenza pandemic could be spawned by the H5N1 strain of avian 

influenza (also known as “bird flu”) that is currently circulating in parts of 

Asia, the Middle East, Europe, and Africa, it is unknown when an influenza 

pandemic will occur, where it will begin, or whether a variant of the H5N1 

strain or some other strain would be the cause. Moreover, the severity of

an influenza pandemic, as well as the groups of people most at risk for 

infection, cannot be accurately predicted. Additionally, responding to an

influenza pandemic would be more challenging than dealing with annual 

influenza in several ways. Each year, annual influenza causes 

Page 1 GAO-06-1042 Influenza Pandemic
approximately 226,000 hospitalizations and 36,000 deaths in the United 

States. According to the World Health Organization (WHO), an influenza 

pandemic would spread throughout the world very quickly, usually in less 

than a year, and could sicken more than a quarter of the global population, 

including young, healthy individuals who are not normally as affected by 

the annual influenza. However, despite all of these uncertainties, sound 

planning and preparedness could lessen the impact of any influenza 

pandemic. 

To address the potential threat of an influenza pandemic, the Homeland 

Security Council issued its National Strategy for Pandemic Influenza in 

November 2005.1

 The Implementation Plan for the National Strategy for 

Pandemic Influenza,

2

 which was released in May 2006, proposes actions 

for federal departments—including DOD—in support of the national 

strategy and describes expectations for nonfederal entities, including 

state, local, and tribal governments; the private sector; international 

partners; and individuals. The national implementation plan tasked each 

federal agency to develop an implementation plan that addresses two 

issues, as shown in figure 1. First, each federal department was to detail 

how it would carry out the department’s responsibilities in the national

implementation plan. For example, of the more than 300 actions in the 

national implementation plan, DOD was responsible for 114 actions—31 

actions as a lead agency and 83 actions as a supporting agency. Second, 

each federal department was to include the department’s approach to 

employee safety, continuity of operations, and communications with 

stakeholders in its implementation plan. 

 1

Homeland Security Council, National Strategy for Pandemic Influenza (Washington,

D.C.: Nov. 2005). 

2

Homeland Security Council, Implementation Plan for the National Strategy for 

Pandemic Influenza (Washington, D.C.: May 2006). 

Page 2 GAO-06-1042 Influenza Pandemic
Figure 1: Issues to Be Addressed in DOD’s Pandemic Influenza Implementation

Plan 

Source: GAO analysis.

The Implementation Plan for 

the National Strategy for 

Pandemic Influenza tasked 

each federal agency to address

the following two issues in its

implementation plan

How it would address the 

tasks assigned to the 

agency__DOD was identified 

as a lead agency for 31 tasks.

Its approach to employee 

safety, continuity of operations, 

and communications with 

stakeholders departmentwide.

WHO defines the emergence of an influenza pandemic in six phases (see 

fig. 2). Based on this definition, the world currently is in phase 3, in which 

there are human infections from a new influenza subtype, but no or very 

limited human-to-human transmission of the disease. In addition, the 

Homeland Security Council developed “stages,” also shown in figure 2, to

provide a framework for a federal government response to an influenza 

pandemic, which characterize the outbreak in terms of the threat that the 

pandemic virus poses to the U.S. population. Currently there are new 

domestic animal outbreaks in an at-risk country, which is stage 0. 

Page 3 GAO-06-1042 Influenza Pandemic
Figure 2: Comparison of WHO Pandemic Phases and U.S. Government Stages 

Description

No new influenza virus subtypes have been 

detected in humans. An influenza virus subtype 

that has caused infection may be present in 

animals. If present in animals, the risk of human 

infection or disease is considered to be low.

No new influenza virus subtypes have been 

detected in humans. However, a circulating 

animal influenza virus subtype poses a

substantial risk of human disease.

Human infections with a new subtype, but no 

human-to-human spread, or at most rare 

instances of spread to a close contact.

Small clusters with limited human-to-human 

transmission but spread is highly localized, 

suggesting that the virus is not well adapted to 

humans.

Larger clusters but human-to-human spread still 

localized, suggesting that the virus is becoming 

increasingly better adapted to humans, but may 

not yet be fully transmissible (substantial 

pandemic risk).

Pandemic: increased and sustained 

transmission in the general population.

Federal 

government

stage

Stage 0

Stage 0

Stage 1

Stage 2

Stage 3

Stage 4

Stage 5

Stage 6

Description

New domestic 

animal outbreak in 

an at-risk country.

New domestic 

animal outbreak in 

an at-risk country.

Suspected human 

outbreak overseas.

Confirmed human 

outbreak overseas.

Widespread human 

outbreaks in multiple 

locations overseas.

First human case in 

North America.

Spread throughout 

the United States.

Recovery and 

preparation for 

subsequent waves.

WHO phase

Interpandemic period

Phase 1

Phase 2

Pandemic alert period

Phase 3

Phase 4

Phase 5

Pandemic period

Phase 6

Source: Homeland Security Council.

You asked that we examine DOD’s planning and preparedness efforts for 

an influenza pandemic. Because DOD’s implementation plan was still 

being drafted at the time of our review, we focused our work on DOD’s 

pandemic influenza planning and preparedness efforts to date for its own 

workforce. DOD is a large, complex organization of departments, 

agencies, and other components with a workforce spread around the 

world, which, as of April 30, 2006, included nearly 1.4 million active duty 

military personnel and nearly 675,000 civilian personnel. This total does 

not include the numerous reserve and mobilized National Guard 

Page 4 GAO-06-1042 Influenza Pandemic
personnel,3

 contractors, dependents, and beneficiaries for which DOD also 

is responsible. 

We are reporting to you at this time to highlight some of our observations

to date on DOD’s approach to planning and preparing to protect its 

workforce so DOD can consider and address them as the department 

continues its ongoing planning efforts. This report is largely focused on 

DOD’s plans to protect its own workforce and addresses (1) actions DOD 

has taken to date to prepare for an influenza pandemic and 

(2) management challenges DOD faces going forward as the department 

continues its planning efforts. We expect to issue another report at a later 

date on DOD’s plans and preparedness for an influenza pandemic, which 

will include our evaluation of DOD’s final implementation plan, the 

combatant command plans, and selected installation plans. 

To address these objectives, we reviewed a draft of the department’s 

implementation plan for pandemic influenza dated March 2006;4

 guidance 

and planning orders for pandemic influenza issued by the Assistant 

Secretary of Defense (ASD) for Health Affairs, the Joint Chiefs of Staff, 

Army Medical Command, and Army Installation Management Agency; and 

the department’s existing directives for force health protection. Also, we 

reviewed the Implementation Plan for the National Strategy for 

Pandemic Influenza, the Department of Health and Human Services’ 

(HHS) contract with a vaccine manufacturer, and DOD’s contracts with 

two antiviral manufacturers. Additionally, we met in the Washington, D.C., 

area with cognizant DOD officials from the Office of the Secretary of 

Defense, including officials from the Offices of the ASD for Homeland 

Defense, ASD for Health Affairs, and ASD for Special Operations and Low 

Intensity Conflict; the Joint Chiefs of Staff; and each of the military 

services. Some officials from these offices were involved in the 

development of the National Strategy for Pandemic Influenza and its 

 3

According to DOD officials, DOD would be responsible for National Guard personnel who

have been mobilized under Title 10, United States Code. Otherwise, the individual states 

would be responsible for National Guard personnel serving under Title 32, United States

Code, or under State Active Duty. 

4

DOD released its implementation plan to the Homeland Security Council on August 16, 

2006, as we were completing our review. However, according to an official in the Office of

the ASD for Homeland Defense, DOD cannot release its implementation plan externally 

until it is coordinated and approved by the Homeland Security Council. We reviewed the 

final plan and determined that it was not significantly different from the March 2006 draft

that we previously reviewed. 

Page 5 GAO-06-1042 Influenza Pandemic
implementation plan. We conducted our review from December 2005 

through August 2006 in accordance with generally accepted government 

auditing standards. Further details on our scope and methodology are in 

appendix I. 

DOD has taken a number of important actions to prepare for an influenza 

pandemic since September 2004, well before the federal government 

released the National Strategy for Pandemic Influenza in November 2005

and its implementation plan in May 2006, and these efforts continue to 

evolve. Going forward, DOD faces several management challenges as it 

continues its ongoing planning efforts. Certain offices within DOD 

established working groups, such as the Pandemic Influenza Task Force, 

which coordinated and implemented DOD’s pandemic influenza policies 

and plans. Also, in September 2004 and January 2006, the ASD for Health 

Affairs issued guidance to the military departments, which, among other 

things, provided tasks for several DOD organizations to complete for each

of WHO’s phases of an influenza pandemic. The guidance also established 

generic priorities for the distribution of vaccines and antivirals. For 

example, deployed forces engaged in or supporting armed conflict and 

those personnel necessary to provide essential health care for the force 

are in the top tier of DOD’s prioritization system. Further, at the time of 

our review, two of the three military departments—the Departments of the 

Navy and the Air Force—planned to issue servicewide instructions related 

to pandemic influenza preparedness. The Department of the Army did not 

plan to issue a similar instruction, but two organizations within the Army 

issued guidance to installations on developing pandemic influenza plans. 

DOD also was undertaking influenza pandemic planning efforts at several 

different levels. Specifically, DOD completed its implementation plan for 

an influenza pandemic, as required by the Implementation Plan for the 

National Strategy for Pandemic Influenza. The department started 

drafting its implementation plan in November 2005. The Joint Chiefs of 

Staff tasked the geographic combatant commands to develop plans, which 

were to address force health protection and defense support to civil 

authorities, among other things. According to officials from the Joint Staff, 

these plans were near completion at the time of our review. Installations 

were tasked by the ASD for Health Affairs to develop pandemic influenza 

plans or revise existing plans to address pandemic influenza. Also, DOD 

established Web sites, including the Pandemic Influenza Watchboard, that 

provided information for servicemembers and their families about avian 

Results in Brief 

Page 6 GAO-06-1042 Influenza Pandemic
and pandemic influenza. Moreover, DOD procured more than 2 million 

treatment courses of one antiviral, which were prepositioned in the 

continental United States, Europe, and the Far East.5

 Additionally, DOD 

procured over 2 million doses of an existing H5N1 vaccine, based on the 

strain that circulated in Vietnam in 2004, and planned to purchase in fiscal 

year 2007 additional doses of the Vietnam strain and a strain that 

circulated in Indonesia in 2005.6

 Internationally, the department initiated 

projects to help build host nation capacity to prepare for, mitigate, and 

respond to a potential influenza pandemic. 

At the time of our review, DOD’s planning efforts to protect its personnel 

focused primarily on the military departments, geographic combatant 

commands, and installations. However, as DOD’s focus shifts to the 

workforce departmentwide, including the civilian workforce and 

personnel in defense agencies, we identified four key management 

challenges that DOD faces going forward as it continues its planning and 

preparedness efforts for pandemic influenza. In our prior work, we 

identified six desirable characteristics of national strategies, including 

defining organizational roles, responsibilities, and coordination; 

identifying goals, subordinate objectives, activities, and performance 

measures; and addressing resources, investments, and risk management.7

However, to date, DOD’s pandemic influenza planning may not be as 

effective as it could be because the department had not yet (1) clearly and

fully defined and communicated departmentwide roles and responsibilities 

with clear lines of authority, oversight mechanisms, and goals and 

performance measures; (2) requested funding that is tied to the 

departmentwide goals of pandemic influenza to complete the tasks in the 

national implementation plan and to protect DOD’s own workforce; 

(3) clearly defined the types of personnel—military personnel, civilian 

personnel, contractors, dependents, and beneficiaries—to be included in 

DOD’s vaccine and antiviral distribution; and (4) implemented a 

 5

DOD has purchased an additional 470,000 treatment courses of the antiviral, which are 

scheduled for delivery by the end of 2006. Additionally, DOD has ordered another 530,000

treatment courses of the antiviral, which will increase its stockpile to 3.4 million courses. 

DOD has not yet received these two orders. 

6

These vaccines, which have not been approved by the Food and Drug Administration, may

not be effective against a future pandemic strain, because the pandemic strain has not yet

emerged. 

7

GAO, Combating Terrorism: Evaluation of Selected Characteristics in National

Strategies Related to Terrorism, GAO-04-408T (Washington, D.C.: Feb. 3, 2004). 

Page 7 GAO-06-1042 Influenza Pandemic
departmentwide communications strategy. Specifically, at the time of our 

review, the following conditions existed. 

• First, neither the Secretary of Defense nor the Deputy Secretary of 

Defense had yet issued guidance clearly and fully defining and

communicating lead and supporting roles and responsibilities for DOD’s 

pandemic influenza planning with clear lines of authority; oversight 

mechanisms, including reporting requirements; and departmentwide 

goals—such as a description of a desired end-state—and performance 

measures. Some officials told us that the lines of authority for DOD’s 

pandemic influenza planning efforts were unclear. For example, officials 

told us that some installation personnel were confused about whether or 

not they were supposed to be developing plans, since it was unusual for 

the ASD for Health Affairs to task installations directly with developing

plans, and we observed differences in the military departments’ 

approaches to installation planning. Further, DOD instituted reporting 

requirements for the organizations responsible for implementing the 31 

tasks from the national implementation plan; however, there were not 

similar oversight mechanisms in place for tasks that were not part of the 

national implementation plan. For example, the January 2006 Health 

Affairs guidance tasked installations with developing pandemic influenza 

plans or modifying existing plans to address pandemic influenza and 

DOD’s implementation plan tasked all DOD organizations with developing

or modifying continuity of operations plans to address pandemic 

influenza; however, there were no reporting requirements for these tasks. 

Finally, Navy officials said that they started developing plans for pandemic 

influenza, but it was difficult because the Office of the Secretary of 

Defense had not provided specific goals for what would be expected of the 

services in the event of an influenza pandemic. Over time, a lack of clear 

lines of authority, oversight mechanisms, and goals and performance 

measures could hamper the leadership’s abilities to ensure that planning 

efforts across the department are progressing as intended as DOD 

continues its pandemic influenza planning and preparedness efforts. 

Additionally, without clear departmentwide goals, it may be difficult for all 

DOD components to develop effective plans and guidance. 

• Second, at the time of our review, DOD had started identifying funding 

requirements, but had not yet identified an appropriate funding 

mechanism or requested funding, tied to its departmentwide goals, for its 

pandemic influenza planning efforts. An official from the Office of the ASD

for Homeland Defense said the department had options for requesting the 

required funding, including incorporating the request in future budget

submissions or submitting a supplemental request to the Congress. 

Because DOD had not yet requested funding, it is unclear whether DOD 

Page 8 GAO-06-1042 Influenza Pandemic
can address the tasks assigned to it in the national implementation plan 

and pursue its own preparedness efforts for its workforce departmentwide 

within current resources. 

• Third, at the time of our review, DOD had not yet clearly defined or 

communicated departmentwide which types of personnel—military 

personnel, civilian personnel, contractors, beneficiaries, and dependents—

the department planned to include in its distribution of vaccines and 

antivirals in the event of an influenza pandemic. The ASD for Health 

Affairs issued generic priorities for the department’s vaccine and antiviral 

distribution and noted that these priorities would be clarified when more 

was known about a pandemic strain. An official in the Office of the ASD 

for Homeland Defense said distinctions in the types of personnel who 

would be included in the distribution of DOD-purchased vaccines and 

antivirals would be based on whether the individual was identified as 

critical to the execution of an essential function, as determined by 

components as they develop or modify their continuity of operations plans 

to address pandemic influenza. A factor affecting DOD’s ability to clarify 

priorities for distributing vaccines among its personnel is that the 

department’s priority for receiving additional vaccines, including the 

vaccine for the pandemic strain, from HHS was not yet defined at the time 

of our review. As a result the department cannot realistically determine 

how well it will be able to meet its priorities for vaccinating personnel, and 

without knowing a rough estimate of how many vaccines will be available, 

DOD cannot accurately determine the funding required to purchase 

vaccines or, if needed, additional antivirals. 

• Fourth, DOD had communicated information to many of its personnel 

about what actions they should take in the event of an influenza pandemic; 

however, these communication efforts were inconsistent departmentwide. 

Also, although DOD had not yet decided when, whether, or under what 

conditions it would dispense the vaccines and antivirals it purchased to 

date, DOD did not yet have a plan to communicate with personnel 

information on the safety and efficacy of vaccines and antivirals it 

purchased to date.8

 However, DOD had posted on one of its Web sites the 

package inserts for the two antivirals that it purchased. While DOD 

established Web sites with some information on pandemic influenza, we 

identified unevenness across the department in terms of offices that 

 8

Although information about the safety and efficacy of treatments that DOD has purchased 

to date is available for dissemination, it is not known whether these treatments would be 

effective against a future strain of the virus because an influenza pandemic involving the

H5N1 virus has not occurred. 

Page 9 GAO-06-1042 Influenza Pandemic
regularly received actively distributed messages and other information. 

Without a comprehensive and effective communications strategy 

departmentwide, DOD personnel’s awareness of actions that should be 

taken in the event of an influenza pandemic could become uneven and 

lead to confusion and increased numbers of affected personnel. 

As DOD continues its planning efforts going forward, and to enhance 

DOD’s ongoing planning efforts, we are making recommendations to the 

Secretary of Defense. Specifically, we are recommending that the 

Secretary of Defense (1) instruct the ASD for Homeland Defense, as the 

individual accountable for DOD’s pandemic influenza planning and 

preparedness efforts, to clearly and fully define and communicate 

departmentwide the roles and responsibilities of the organizations that 

will be involved in DOD’s efforts with clear lines of authority; the oversight 

mechanisms, including reporting requirements, for all aspects of DOD’s 

pandemic influenza planning efforts, to include those tasks that are not 

part of the national implementation plan; and the goals and performance 

measures of DOD’s preparedness efforts; (2) instruct the ASD for 

Homeland Defense to work with the Under Secretary of Defense 

(Comptroller) to establish a framework for requesting funding for the 

department’s preparedness efforts that includes the appropriate funding 

mechanism and controls to ensure needed funding for DOD’s pandemic 

influenza preparedness efforts is tied to the department’s goals; 

(3) instruct the ASD for Health Affairs to clarify DOD’s guidance to 

explicitly define and communicate departmentwide whether and how all 

types of personnel—military and civilian personnel, contractors, 

dependents, and beneficiaries—would be included in DOD’s distribution 

of vaccines and antivirals, and (4) instruct the ASD for Public Affairs to 

implement a comprehensive and effective communications strategy for 

personnel departmentwide. 

In written comments on a draft of this report, DOD generally concurred 

with four of our recommendations, and did not address one 

recommendation. DOD’s comments and our evaluation of them are in the 

agency comments section of this report. Based on DOD’s comments and

additional documentation that DOD provided, we combined two of our 

recommendations and clarified another. Specifically, DOD provided 

additional documentation showing that the Deputy Secretary of Defense

designated the ASD for Homeland Defense to lead the department’s 

pandemic influenza efforts. Therefore, we deleted part of the original 

recommendation that the Secretary of Defense or Deputy Secretary of 

Defense designate an individual to be accountable for DOD’s efforts. 

Additionally, DOD commented that it had started to determine funding 

Page 10 GAO-06-1042 Influenza Pandemic
requirements for its pandemic influenza efforts. We recognized this in our 

draft report and, subsequently, we clarified the recommendation to focus

on requesting funding that is tied to the department’s goals. 

Occasionally, worldwide influenza epidemics—called pandemics—occur 

that can have successive “waves” of disease that can last for up to 3 years. 

Three influenza pandemics occurred in the twentieth century. Notable 

among these was the influenza pandemic of 1918, called the “Spanish flu,” 

which killed at least 20 million people worldwide, including 500,000 in the 

United States.

9

 The past pandemics have spread worldwide within months 

and a future pandemic is expected to spread even more quickly given 

modern travel patterns. The major implication of such a rapid spread is 

that many, if not most, countries will have minimal time to implement 

preparations and responses once a pandemic virus begins to spread. 

The current pandemic influenza threat stems from an unprecedented 

outbreak of H5N1 avian influenza that began in Hong Kong in 1997 and has 

spread in bird populations across parts of Asia, the Middle East, Europe, 

and Africa, with limited infections in humans. The Food and Agriculture 

Organization of the United Nations reported in August 2006 that more than 

220 million poultry were culled as a preventive measure or died from the 

H5N1 strain. From January 2003 through August 2006, WHO reported more 

than 240 confirmed human cases and more than 140 confirmed human 

deaths from the H5N1 virus. Scientists and public health officials agree 

that the rapid spread of the H5N1 virus in birds and the occurrence of 

limited infections in humans have increased the risk that this disease may 

mutate into a form that is easily transmissible among humans, resulting in 

an influenza pandemic. Some experts at WHO and elsewhere believe that 

the world is now closer to another influenza pandemic than at any time 

since the last influenza pandemic in 1968. According to Central 

Intelligence Agency officials, the likelihood of an influenza pandemic 

occurring within the next 5 years is greater than any other time in the past 

40 years. Furthermore, the agency officials reported that H5N1 is the most 

likely of all influenza viruses to cause a pandemic. Three conditions must 

be met before an influenza pandemic begins: (1) a new influenza virus 

subtype that has not previously circulated in humans must emerge, (2) the 

virus must be capable of causing disease in humans, and (3) the virus must 

Background 

 9

The pandemics of 1957 (“Asian flu”) and 1968 (“Hong Kong flu”) caused dramatically fewer 

fatalities—70,000 and 34,000, respectively, in the United States—partly because of 

antibiotic treatment of secondary infections and more aggressive supportive care. 

Page 11 GAO-06-1042 Influenza Pandemic
be capable of being passed easily among humans. The H5N1 virus meets 

the first two of these three conditions. 

We previously reported vaccination is considered the first line of defense 

for preventing or reducing influenza-related illness and death; however, 

vaccines may be unavailable, in short supply, or ineffective for certain 

portions of the population during the first wave of a pandemic.10 Because a

pandemic strain has not emerged and an effective vaccine needs to be a 

close match to the actual pandemic virus, vaccine production for the 

pandemic strain cannot begin until a pandemic virus emerges.11 Vaccine

production generally takes at least 6 to 8 months after a virus strain has 

been identified. The length of time required to produce the vaccine, 

combined with limited U.S. manufacturing capability, could lead to a 

shortage of vaccines for the first wave of an influenza pandemic. We 

previously reported that limited studies have shown that when a vaccine

produces a good antibody response to a virus, approximately 70 to 90 

percent of healthy young adults may be protected from influenza. This 

protection drops to about 30 to 40 percent for the elderly and those 

suffering from chronic illness or disease.12

While vaccination has been the primary strategy for preventing influenza,

antiviral drugs can also contribute to the prevention and treatment of 

influenza. The Food and Drug Administration has approved four antiviral 

medications for the prevention and treatment of influenza. If taken within 

2 days of symptoms, these drugs can reduce symptoms and make someone 

with influenza less contagious to others. According to the Centers for 

Disease Control and Prevention, these antivirals are about 70 to 90 percent 

effective for preventing illness in healthy adults. However, influenza virus 

strains can become resistant, so these drugs may not always be effective. 

While antiviral drugs may help prevent or mitigate influenza-related illness 

or death until an effective vaccine becomes available, these drugs are 

expected to be in short supply during an influenza pandemic. 

 10GAO, Influenza Pandemic: Plan Needed for Federal and State Response, GAO-01-4 

(Washington, D.C.: Oct. 27, 2000). 

11Although a vaccine for a pandemic strain cannot be developed until the pandemic strain 

emerges, some vaccine manufacturers have developed vaccines based on the H5N1 strain 

isolated in Vietnam in 2004.

12GAO-01-4. 

Page 12 GAO-06-1042 Influenza Pandemic
We previously reported that DOD provides health care to over 9 million 

active duty personnel, retirees, and their dependents through the 

department’s TRICARE program.13 DOD’s military health system has a dual 

role of medically supporting wartime deployments while caring for active 

duty members, retirees, and their families in peacetime. TRICARE 

beneficiaries can obtain health care through DOD’s direct care system of 

military hospitals and clinics, commonly referred to as military treatment 

facilities, and through DOD’s purchased care system of civilian providers. 

The Army, the Navy, and the Air Force provide most of the system’s care 

through their own medical centers, hospitals, and clinics, while regional

networks of civilian providers supply the remaining care. 

DOD began its pandemic influenza planning and preparedness efforts as 

early as September 2004, well before the White House issued the National 

Strategy for Pandemic Influenza in November 2005 and its 

implementation plan in May 2006, and has taken a number of important 

actions since then to ensure that the department is ready in the event of an 

influenza pandemic. To date, DOD’s actions to prepare for an influenza 

pandemic include establishing working groups, issuing guidance, 

developing plans, establishing Web sites, stockpiling vaccines and 

antivirals, and initiating projects to assist other nations’ preparedness 

efforts. Figure 3 summarizes DOD’s efforts to date related to pandemic 

influenza planning and preparedness. 

DOD Had Taken 

Actions to Prepare for 

an Influenza 

Pandemic 

 13GAO, Defense Health Care: Implementation Issues for New TRICARE Contracts and 

Regional Structure, GAO-05-773 (Washington, D.C.: July 27, 2005). 

Page 13 GAO-06-1042 Influenza Pandemic
Figure 3: Timeline of Actions DOD Has Taken to Prepare for an Influenza Pandemic Compared to Key Homeland Security 

Council Plans

November 2005 

Homeland Security

Council issued the

National Strategy for

Pandemic Influenza.

May 2006 

Homeland Security

Council issued the 

Implementation

Plan for the National 

Strategy for

Pandemic Influenza.

September 2004

Issued guidance on

pandemic influenza.

November 2005

Established the

Pandemic Influenza

Task Force.

Started drafting DOD’s

implementation plan.

Combatant

commands tasked

to develop pandemic

influenza plans.

January 2006 

Issued updated

Health Affairs

guidance on

pandemic influenza.

Established the

Navy Pandemic

Influenza Council.

June 2006

Convened a

senior officer

steering group.

Through July 2006

Accepted proposals

for international

projects on

pandemic

influenza.

August 2006

Transmitted DOD’s

implementation

plan to the

Homeland

Security Council.

Source: GAO analysis.

Certain DOD Offices 

Established Pandemic 

Influenza Working Groups 

The ASD for Homeland Defense and ASD for Health Affairs, as well as the 

Chief of Naval Operations and Commandant of the Marine Corps, 

established pandemic influenza working groups. The ASD for Homeland 

Defense and ASD for Health Affairs established the Pandemic Influenza 

Task Force in November 2005, which was led by the ASD for Homeland 

Defense and met bimonthly. As the lead entity for pandemic influenza 

policy within the department, the Pandemic Influenza Task Force 

coordinated and implemented policies and plans that would (1) prepare 

for, prevent, and contain the effects of an influenza pandemic in military 

forces, (2) ensure DOD protects U.S. interests at home and abroad, and 

(3) render appropriate assistance to civilian authorities in the United 

States. The members of the Pandemic Influenza Task Force included the 

following: 

• Office of the ASD for Homeland Defense 

• Office of the ASD for Health Affairs 

• Office of the ASD for Special Operations and Low Intensity Conflict 

Page 14 GAO-06-1042 Influenza Pandemic
• Joint Chiefs of Staff 

• Office of the Under Secretary of Defense for Intelligence

• Office of the Under Secretary of Defense for Acquisition, Technology and

Logistics 

• Office of the Under Secretary of Defense (Comptroller) 

• Office of the Deputy Under Secretary of Defense for Military Personnel 

Policy 

• Office of the Deputy Under Secretary of Defense for Civilian Personnel 

Policy 

• Office of the Assistant Secretary of Defense for Public Affairs 

The Deputy Secretary of Defense verbally designated the ASD for 

Homeland Defense as the lead for DOD’s pandemic influenza planning

efforts and DOD identified four functional leads to oversee the 31 tasks 

assigned to DOD as a lead agency in the national implementation plan. In 

addition to its overall lead role, the Office of the ASD for Homeland 

Defense was the functional lead for those tasks in the national

implementation plan related to providing defense support to civil 

authorities. The Office of the ASD for Health Affairs was the functional 

lead for force health protection tasks in the national implementation plan. 

The Office of the ASD for Special Operations and Low Intensity Conflict 

was the functional lead for tasks in the national implementation plan 

related to stability operations and international support. Finally, the Joint

Chiefs of Staff were overseeing the combatant commands’ planning and 

implementation efforts. According to officials in the Offices of the ASD for 

Homeland Defense and ASD for Health Affairs, DOD intentionally 

organized its functional lead offices to mirror the federal government’s 

organization for pandemic influenza to improve coordination between 

DOD and other federal government agencies. For example, in general, the 

Office of the ASD for Health Affairs coordinated with HHS on medical 

issues and the Office of the ASD for Special Operations and Low Intensity 

Conflict coordinated with the Department of State on international issues. 

In addition to the Pandemic Influenza Task Force, in June 2006 the ASD 

for Homeland Defense convened a senior officer steering group comprised 

of senior military and civilian officials. The steering group was to meet 

quarterly and submit a report to the Homeland Security Council detailing

DOD’s progress on the actions assigned to the department in the national 

implementation plan. The Chief of Naval Operations also developed a

working group, called the Navy Pandemic Influenza Council, in January 

2006, which met quarterly to examine issues related to an influenza 

pandemic. The Commandant of the Marine Corps originally established his 

Page 15 GAO-06-1042 Influenza Pandemic
own working group that merged with the Navy Pandemic Influenza 

Council to create one working group for the Department of the Navy. 

In September 2004, the ASD for Health Affairs issued guidance to the 

military departments related to preparing for an influenza pandemic,14 with 

the most recent guidance issued in January 2006.

15 This guidance is in 

addition to the department’s existing policies on force health protection. 

The January 2006 guidance, which supersedes the September 2004

guidance, was developed by preventive medicine experts in the Office of 

the ASD for Health Affairs to provide comprehensive policy guidance for 

writing the combatant command and installation pandemic influenza 

plans. The guidance also provided information on assumptions to use 

when developing plans, such as the percentage of people that could be 

affected by a pandemic and that antiviral supplies will likely be insufficient 

to meet demands. The guidance listed tasks, such as developing and 

exercising plans, for the Office of the Secretary of Defense, Joint Chiefs of 

Staff, military departments, installation commanders, military treatment 

facility commanders, and Public Health Emergency Officers to complete 

for each of WHO’s phases of an influenza pandemic. Additionally, the 

guidance tasked installations with developing community containment 

plans to contain infections at their source or slow the spread of the 

disease. The guidance also provided information on home care infection

control that recommended infection control measures, such as hand 

washing. Finally, the guidance included a generic prioritization system for 

DOD’s limited supplies of vaccines and antivirals and noted that these 

priorities would be clarified in the event of an influenza pandemic. Table 1 

lists DOD’s current generic priorities for vaccines and antivirals. 

Some Offices and 

Components Issued 

Guidance on and 

Developed Plans for 

Pandemic Influenza 

 14Department of Defense, Office of the Assistant Secretary of Defense for Health Affairs, 

Department of Defense Guidance for Preparation and Response to an Influenza

Pandemic Caused By the Bird Flu (Avian Influenza) (Washington, D.C.: Sept. 21, 2004). 

15Department of Defense, Office of the Assistant Secretary of Defense for Health Affairs, 

Department of Defense Influenza Pandemic Preparation and Response Health Policy

Guidance (Washington, D.C.: Jan. 25, 2006). 

Page 16 GAO-06-1042 Influenza Pandemic
Table 1: DOD’s Current Priorities for Vaccine and Antiviral Distribution

Tier Personnel included in tier

Tier 1 Those personnel necessary to respond to global military contingencies and 

provide essential health care for the force structure, including (1) those required 

to maintain national strategic and critical operational capabilities, as defined by 

the Joint Chiefs of Staff, (2) deployed forces engaged in or supporting armed 

conflict, and (3) those personnel necessary to maintain a functioning health care 

system. 

Tier 2 Nondeployed forces that are on alert or designated to conduct critical 

contingency operations as defined by the Joint Chiefs of Staff. 

Tier 3 Personnel necessary to maintain critical mission-essential capabilities at each 

organizational level. 

Tier 4 All other Active Component or mobilized reserve component personnel. 

Tier 5 All other beneficiaries not included previously according to the Centers for 

Disease Control and Prevention priority tiers. 

Source: DOD. 

Note: DOD’s antiviral priorities are the same as its vaccine priorities except for individuals who are 

hospitalized due to a pandemic influenza are in the top tier for antivirals. 

The Department of the Navy and the Department of the Air Force planned 

to issue servicewide instructions related to pandemic influenza 

preparedness. Navy and Marine Corps officials said that the Department of 

the Navy was drafting an instruction that would cover all biological 

hazards and would include information on an influenza pandemic. 

According to a Navy official, the instruction was expected to be released 

in the fall of 2006. Similarly, Air Force officials said that the Department of 

the Air Force was developing a servicewide instruction on disease 

containment that would include guidance on actions that personnel should 

take in the event of an influenza pandemic. The instruction was expected 

to be released by the end of the summer of 2006. At the time of our review, 

the Department of the Army had not drafted or released a servicewide 

instruction related to pandemic influenza for the department; however, its 

Medical Command and Installation Management Agency had released 

guidance to Army military treatment facilities and installations. In 

November 2004, the Army Medical Command tasked its military treatment

facilities, including hospitals and clinics, on Army installations with 

updating existing plans for Severe Acute Respiratory Syndrome (SARS).16

The tasking included guidance to address issues related to influenza 

 16United States Army Medical Command, Avian Influenza Planning Guidance and

Tasking (Fort Sam Houston, Tx.: 2004). 

Page 17 GAO-06-1042 Influenza Pandemic
pandemics in the installations’ revised plans, such as identifying facilities 

other than normal hospital or clinic locations at which mass vaccinations

could be administered. In May 2006, the Army Installation Management 

Agency tasked Army installations to develop or update Installation 

Emergency Response Plans by the end of June 2006 to address a response 

to an influenza pandemic.17 The tasking included specific guidance on what 

should be included in the installation plans, such as incorporating 

pandemic-specific information into continuity of operations plans to 

account for a potential reduction of staff. 

The Office of the ASD for Homeland Defense, with support from the 

Offices of the ASD for Health Affairs and ASD for Special Operations and

Low Intensity Conflict and the Joint Chiefs of Staff, completed DOD’s 

implementation plan for an influenza pandemic, as required by the 

national implementation plan. DOD started drafting its implementation 

plan in November 2005 and had a draft implementation plan in December 

2005. DOD submitted its implementation plan to the Homeland Security 

Council in August 2006; however, according to an official in the Office of 

the ASD for Homeland Defense, DOD cannot release its implementation 

plan externally until after it is coordinated and approved by the Homeland 

Security Council. The official said that DOD’s implementation plan 

provided some guidance on protecting DOD’s military and civilian 

personnel, contractors, dependents, and beneficiaries in the event of an 

influenza pandemic; however, the plan focused on the actions assigned to 

DOD in the national implementation plan because force health protection 

measures already exist. Appendix II summarizes the guidance and existing 

force health protection policies related to DOD’s efforts to protect its 

workforce in the event of an influenza pandemic. The officials indicated 

that DOD expected to update its implementation plan as needed. DOD’s 

implementation plan also tasked all offices, components, and agencies 

departmentwide to begin developing or modifying existing continuity of 

operations plans in preparation for an influenza pandemic. 

Additionally, DOD’s geographic combatant commands—U.S. Central 

Command, U.S. European Command, U.S. Northern Command, U.S. 

Pacific Command, and U.S. Southern Command—and installations were 

tasked with developing pandemic influenza plans. In November 2005, the 

Joint Chiefs of Staff requested that the geographic combatant commands 

 17United States Army Installation Management Agency, Influenza Pandemic Preparation 

and Response (Arlington, Va.: 2006). 

Page 18 GAO-06-1042 Influenza Pandemic
develop plans for DOD’s response to an influenza pandemic that addressed 

force health protection, defense support to civil authorities, and support to 

humanitarian assistance and disaster relief operations. According to an 

official in the Office of the ASD for Homeland Defense, the combatant 

command plans would further define how DOD would implement its 

assigned actions from the national implementation plan. According to 

officials with the Joint Staff, the combatant command plans were almost 

complete at the time of our review. Furthermore, the January 2006 Health 

Affairs guidance tasked installation commanders with developing 

pandemic influenza plans for their installations. According to officials in

the offices of the ASD for Homeland Defense and ASD for Health Affairs, 

the military services were responsible for overseeing the installations’ 

planning efforts. 

The Office of the Deputy ASD for Force Health Protection and Readiness 

developed a Web site, the Pandemic Influenza Watchboard, which 

provided information to servicemembers and their families on pandemic 

and avian influenza.18 The Web site provided answers to frequently asked 

questions about avian influenza; links to two of DOD’s policies for 

pandemic influenza; data on confirmed human and animal H5N1 influenza 

cases; links to some WHO information on response to and containment of 

an influenza pandemic; links to federal government documents, such as 

the national implementation plan; and other federal government Web sites, 

such as the federal government’s pandemic influenza Web site

(www.pandemicflu.gov). Additionally, there was a link from the 

Watchboard to DOD’s Deployment Health Web site, which is described 

below. According to an official from the Office of the ASD for Homeland 

Defense, by September 2006, all servicemembers, their families, and 

military health system providers will be directed to use the Watchboard as 

the primary DOD platform for messages and information on pandemic 

influenza, with appropriate hyperlinks to other non-DOD Web sites. 

Additionally, the Deployment Health Support Directorate, within the 

Office of the ASD for Health Affairs, established in November 2005 an 

informational Web site on avian and pandemic influenza for 

servicemembers and their families.19 It included strategies for personnel to 

protect themselves, such as avoiding poultry farms in countries that have 

DOD Established Web 

Sites for Pandemic and 

Avian Influenza 

Information 

 18See https://fhp.osd.mil/aiWatchboard/index.html. 

19See http://deploymentlink.osd.mil/medical/medical_issues/immun/avian_flu.shtml. 

Page 19 GAO-06-1042 Influenza Pandemic
had avian influenza outbreaks and washing hands with soap and water or 

using alcohol-based hand sanitizer. In addition, it provided links to 

additional resources, such as the federal government’s pandemic influenza 

Web site. At the time of our review, there was a link from the Deployment 

Health Web site to the DOD Military Vaccine Agency’s pandemic influenza 

Web site, but not to DOD’s other pandemic influenza Web sites. 

As part of its Disaster Preparedness and Response Information Web site,

DOD’s Civilian Personnel Management Service developed a Web site with 

some information on pandemic influenza.20 The Web site provided 

information for employees, supervisors, and managers, such as a list of 

phone numbers that civilian employees could call for assistance and 

information; statutory authorities for evacuations; and general information 

on pay, leave, telework, and benefits in a natural disaster or declared 

emergency. The Web site also provided links to other resources, such as 

DOD’s Pandemic Influenza Watchboard, additional information on avian 

and pandemic influenza on WHO’s and the Centers for Disease Control 

and Prevention’s Web sites, and the Office of Personnel Management’s 

guidance on human capital planning for an influenza pandemic.21 The 

Civilian Personnel Management Service Web site stated that additional 

information will be posted as it becomes available. 

Additionally, DOD’s Military Vaccination Agency Web site provided 

information on pandemic influenza.22 The Web site provided links to news 

articles on avian influenza; some of DOD’s pandemic influenza policies 

and planning documents; two service messages related to pandemic 

influenza; questions and answers on avian and pandemic influenza; and 

some links to related information, including links to the Centers for 

Disease Control and Prevention, WHO, and some DOD components’ Web 

sites. 

The Office of the ASD for Health Affairs procured antivirals and an 

existing H5N1 vaccine. DOD purchased more than 2 million treatment 

courses of one antiviral and has prepositioned it at three storage sites 

DOD Procured Antiviral 

Medications and Vaccines 

 20See http://www.cpms.osd.mil/disasters/pan.htm. 

21Office of Personnel Management, Agency Guidance – Human Capital Management 

Policy for a Pandemic Influenza (Washington, D.C.: Aug. 2006). 

22See http://www.vaccines.mil/. 

Page 20 GAO-06-1042 Influenza Pandemic
around the world—40 percent of the stockpile is in the continental United

States, 30 percent is in Europe, and 30 percent is in the Far East.23

According to officials in the Office of the ASD for Health Affairs, DOD 

purchased an additional 470,000 treatment courses of the antiviral, which 

were expected to be delivered by December 2006, and 241,000 treatment 

courses of another antiviral, which were expected to be delivered by

March 2007. The additional treatment courses of the first antiviral would 

be located at DOD’s military treatment facilities on installations, and the 

second antiviral would be distributed among the three antiviral storage 

sites. Additionally, DOD purchased an additional 530,000 treatment 

courses of the first antiviral, which will increase DOD’s stockpile of 

antivirals to 3.4 million treatment courses once all of the antivirals are 

delivered. The Office of the ASD for Health Affairs purchased more than 

2 million doses of an existing H5N1 vaccine based on the strain that 

circulated in Vietnam in 2004 and, in fiscal year 2007, planned to purchase

an additional 3.6 million doses of the Vietnam strain and 2.5 million doses 

of a strain that circulated in Indonesia in 2005. Officials said that even 

though a vaccine based on existing strains of the H5N1 virus will not 

necessarily protect its recipients from a further mutated pandemic strain, 

one option is to vaccinate personnel with an existing H5N1 vaccine before

an influenza pandemic starts, which may provide personnel some 

immunity from the disease.24 Officials said that no decision had been made 

on whether to vaccinate personnel before a pandemic, but an official in 

the Office of the ASD for Health Affairs said that the current plan was not 

to administer the vaccine until it had been approved or licensed by the 

Food and Drug Administration. According to officials in the Office of the 

ASD for Health Affairs, DOD had a verbal agreement with HHS to 

purchase additional vaccines for future strains of the virus, including a 

pandemic strain. 

 23A treatment course consists of two capsules per day for 5 days if used for treatment, and 

one capsule per day for at least 10 days for prevention. 

24There is currently some scientific debate regarding the appropriateness of using a prepandemic vaccine. In addition to concerns about the vaccine’s effectiveness against a 

pandemic strain, some health experts have expressed concern that vaccinating individuals

with a pre-pandemic vaccine could reduce the effectiveness of vaccines subsequently 

produced from the pandemic strain for these individuals. 

Page 21 GAO-06-1042 Influenza Pandemic
The ASD for Special Operations and Low Intensity Conflict and the 

Defense Security Cooperation Agency issued guidance and accepted

proposals from the combatant commands for projects to build host nation 

military capacity for preparing for, mitigating, and responding to a 

potential influenza pandemic. The combatant commands could request 

funding for projects in four categories: (1) influenza planning and 

preparedness assessments, (2) influenza preparedness training programs, 

(3) response training and exercise programs, and (4) increasing military 

infrastructure capacity. Through the end of July 2006, the Office of the 

ASD for Special Operations and Low Intensity Conflict and the Defense 

Security Cooperation Agency had approved nearly 50 proposals from the 

U.S. European Command, U.S. Pacific Command, and U.S. Southern 

Command for projects covering 30 countries. Individual project costs 

ranged from about $17,000 to $150,000 and totaled over $3 million for 

fiscal years 2006 and 2007. For example, the U.S. Pacific Command 

requested a total of about $72,000 to provide the Chinese and Indonesian 

militaries with subject matter experts to share experiences in operational 

planning, health surveillance, laboratory testing, and other preparedness 

and control activities, including tools and mechanisms for detecting and 

tracking cases. Additionally, the U.S. European Command requested 

$100,000 to assess the Zambian Defense Force’s current capabilities 

related to avian influenza and to develop and implement the capabilities 

necessary to respond to an avian influenza outbreak within Zambia. 

DOD began its planning efforts in September 2004 and, to date, efforts 

related to protecting DOD’s personnel have focused primarily on the 

personnel in the military departments, geographic combatant commands, 

and installations. However, as the focus shifts to the workforce 

departmentwide, including its civilian workforce and personnel at defense 

agencies, DOD faces four key management challenges going forward as 

the department continues its planning and preparedness efforts related to 

an influenza pandemic. First, neither the Secretary of Defense nor the 

Deputy Secretary of Defense had yet issued departmentwide guidance that 

fully defined an accountability framework for DOD’s pandemic influenza 

planning efforts, including defining lead and supporting roles and 

responsibilities with clear lines of authority, formal oversight mechanisms, 

and goals and performance measures. Establishing an accountability 

framework could help the Secretary of Defense or Deputy Secretary of 

Defense monitor the department’s preparedness for an influenza 

pandemic. Second, at the time of our review, DOD had not yet requested 

funding for its preparedness efforts that was tied to its departmentwide 

goals. Additional funding was necessary to ensure that DOD could 

DOD Initiated Projects to 

Assist Other Nations’ 

Preparedness 

Going Forward, DOD 

Faces Four Key 

Management 

Challenges in Its 

Pandemic Influenza 

Planning and 

Preparedness Efforts 

for Its Workforce 

Departmentwide 

Page 22 GAO-06-1042 Influenza Pandemic
complete the actions assigned to the department in the national 

implementation plan. Third, DOD had not yet fully defined and 

communicated departmentwide which types of its personnel the 

department expected to include in its distribution of vaccines and 

antivirals in the event of an influenza pandemic. Clarifying this information 

before a pandemic may lessen the confusion over who is to receive DODpurchased vaccines and antivirals during an influenza pandemic. Fourth, 

while certain parts of DOD received actively distributed guidance and 

other information, DOD had not yet fully communicated key information 

to personnel departmentwide on actions they should take in the event of 

an influenza pandemic, as well as information on the safety and efficacy of 

vaccines and antivirals. Ensuring that personnel departmentwide receive 

information in advance of an influenza pandemic may lessen confusion 

about what actions personnel should take to protect themselves in the 

event of an influenza pandemic. 

At the time of our review, neither the Secretary of Defense nor the Deputy 

Secretary of Defense had yet issued guidance that fully and clearly defined 

the lead and supporting roles and responsibilities and clear lines of 

authority for the organizations involved in departmentwide pandemic 

influenza planning efforts, formal oversight mechanisms, and goals and 

performance measures for what the leadership expects from DOD’s 

preparedness efforts. In our prior work, we have identified six desirable 

characteristics of strategies.25 One of these characteristics is that the 

strategy should address who is implementing the strategy, what the roles 

of organizations will be compared to others, and mechanisms to 

coordinate efforts. Similarly, in our work on the federal government’s 

response to Hurricane Katrina, we found that, in the event of a 

catastrophic disaster, the leadership roles, responsibilities, and lines of 

authority for response at all levels must be clearly defined and effectively 

communicated to facilitate rapid and effective decision making, especially

in preparing for and in the early hours and days after the disaster.26

Neither the Secretary of Defense nor the Deputy Secretary of Defense had

issued guidance on the specific roles and responsibilities of the lead and 

supporting organizations with clear lines of authority for DOD’s pandemic 

DOD Had Not Yet Fully 

Defined Departmentwide 

Lead and Supporting Roles 

and Responsibilities, 

Formal Oversight 

Mechanisms, and Goals 

and Performance 

Measures for Pandemic 

Influenza 

 25GAO-04-408T. 

26GAO, Hurricane Katrina: GAO’s Preliminary Observations Regarding Preparedness, 

Response, and Recovery, GAO-06-442T (Washington, D.C.: Mar. 8, 2006). 

Page 23 GAO-06-1042 Influenza Pandemic
influenza planning efforts. Officials from the Offices of the ASD for 

Homeland Defense and ASD for Health Affairs said that the Deputy 

Secretary of Defense verbally designated the ASD for Homeland Defense

to lead the department’s pandemic influenza planning and preparedness 

efforts with the ASD for Health Affairs providing support on medical force 

health protection issues. However, at the time of our review, we were not 

able to corroborate this information because a memorandum documenting 

this verbal agreement had not been distributed throughout the 

department. In commenting on a draft of this report, DOD provided a 

memorandum dated July 25, 2006, from the Principal Deputy to the ASD 

for Homeland Defense that documented this information. 

An official from the Office of the ASD for Homeland Defense stated that, in

preparing for an influenza pandemic, organizations would handle issues 

for which they are responsible in their existing directives. However, we 

observed that the ASD for Homeland Defense had not issued a directive

outlining its office’s general roles and responsibilities. While existing 

policies and directives outline the general roles and responsibilities of 

most DOD organizations, we found that some organizations within the 

department were unclear about other organizations’ specific roles and 

responsibilities related to preparing for an influenza pandemic. For 

example, an official from one combatant command said that clarification 

was needed on the roles and responsibilities of the service headquarters 

compared to the combatant commands. Moreover, an official in one of the

services said that more guidance was needed on the services’ 

responsibilities in planning for and responding to an influenza pandemic. 

Also, a defense agency official was unsure about the agency’s role in 

preparing for an influenza pandemic.

In addition to not yet clearly defining the roles and responsibilities for 

organizations involved in DOD’s pandemic influenza planning efforts, lines 

of authority were not yet clearly defined. An official from the Office of the 

ASD for Homeland Defense stated that organizations would maintain their 

current lines of authority for DOD’s pandemic influenza planning efforts; 

however, as noted earlier, the ASD for Homeland Defense currently did 

not have a directive, which should outline the office’s relationship with 

others. Additionally, officials from different DOD organizations told us 

that the current lines of authority for DOD’s pandemic influenza planning 

efforts were unclear. For example, officials from two of the military 

services said that it was unusual for the ASD for Health Affairs to task 

installations directly with developing plans; rather, the tasking usually 

comes through the military services. One official said that installation 

personnel in that service were confused about whether or not they were 

Page 24 GAO-06-1042 Influenza Pandemic
supposed to be developing plans. We further observed differences in the 

military departments’ approach to installation planning. Specifically, the 

Army Medical Command and Installation Management Agency issued 

guidance directing Army installations to plan. On the other hand, an Air 

Force official said that the Air Force had not yet tasked its installations 

servicewide to develop plans for an influenza pandemic, but planned to 

task installations to develop disease containment plans, which would 

include information about pandemic influenza, after the Air Force’s 

related instruction is published. Defining the roles and responsibilities of 

the lead and supporting offices and organizations participating in DOD’s 

pandemic influenza planning efforts departmentwide with clear lines of 

authority could better ensure that there are not gaps in DOD’s policies and 

plans for pandemic influenza or uncertainty about each organization’s 

authorities and responsibilities. 

While the ASD for Homeland Defense established reporting requirements 

for the 31 tasks assigned to DOD in the national implementation plan, 

there was no oversight mechanism for those tasks that were not part of 

the national implementation plan. DOD’s July 25, 2006, memorandum 

stated that organizations identified as the lead implementers for the 31 

tasks assigned to DOD as a lead agency in the national implementation 

plan should report their progress on these tasks each month. However, 

this reporting requirement does not apply to other efforts that DOD has 

undertaken, including the tasking in DOD’s implementation plan that all

DOD organizations develop or revise their continuity of operations plans 

in preparation for an influenza pandemic. 

Because of the lack of reporting mechanisms for tasks that are not part of

the national implementation plan, it is unclear whether anyone in the 

department had an accurate picture of the status of DOD’s preparedness. 

At the time of our review, we identified some gaps in DOD’s planning 

efforts. For example, at that time, only the geographic combatant 

commands and installations were required to develop plans for pandemic 

influenza. However, numerous DOD personnel would not have been 

covered by these plans, such as personnel located in the Pentagon or in 

DOD-leased space, functional combatant commands, and defense 

agencies. An official in the Office of the ASD for Homeland Defense 

acknowledged the gap in planning for personnel in the Pentagon and DODleased space. DOD has since addressed this gap by tasking all DOD 

organizations to develop or revise their respective continuity of operations 

plans in preparation for an influenza pandemic in DOD’s implementation 

plan. Additionally, we identified some overlaps in DOD’s planning efforts. 

For example, the January 2006 Health Affairs guidance tasked the military 

Page 25 GAO-06-1042 Influenza Pandemic
departments to develop plans for providing support to civil authorities and 

humanitarian assistance, but the combatant commands were already 

tasked to address these issues by the Joint Chiefs of Staff. Without 

oversight mechanisms that address the full range of DOD’s preparedness 

efforts, to include those tasks that are not part of the 31 tasks for which 

DOD is named as a lead in the national implementation plan, it is unclear 

whether anyone in the department has an accurate picture of the status of 

DOD’s preparedness. As DOD continues its planning and preparedness 

efforts for an influenza pandemic, this lack of a formal oversight 

mechanism for those tasks that are not part of the national

implementation plan may hamper the leadership’s abilities to ensure that 

departmentwide planning efforts are progressing as intended. 

Moreover, DOD had not yet established goals or performance measures 

for its pandemic influenza preparedness efforts. Another desirable 

characteristic of strategies is that they should establish goals for what the 

strategy strives to achieve—such as a description of a desired end-state—

and performance measures to gauge progress toward results. Identifying 

goals and performance measures aids implementing parties in achieving

results and enables more effective oversight and accountability. 

Additionally, the goals would provide a baseline, or minimum expectation,

of what the Secretary of Defense or the Deputy Secretary of Defense 

expects from DOD organizations as they move forward in their planning 

efforts. 

One example of a potential goal, with some modification, for DOD’s 

pandemic influenza preparedness efforts comes from the department’s 

January 2006 Health Affairs guidance. The purpose of the January 2006 

guidance was to maintain operational effectiveness by minimizing death, 

disease, and lost duty time due to an influenza pandemic. While the 

purpose of the January 2006 Health Affairs guidance may serve as the 

underpinning of a goal for DOD’s overall preparedness efforts, we 

previously reported that goals should have quantifiable, numerical targets 

or other measurable values, which facilitate assessments of whether 

overall goals were achieved. Other examples of goals for DOD’s efforts 

could be ensuring 100 percent of DOD’s organizations develop plans or 

update existing plans to address pandemic influenza and communicate 

this information to personnel, or identifying personnel supporting critical

operations and have a backup plan for their absence. After DOD has 

established overall goals for its preparedness efforts, performance 

measures can assist DOD in assessing its progress toward its goals. 

Page 26 GAO-06-1042 Influenza Pandemic
Navy officials said that they had started developing plans for pandemic 

influenza, but it was difficult because the Office of the Secretary of 

Defense had not provided specific information to the military services on 

what is expected of the military services in the event of an influenza 

pandemic. The Navy officials explained that if the Office of the Secretary 

of Defense set goals, such as required readiness levels, then Navy officials 

could develop detailed plans for an influenza pandemic. Without overall 

goals for DOD’s preparedness efforts and performance measures, it could 

be difficult for combatant commands, the military services, and 

installations to develop plans for an influenza pandemic and for the 

Secretary of Defense to gauge the department’s progress toward 

preparedness as DOD continues its ongoing planning efforts. 

Issuing departmentwide guidance detailing roles and responsibilities, 

reporting mechanisms, and goals is not without precedent. For example, in 

November 2002, the Secretary of Defense issued a memorandum initiating 

DOD’s Base Realignment and Closure process. The memorandum 

specifically:

• Identified the Deputy Secretary of Defense as the individual responsible 

for overseeing the departmentwide process and the Under Secretary of 

Defense for Acquisition, Technology and Logistics as the individual 

responsible for issuing operating policies and detailed direction necessary

to conduct the process. 

• Established two senior groups to oversee the departmentwide efforts and 

identified the members of these groups. 

• Described the roles of the organizations involved in the effort. 

• Established the reporting mechanisms for the process and future 

memoranda more clearly defined the specific reporting time frames. 

• Established goals for the process. 

At the time of our review, DOD had started identifying funding 

requirements, but had not yet identified an appropriate funding 

mechanism or requested funding, tied to its departmentwide goals, for its 

pandemic influenza planning efforts. Another desirable characteristic of a 

strategy is that the strategy should address resources, investments, and 

risk management—what the strategy will cost; where resources will be 

targeted to achieve the end-state; and how the strategy balances benefits,

risks, and costs. Using a risk management approach helps implementing 

parties allocate resources according to priorities; track costs and 

performance; and shift resources, as appropriate. This information also 

DOD Had Not Yet 

Identified an Appropriate 

Funding Mechanism or 

Requested Funding Tied to 

Departmentwide Goals 

Page 27 GAO-06-1042 Influenza Pandemic
would assist DOD in developing a more effective strategy to achieve its 

desired end-state. 

DOD started collecting information on funding requirements for its 

pandemic influenza preparedness efforts. In June 2006, the Joint Chiefs of 

Staff requested that the combatant commands and military services 

identify funding necessary to meet the requirements in the national 

implementation plan and the combatant command plans, which could 

include funding for force health protection, training and exercises, 

laboratory surveillance, and other activities. According to most officials 

we met with in the Office of the Secretary of Defense and the military 

services, funding was a challenge regarding the department’s influenza 

pandemic preparedness efforts. For example, according to an official in 

the Office of the ASD for Homeland Defense, the national implementation 

plan tasked DOD with increased surveillance activities, which will require 

substantial additional funding to complete, but DOD had not yet included 

this requirement in a budget request to the Congress. 

While DOD had started identifying its funding requirements, at the time of 

our review, DOD had not yet identified a mechanism to request funding to 

complete the tasks assigned to DOD in the national implementation plan 

and protect its own personnel. An official from the Office of the ASD for 

Homeland Defense said the department had options for requesting the 

required funding, including incorporating the request in future budget

submissions or submitting a supplemental request to the Congress. An 

official from the Office of the ASD for Health Affairs noted that it was 

difficult for the department to accurately identify the department’s funding 

requirements before DOD completed its implementation plan. 

Additionally, according to the official, the department was not aware of 

the funding requirements in support of the national implementation plan 

before the department’s previous budget submissions to the Congress. 

However, there were more than 50 tasks in the national implementation 

plan for which DOD was either a lead or support agency that were to be 

completed before the end of 2006. Because DOD had not yet requested 

funding, it is unclear whether DOD can address the tasks assigned to it in 

the national implementation plan and pursue its own preparedness efforts 

for its workforce departmentwide within current resources. 

Page 28 GAO-06-1042 Influenza Pandemic
At the time of our review, DOD had not yet clearly defined or 

communicated departmentwide which types of DOD personnel—military 

and civilian personnel, contractors, dependents, and beneficiaries—the 

department planned to include in its distribution of vaccines and antivirals

in the event of an influenza pandemic. We have reported on the 

importance of DOD managing its workforce from a total force perspective, 

which includes active duty and reserve military personnel, civilian 

personnel, and contractor personnel.27 In addition to providing medical 

care to active duty and reserve personnel, DOD is required by law to 

provide medical care to dependents of military personnel and certain 

beneficiaries.28 At the same time, planning to protect all of DOD’s active 

duty and reserve personnel, civilian personnel, and contractor personnel—

as well as beneficiaries and dependents—with vaccines and antivirals in 

the event of an influenza pandemic would require extensive resources and 

likely is unrealistic. It will take 6 to 8 months after the pandemic strain is 

identified to produce a vaccine and there are only two manufacturers 

producing vaccines domestically and a limited number of antiviral 

manufacturers. Moreover, there will be widespread demand for vaccines 

and antiviral medications. 

DOD’s guidance was vague as to the types of personnel to be included in 

the department’s distribution of vaccines and antivirals. The ASD for 

Health Affairs developed generic priorities for distributing vaccines to its 

personnel, as detailed in table 1, which would be clarified in the event of 

an influenza pandemic. While DOD’s vaccine and antiviral priorities 

specifically mentioned DOD beneficiaries, the guidance did not clearly 

state which types of DOD’s employees—military personnel, civilian 

personnel, and contractors—would receive vaccines and antivirals from 

the DOD stockpile. An official in the Office of the ASD for Homeland 

Defense said that the primary purpose of DOD’s vaccine and antiviral 

stockpiles was to preserve the department’s ability to meet the mission 

requirements of national defense and domestic support. The official stated

that distinctions regarding types of employees—military personnel, 

civilian personnel, and contractors—were not made because whether an 

individual would be included in the distribution of vaccines and antivirals

was based on whether the individual was identified as critical to the 

DOD Had Not Yet Defined 

the Types of Personnel 

Included in Its Vaccine and 

Antiviral Distribution 

Plans or Communicated 

That Information 

Departmentwide 

 27GAO, DOD Personnel: DOD Actions Needed to Strengthen Civilian Human Capital 

Strategic Planning and Integration with Military Personnel and Sourcing Decisions, 

GAO-03-475 (Washington, D.C: Mar. 28, 2003). 

2810 U.S.C. 1071 et. seq. 

Page 29 GAO-06-1042 Influenza Pandemic
execution of an essential mission, which would be determined by 

components as they developed their continuity of operations plans. 

However, this information was not stated in the January 2006 Health 

Affairs guidance or DOD’s implementation plan. Additionally, DOD’s 

January 2006 Health Policy guidance stated that military treatment 

facilities would obtain vaccines for civilian beneficiaries through their 

usual logistics channels or local or state health departments. Similarly, the 

military treatment facilities would obtain antivirals for civilian 

beneficiaries through their usual logistics channels or through the local 

health department to access the Strategic National Stockpile. An official in

the Office of the ASD for Homeland Defense stated that specific use of the 

antiviral supply through the Strategic National Stockpile would be 

described in an updated antiviral release policy that was expected to be 

issued soon. The lack of clarity of which types of personnel DOD plans to 

include in its distribution of vaccines and antivirals could lead to 

confusion among personnel as to whether they will receive vaccines and 

antivirals from the department or should try to obtain them from other 

sources. 

A major factor affecting DOD’s ability to clarify priorities for the 

department’s current and future vaccine supplies is that DOD’s priority for 

receiving future influenza vaccines from HHS had not yet been defined. 

The Office of the ASD for Health Affairs had a verbal agreement with HHS 

to purchase vaccines for future strains of influenza, including the 

pandemic strain. In the event of an influenza pandemic, there will likely be 

high, widespread demand for a vaccine across the United States and 

vaccine production capabilities will be limited, particularly compared to 

the demand. At the time of our review, DOD’s priority compared to others

for receiving vaccines for future strains—including the pandemic strain—

and how many vaccines it will receive was not defined and DOD did not 

have a written agreement with HHS addressing these issues. An official 

from the Office of the ASD for Health Affairs said that the prioritization of 

vaccines for future influenza strains, including the pandemic strain, from 

the HHS contract with the vaccine manufacturer was being reevaluated by

the Homeland Security Council; however, the official said that previous

discussions had placed DOD in the first tier of agencies to receive the 

vaccine for a pandemic strain when it becomes available. The exact 

number of vaccine doses for future influenza strains that will be available 

is unknown, in part because of the unknown production output for a 

pandemic-specific vaccine. Under these circumstances, the department 

cannot realistically determine how well it will be able to meet its priorities 

for vaccinating personnel. Additionally, without knowing a rough estimate 

of how much vaccine will be available, DOD cannot accurately determine 

Page 30 GAO-06-1042 Influenza Pandemic
the funding required to purchase vaccines or, if needed, additional 

antivirals. 

At the time of our review, DOD was developing a communications strategy 

for an influenza pandemic, and while not fully developed, it continues to 

evolve. We reported that communication on threats should be timely and

include specific information on the nature, location, and timing of the 

threat as well as guidance on actions to take in response to the threat to 

ensure early and comprehensive information sharing and allow for 

informed decision making.29 These risk communication concepts have 

been used in a variety of warning contexts, including warnings of 

infectious disease outbreaks. Additionally, the national implementation 

plan states that government officials must communicate clearly and 

continuously with the public now and throughout a pandemic, and public

officials at all levels of government must provide unambiguous and 

consistent guidance on what individuals can do to protect themselves, 

how to care for family members at home, when and where to seek medical 

care, and how to protect others and minimize the risks of disease 

transmission. However, so much is unknown about a potential influenza 

pandemic that it is difficult to provide extensive information on preparing 

for an influenza pandemic. 

Some, but not all, organizations received frequent communications about 

avian or pandemic influenza. Several officials across the department said 

their organizations distributed information about the current avian 

influenza threat and pandemic influenza to their personnel. For example, 

an official from U.S. Northern Command’s Washington office mentioned 

receiving frequent e-mails from the command on the status of avian 

influenza. In contrast, it was unclear whether other DOD organizations, 

such as the defense agencies, received and distributed such information to 

their personnel. For example, at least one defense agency had not received 

any information on planning or preparing for an influenza pandemic, 

including what actions its personnel should take in the event of an 

influenza pandemic. DOD officials said the department’s communications 

with its personnel were currently limited, in part because DOD’s 

communications strategy for an influenza pandemic still was under 

development and had been implemented only to a limited extent. As a 

Although a 

Communications Strategy 

Was under Development, 

DOD’s Communication 

Efforts to Date Were 

Inconsistent 

Departmentwide 

 29 GAO, Homeland Security: Communication Protocols and Risk Communication 

Principles Can Assist in Refining the Advisory System, GAO-04-682 (Washington, D.C.: 

June 25, 2004). 

Page 31 GAO-06-1042 Influenza Pandemic
result, there currently may be gaps and unevenness in awareness among 

DOD’s personnel across the department, including military and civilian 

personnel, contractors, dependents, and beneficiaries, about actions they 

should take in the event of an influenza pandemic, which could lead to 

confusion and increased numbers of personnel affected by a pandemic.

Officials from the Offices of the ASD for Homeland Defense and ASD for 

Health Affairs said that DOD planned to use communications strategies 

already in place in addition to those created specifically for an influenza 

pandemic to share information on the disease to ensure that personnel 

know how to protect themselves. DOD’s January 2006 Health Affairs 

guidance, which was issued to the military departments but not 

departmentwide, provided some information on actions, such as hand 

washing, that personnel should take in the event of an influenza pandemic. 

According to a public affairs official with the Joint Staff, the department 

planned to use its existing influenza Web sites, as well as key messages 

that will be distributed at the installation level, to let personnel know what 

actions to take in the event of an influenza pandemic. Existing Web sites 

had some information on what personnel should do to protect themselves, 

but as DOD continues its planning and preparedness efforts, more 

information could be added. For example, one Web site mentioned, among 

other things, that personnel should wash hands and cover coughs and 

sneezes; however, there was no information on what personnel should do

specifically in the event of an influenza pandemic, such as the

department’s policies on who should seek medical care at DOD’s military 

treatment facilities or whether personnel should telework from home 

during an influenza pandemic. Using multiple methods—both active and 

passive—of sharing information on what actions to take in the event of an 

influenza pandemic will be useful. For example, some of DOD’s personnel 

are deployed in austere or rural environments and may not have access to 

the Internet and, therefore, may not have access to the information 

currently posted on various Web sites. 

In addition to providing information passively on Web sites and actively 

through distributed messages, there is a need to communicate with 

employees deemed “critical” and in the top tiers for vaccine and antiviral 

distribution. These personnel will need to know who they are and when 

and where they should obtain vaccines and antivirals. Conversely, 

employees in the lower tiers for vaccine and antiviral distribution will 

need to be told that they will need to rely on other resources to obtain 

these treatments, such as HHS’s Strategic National Stockpile or other state 

and local public health sources. 

Page 32 GAO-06-1042 Influenza Pandemic
DOD also had not yet developed a plan to communicate information to its 

personnel on the efficacy of vaccines and antivirals, in the event DOD 

decides to dispense those it has purchased to date, but it had posted the 

package inserts for the two antivirals that it purchased on one of its Web 

sites. In 2002, we reported that survey respondents from the Air National 

Guard and Air Force Reserve were generally dissatisfied with the 

information DOD provided about its Anthrax Vaccine Immunization 

Program. They were particularly concerned about the (1) military threat 

from anthrax, (2) anthrax vaccine’s battlefield effectiveness, (3) vaccine’s

history and past usage, (4) short-term and long-term safety risks of the 

vaccine, and (5) possible side effects from reactions to the vaccine.30 As 

indicated earlier, DOD is considering whether or not to vaccinate 

personnel before an influenza pandemic to possibly provide personnel 

some degree of immunity from the pandemic strain. Based on DOD’s 

experience with the anthrax vaccine, if DOD decides to vaccinate its 

personnel early or after an influenza pandemic starts, then the department

would benefit from a plan addressing how it will communicate 

information to its personnel on the threat of an influenza pandemic and 

the vaccine’s efficacy, risks, and potential side effects. 

To date, DOD’s efforts to protect its personnel from an influenza pandemic 

have focused primarily on the military departments, geographic combatant 

commands, and installations. However, going forward, as the department’s 

focus shifts to the workforce departmentwide, DOD faces some key 

management challenges as it continues its planning and preparedness 

efforts related to an influenza pandemic. While we recognize that DOD’s 

planning for an influenza pandemic continues to evolve, we believe DOD’s 

planning efforts would benefit from taking steps to address the challenges

and gaps we have identified. Planning in an environment of tremendous 

uncertainty for a large workforce deployed worldwide is an extremely 

difficult and complex task. Although DOD has mechanisms, systems, and 

processes in place for force health protection, an influenza pandemic 

would create a different set of challenges for DOD. Unlike most diseases, 

an influenza pandemic would spread quickly around the world and, 

according to government estimates, the disease could result in a 40

percent absenteeism rate in general through illness, taking care of 

someone who is ill, or fear of becoming ill. Although DOD has taken many 

Conclusions 

 30GAO, Anthrax Vaccine: GAO’s Survey of Guard and Reserve Pilots and Aircrew,

GAO-02-445 (Washington, D.C.: Sept. 20, 2002). 

Page 33 GAO-06-1042 Influenza Pandemic
appropriate and important steps to prepare for an influenza pandemic, 

challenges remain. First, DOD’s planning efforts would benefit from an 

accountability framework, with clearly defined roles and responsibilities, 

an oversight mechanism, and goals and performance measures. Such an 

accountability framework could help the Secretary of Defense or Deputy 

Secretary of Defense to monitor the department’s readiness for an 

influenza pandemic and the Secretary of Defense—and the Congress—

could better ascertain when and to what extent the Armed Forces and 

critical functions departmentwide are prepared to meet this potential 

emergency at home and abroad. Second, by identifying an appropriate 

funding mechanism and requesting funding for pandemic influenza 

preparedness efforts that is tied to the department’s goals, the Secretary of

Defense can better ensure that the department can accomplish its tasks in 

the national implementation plan and protect its personnel. Third, going 

forward, DOD would benefit from clarifying in advance and 

communicating with personnel which types of personnel it plans to 

include in its distribution of vaccines and antivirals, which may lessen the 

confusion over who is to receive DOD-purchased vaccines and antivirals

during an influenza pandemic. Fourth, by developing a departmentwide 

strategy that communicates key information to all of its workforce, DOD’s 

military and civilian personnel, contractors, dependents, and beneficiaries 

may better know what actions to take to protect themselves in the event of 

an influenza pandemic. 

To improve accountability and oversight of planning efforts across DOD as 

the department continues its pandemic influenza planning for its 

workforce, we recommend that the Secretary of Defense do the following. 

Recommendations for 

Executive Action 

• Instruct the Assistant Secretary of Defense for Homeland Defense, as the

individual accountable for DOD’s pandemic influenza planning and 

preparedness efforts, to clearly and fully define and communicate 

departmentwide the roles and responsibilities of the organizations that 

will be involved in DOD’s efforts, with clear lines of authority; the 

oversight mechanisms, including reporting requirements, for all aspects of

DOD’s pandemic influenza planning efforts, to include those tasks that are 

outside of the national implementation plan; and the goals and 

performance measures for DOD’s planning and preparedness efforts. 

• Instruct the Assistant Secretary of Defense for Homeland Defense to work 

with the Under Secretary of Defense (Comptroller) to establish a 

framework for requesting funding for the department’s preparedness 

efforts. The framework should include the appropriate funding mechanism 

Page 34 GAO-06-1042 Influenza Pandemic
and controls to ensure that needed funding for DOD’s pandemic influenza 

preparedness efforts is tied to the department’s goals. 

• Instruct the Assistant Secretary of Defense for Health Affairs to clarify 

DOD’s guidance to explicitly define whether or how all types of 

personnel—including DOD’s military and civilian personnel, contractors, 

dependents, and beneficiaries—would be included in DOD’s distribution 

of vaccines and antivirals and communicate this information 

departmentwide. 

• Instruct the Assistant Secretary of Defense for Public Affairs to implement 

a comprehensive and effective communications strategy departmentwide 

that is transparent as to what actions each group of personnel should take

and the limitations of the efficacy, risks, and potential side effects of 

vaccines and antivirals.

In written comments on a draft of this report, DOD concurred, with 

comment, with four of our five original recommendations, and did not 

address one recommendation. DOD also provided technical comments, 

which we have incorporated in the report, as appropriate. Based on DOD’s 

written and technical comments and supporting documentation DOD 

provided in response to our draft report, we combined two of our 

recommendations and modified another recommendation, as discussed 

below. 

In written comments, DOD stated that the recommendations in the draft 

report reflected information that was over a year old. As stated in our 

scope and methodology in appendix I, we based our report on information 

gathered from December 2005 through August 2006. Notwithstanding, 

after reviewing a draft of this report, DOD provided some additional 

documentation, which we incorporated, as discussed below. 

We originally recommended that the Secretary of Defense designate a lead

individual within DOD who is accountable to the Secretary for influenza 

pandemic planning and preparedness efforts, and provide the individual 

with the authority to establish oversight mechanisms, including reporting 

requirements, for the department’s pandemic influenza efforts. We also 

recommended that this lead individual identify and communicate roles and 

responsibilities of the offices and components involved in DOD’s 

preparedness efforts, and the goals and performance measures for DOD’s 

efforts. In its written and technical comments, DOD stated that the Deputy

Secretary of Defense verbally designated the ASD for Homeland Defense

Agency Comments 

and Our Evaluation 

Page 35 GAO-06-1042 Influenza Pandemic
to lead the department’s preparation for a potential influenza pandemic. 

Our draft report reflected this statement and noted we could not 

corroborate or find documentation of this verbal designation. DOD’s 

comments referred to a July 25, 2006, memorandum from the Principal 

Deputy to the ASD for Homeland Defense, which we subsequently 

obtained. This memorandum states that the Deputy Secretary of Defense 

designated the ASD for Homeland Defense to lead the department’s 

preparation for a potential pandemic influenza. The memorandum also 

directs individual offices to carry out each of the 31 tasks for which DOD 

is the lead agency in the national implementation plan and report each 

month on their progress on the 31 tasks. However, the 31 tasks do not 

address the entirety of DOD’s planning efforts and specifically exclude 

DOD organizations’ planning efforts to protect its workforce 

departmentwide. With regard to our recommendation to establish goals 

and performance measures, DOD concurred and commented that the 

January 2006 Health Affairs guidance and the national and DOD 

implementation plans describe the roles and responsibilities of several 

DOD organizations. While we agree that these documents list specific 

tasks for some organizations to complete, they do not address overall roles 

and responsibilities for departmentwide pandemic influenza planning 

efforts. DOD also commented that the national implementation plan and

DOD’s implementation plan already provide specific tasks with specific 

time frames for completion. We agree that these implementation plans, as 

well as the July 25, 2006, memorandum from the Principal Deputy to the 

ASD for Homeland Defense, provide time frames to complete individual 

tasks. Nevertheless, the intent of our recommendation is that DOD 

develop departmentwide goals and performance measures for DOD’s 

overall pandemic influenza planning and preparedness efforts, including 

that for its total workforce, rather than time frames for individual tasks. In

light of the additional information DOD provided on the role of the ASD 

for Homeland Defense as the lead for DOD’s pandemic influenza planning 

efforts, we revised our recommendation to read that the Secretary of 

Defense instruct the ASD for Homeland Defense to clearly and fully define 

and communicate departmentwide the roles and responsibilities of 

organizations involved in DOD’s efforts with clear lines of authority, 

oversight mechanisms, and goals and performance measures for DOD’s 

efforts. 

DOD concurred, with comment, with our recommendation that the 

Secretary’s designated lead for DOD’s influenza pandemic planning and 

preparedness efforts task the combatant commands and military 

departments to identify funding requirements that are linked to the 

department’s preparedness goals and build them into DOD’s future budget 

Page 36 GAO-06-1042 Influenza Pandemic
requests. DOD commented, and we acknowledged in our draft report, that 

DOD had begun to gather funding requirements for the department’s 

pandemic influenza efforts. Nevertheless, we modified our 

recommendation to include a focus on requesting needed funding that is

tied to departmentwide goals. 

DOD’s written comments did not address our recommendation that the 

Secretary’s designated lead for DOD’s planning and preparedness efforts 

instruct the ASD for Health Affairs to clarify DOD’s guidance to more 

clearly define the types of personnel included in DOD’s distribution of 

vaccines and antivirals and communicate this information 

departmentwide. However, in its technical comments, DOD stated that the 

department’s prioritization list for vaccines and antivirals is based on 

functional roles in the organization and distinctions in the type of 

personnel are not made because these divisions do not reflect function. 

DOD also stated that individual components are responsible for 

determining which individuals are critical when updating their continuity 

of operations plans. We incorporated this information into our report. We 

continue to believe our recommendation has merit and should be 

implemented because DOD’s existing guidance remains unclear on what 

types of personnel are included in DOD’s distribution of vaccines and 

antivirals and components’ continuity of operations plans are not yet 

complete. 

Additionally, DOD concurred, with comment, with our recommendation 

that the ASD for Public Affairs clarify and implement a comprehensive and 

effective communications strategy. In its written and technical comments, 

DOD stated that the Office of the ASD for Public Affairs developed an 

annex for DOD’s implementation plan and plans to issue an integrated 

internal communications plan in September 2006. We are encouraged that 

the ASD for Public Affairs is developing an integrated internal

communications plan for reaching DOD’s internal audiences. Because the 

plan is not yet complete, we continue to believe our recommendation has 

merit and should be implemented. 

As we agreed with your office, unless you publicly announce the contents

of this report earlier, we plan no further distribution of it until 30 days 

from the date of this letter. We will then send copies to the Chairmen and 

Ranking Members of the Senate and House Committees on 

Appropriations; the Chairmen and Ranking Members, Senate and House 

Committees on Armed Services; and other interested congressional 

parties. We also are sending copies to the Secretary of Defense; Secretary 

Page 37 GAO-06-1042 Influenza Pandemic
of Health and Human Services; Secretary of Homeland Security; and 

Director, Office of Management and Budget. We will make copies available 

to others upon request. In addition, the report will be available at no 

charge on GAO’s Web site at http://www.gao.gov.

If you or your staff have any questions concerning this report, please 

contact me at (202) 512-5431 or by e-mail at dagostinod@gao.gov. Contact

points for our Offices of Congressional Relations and Public Affairs may 

be found on the last page of this report. GAO staff who made contributions 

to this report are listed in appendix IV. 

Davi M. D’Agostino 

Director 

Defense Capabilities and Management 

Page 38 GAO-06-1042 Influenza Pandemic
Appendix I: Scope and Methodology Appendix I: Scope and Methodology 

As part of our review of the Department of Defense’s (DOD) planning and 

preparedness for a pandemic influenza, we determined (1) actions that 

DOD has taken to date to prepare for an influenza pandemic and 

(2) management challenges that DOD faces going forward as the 

department continues its planning efforts. We are reporting on these 

issues now so that DOD can consider and address our findings as the 

department continues its planning and preparedness efforts. We have not

yet assessed DOD’s implementation plan for pandemic influenza, since it 

was not yet complete at the time of our review; however, we plan to assess 

DOD’s implementation plan, the combatant commands’ implementation 

plans, and selected installation plans in another report that will be issued 

at a later date. 

To determine the actions that DOD has taken to date to prepare for an 

influenza pandemic, we reviewed a draft of DOD’s implementation plan for 

pandemic influenza dated March 2006.1

 Additionally, we reviewed 

guidance issued by the Office of the Assistant Secretary of Defense (ASD) 

for Health Affairs in September 2004 and January 2006; a planning order 

issued by the Joint Chiefs of Staff to the combatant commands in 

November 2005; planning guidance issued by the Army Medical Command 

to the Army regional medical commands in November 2004; and planning

guidance issued by the Army Installation Management Agency to Army 

installations in May 2006. We also reviewed the department’s existing 

force health protection directives, which were identified in DOD’s January 

2006 Health Affairs guidance and DOD’s draft implementation plan and by 

officials in the Office of the ASD for Health Affairs. These directives are

summarized in appendix II. We reviewed the Implementation Plan for the 

National Strategy for Pandemic Influenza to understand what was 

required of federal departments—including DOD—in their pandemic 

influenza preparedness efforts. Furthermore, we reviewed HHS’s contract

with a vaccine manufacturer and DOD’s antiviral contracts with two 

manufacturers. Additionally, we met in the Washington, D.C., area with 

DOD officials from the Office of the Under Secretary of Defense for Policy, 

Office of the ASD for Homeland Defense, Office of the ASD for Health 

Affairs, Office of the ASD for Reserve Affairs, Office of the Deputy Under 

 1

DOD released its implementation plan to the Homeland Security Council on August 16, 

2006, as we were completing our review. However, according to an official in the Office of

the ASD for Homeland Defense, DOD cannot release its implementation plan externally 

until it is coordinated and approved by the Homeland Security Council. We reviewed the 

final plan and determined that it was not significantly different from the March 2006 draft

that we previously reviewed. 

Page 39 GAO-06-1042 Influenza Pandemic
Appendix I: Scope and Methodology 

Secretary of Defense for Logistics and Materiel Readiness, Office of the

Deputy ASD for Stability Operations, Office of Force Transformation 

(Defense), National Guard Bureau, Joint Chiefs of Staff, Department of the 

Army, Department of the Navy, Marine Corps Headquarters, and 

Department of the Air Force. 

To better understand the threat of an influenza pandemic, we met with 

officials from the Defense Intelligence Agency’s Armed Forces Medical 

Intelligence Center, Fort Detrick, Maryland, and the Central Intelligence 

Agency, McLean, Virginia. 

To determine management challenges that DOD faces as it continues its 

planning efforts, we compared the department’s actions to date to best 

practices that we have identified in our prior work. Specifically, we 

compared DOD’s actions to date to the desirable characteristics of 

national strategies, which state that a national strategy should include 

• purpose, scope, and methodology; 

• problem definition and risk assessment; 

• goals, subordinate objectives, activities, and performance measures; 

• resources, investments, and risk management; 

• organizational roles, responsibilities, and coordination; and 

• integration and implementation. 

While we are not yet assessing DOD’s draft implementation plan and it is 

not a national strategy, we determined that some of the characteristics are 

applicable to planning efforts in general, specifically those related to 

identifying goals and performance measures, resources and investments, 

and organizational roles and responsibilities. Because we are not yet 

assessing DOD’s implementation plan, we used the characteristics as 

guidance for how DOD could approach its planning efforts, as opposed to 

a checklist of what DOD should be doing. Additionally, we relied on our 

previous work on total force management to determine which types of 

personnel DOD should include in its plans for vaccine and antiviral 

distribution. Furthermore, we relied on our previous work on risk 

communication principles to determine whether DOD’s current 

communications strategy meets these principles. Finally, we reviewed our

prior work on influenza pandemics. 

We conducted our review from December 2005 through August 2006 in

accordance with generally accepted government auditing standards. 

Page 40 GAO-06-1042 Influenza Pandemic
Appendix II: Summary of DOD’s Guidance for 

Pandemic Influenza and Related Force Health

Protection Policies 

Title of guidance, responsible office or

organization, and date Purpose of guidance Applicability of the guidance 

Department of Defense Influenza

Pandemic Preparation and Response

Health Policy Guidance (January 2006) 

To provide policy and instructions to 

prepare for and respond to an influenza 

pandemic; facilitate integration into the 

National Strategy for Pandemic Influenza, 

outline an appropriate response for military 

installations and contingency operations 

worldwide, and provide guidance for 

defense support to civil authorities. 

Military departments, the Joint Staff, and 

the combatant commands; the guidance 

was provided to the Coast Guard as a 

reference. 

Policy for Release of Tamiflu® 

(Oseltamivir) Antiviral Stockpile During an 

Influenza Pandemic (January 2006) 

To provide guidance for the release of the 

Department of Defense’s (DOD) Tamiflu 

stockpile; establishes generic prioritization 

tiers for Tamiflu. 

Applicability was not listed, but guidance 

was addressed to the secretaries of the 

military departments, Chairman of the Joint 

Chiefs of Staff, Under Secretaries of 

Defense, Commandant of the U.S. Coast 

Guard, Assistant Secretaries of Defense, 

DOD General Counsel, DOD Inspector 

General, and directors of defense 

agencies. 

Policy for the Use of Influenza Vaccine for 

the 2005-2006 Influenza Season 

(November 2005) 

To set policy and priorities for use of 

influenza vaccine for the 2005-2006 

influenza season. 

Applicability was not listed, but guidance 

was addressed to the Assistant Secretaries 

of the Military Departments for Manpower 

and Reserve Affairs; Director, Joint Staff; 

ASD for Reserve Affairs; Military 

Department Surgeons General; and 

Defense Supply Center Philadelphia. 

DOD Directive 6490.2, Comprehensive 

Health Surveillance (October 2004) 

To establish policy and assign

responsibility for routine, comprehensive 

health surveillance of all military 

servicemembers during active federal 

service. 

Office of the Secretary of Defense, military 

departments, Chairman of the Joint Chiefs 

of Staff, combatant commands, defense 

agencies, DOD field activities, and all other 

organizational entities in DOD.

DOD Directive 6200.4, Force Health 

Protection (October 2004) 

To establish policy and assign

responsibility for implementing force health 

protection measures on behalf of all military 

servicemembers during active and reserve 

military service. 

Office of the Secretary of Defense, military 

departments, Chairman of the Joint Chiefs 

of Staff, combatant commands, Office of 

the Inspector General, defense agencies, 

DOD field activities, and all other 

organizational entities in DOD.

Department of Defense Guidance for 

Preparation and Response to an Influenza

Pandemic Caused by the Bird Flu (Avian 

Influenza) (September 2004) 

To provide instruction on actions to take in 

preparation for the possibility of an 

influenza pandemic, to implement 

recommendations from the Department of 

Health and Human Services’ National 

Pandemic Influenza Response Plan. 

Military departments, nonmilitary persons 

under military jurisdiction, selected federal 

employees, and family members and other 

people eligible for care within the military 

health system. 

DOD Directive 6200.3, Emergency Health 

Powers on Military Installations (May 2003) 

To establish policy to protect installations, 

facilities, and personnel in the event of a 

public health emergency due to biological 

warfare, terrorism, other public health 

emergency, or a communicable disease 

epidemic. 

Office of the Secretary of Defense, military 

departments, Chairman of the Joint Chiefs 

of Staff, Office of the Inspector General, 

combatant commands, defense agencies, 

DOD field activities, and all other 

organizational entities in DOD.

Appendix II: Summary of DOD’s Guidance for 

Pandemic Influenza and Related Force 

Health Protection Policies 

Page 41 GAO-06-1042 Influenza Pandemic
Appendix II: Summary of DOD’s Guidance for 

Pandemic Influenza and Related Force Health

Protection Policies 

Title of guidance, responsible office or

organization, and date Purpose of guidance Applicability of the guidance 

Policy for Use of Force Health Protection 

Prescription Products (April 2003) 

To establish policy to comply with the 

statutory requirement regarding use of 

prescription-only drugs, vaccines, and other 

medical products. 

Applicability was not listed, but guidance 

was addressed to the Assistant Secretaries 

of the Military Services for Manpower and 

Reserve Affairs; Director, Joint Staff; 

Surgeons General of the Military 

Departments; and Deputy Director for 

Medical Readiness, Joint Staff. 

DOD Directive 6200.2, Use of 

Investigational New Drugs for Force Health 

Protection (August 2000) 

To establish policy and assign

responsibility regarding legal requirements 

for use of investigational new drugs and 

designates the Secretary of the Army as 

the Executive Agent for the use of 

investigational new drugs for force health 

protection. 

Office of the Secretary of Defense, military 

departments, Chairman of the Joint Chiefs 

of Staff, combatant commands, Office of 

the DOD Inspector General, defense 

agencies, DOD field activities, and all other 

organizational entities within DOD. 

Policy for DOD Global, Laboratory-Based 

Influenza Surveillance (February 1999) 

To set DOD policy to conduct global, 

operationally relevant laboratory-based

influenza surveillance. 

Applicability was not listed, but guidance 

was addressed to the Surgeons General of 

the Military Services; and Deputy Director 

for Medical Readiness, J-4, Joint Staff. 

Joint Tactics, Techniques, and Procedures

for Noncombatant Evacuation Operations

Joint Report 3-07.51 (September 1997) 

To guide combatant commanders and their 

subordinate joint force and component 

commanders in preparing for and 

conducting noncombatant evacuation 

operations. 

Commanders of combatant commands, 

subunified commands, joint task forces, 

and subordinate components of the 

commands. 

DOD Instruction 3020.37, Continuation of 

Essential DOD Contractor Services During 

Crises (November 1990), Administrative 

Reissuance Incorporating Change 1

(January 1996), Enclosure E3, Guidelines 

for Theater Admission Procedures

Enclosure E3 sets policy for civilian 

contractors entering a theater of 

operations, including ensuring them the 

same medical care given to military 

personnel. 

Office of the Secretary of Defense; military 

departments including the Coast Guard 

when operating as a service in the Navy; 

Chairman of the Joint Chiefs of Staff and 

the Joint Staff; combatant commands; 

Inspector General; and defense agencies. 

DOD Directive 1404.10, Emergency 

Essential (E-E) DOD U.S. Citizen Civilian 

Employees (April 1992) 

Updates policy, responsibilities, and 

procedures regarding employees in civilian 

positions designated emergency essential. 

Office of the Secretary of Defense; military 

departments, including the Coast Guard 

when operating as a service in the Navy; 

Chairman of the Joint Chiefs of Staff and 

the Joint Staff; combatant commands; 

Inspector General; defense agencies; and 

DOD field activities. 

DOD Directive 3025.14, Protection and

Evacuation of U.S. Citizens and 

Designated Aliens in Danger Areas Abroad 

(November 1990) 

Updates policies, responsibilities, and 

procedures for protection and evacuation of 

U.S. citizens and designated aliens in 

danger areas abroad, and assigns 

responsibilities for noncombatant 

evacuation operations planning and 

implementation.

Office of the Secretary of Defense; military 

departments, including the Coast Guard 

when operating as a service in the Navy; 

Chairman of the Joint Chiefs of Staff and 

the Joint Staff; combatant commands; and 

defense agencies. 

DOD Directive 6205.2, Immunization 

Requirements (October 1986)

Addresses immunization policies for all 

armed forces members, DOD civilian 

employees, and eligible beneficiaries of the 

military health care system. 

Office of the Secretary of Defense; military 

departments, including their guard and 

reserve components; Organization of the 

Joint Chiefs of Staff; and defense agencies.

Source: GAO analysis.

Page 42 GAO-06-1042 Influenza Pandemic
Appendix III: Comments from the Department Appendix III: Comments from the of Defense 

Department of Defense 

Page 43 GAO-06-1042 Influenza Pandemic
Appendix III: Comments from the Department 

of Defense 

Page 44 GAO-06-1042 Influenza Pandemic
Appendix III: Comments from the Department 

of Defense 

Page 45 GAO-06-1042 Influenza Pandemic
Appendix III: Comments from the Department 

of Defense 

Page 46 GAO-06-1042 Influenza Pandemic
Appendix IV: 

A

GAO Contact and Staff 

cknowledgments 

Page 47 GAO-06-1042

Appendix IV: GAO Contact and Staff 

Acknowledgments 

Davi M. D’Agostino, Director, 202-512-5431, dagostinod@gao.gov

Mark A. Pross, Assistant Director; Susan Ditto; Nicole Gore; Simon 

Hirschfeld; Aaron Johnson; John E. Miller; and Hilary Murrish made key 

contributions to this report. 

GAO Contact 

Staff 

Acknowledgments 

Influenza Pandemic
Related GAO Products Related GAO Products 

Hurricane Katrina: Better Plans and Exercises Needed to Guide the 

Military’s Response to Catastrophic Natural Disasters. GAO-06-643. 

Washington, D.C.: May 15, 2006. 

Hurricane Katrina: GAO’s Preliminary Observations Regarding 

Preparedness, Response, and Recovery. GAO-06-442T. Washington, D.C.: 

March 8, 2006. 

Emergency Preparedness and Response: Some Issues and Challenges 

Associated with Major Emergency Incidents. GAO-06-467T. Washington,

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Influenza Vaccine Shortage. GAO-06-221T. Washington, D.C.: November 4, 

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Better Preparation. GAO-05-984. Washington, D.C.: September 30, 2005. 

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GAO-05-863T. Washington, D.C.: June 30, 2005. 

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Washington, D.C.: May 26, 2005. 

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GAO-05-177T. Washington, D.C.: November 18, 2004. 

Emerging Infectious Diseases: Review of State and Federal Disease 

Surveillance Efforts. GAO-04-877. Washington, D.C.: September 30, 2004. 

Infectious Disease Preparedness: Federal Challenges in Responding to 

Influenza Outbreaks. GAO-04-1100T. Washington, D.C.: September 28, 

2004. 

Emerging Infectious Diseases: Asian SARS Outbreak Challenged 

International and National Responses. GAO-04-564. Washington, D.C.: 

April 28, 2004. 

Page 48 GAO-06-1042 Influenza Pandemic
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Remains to Be Accomplished. GAO-04-458T. Washington, D.C.: February 

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Fell Short of Program Goals for 2002. GAO-04-360R. Washington, D.C.: 

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but Lack Certain Capacities for Bioterrorism Response. GAO-03-924. 

Washington, D.C.: August 6, 2003. 

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Control Measures Helped Contain Spread, But a Large-Scale Resurgence

May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003. 

SARS Outbreak: Improvements to Public Health Capacity Are Needed for 

Responding to Bioterrorism and Emerging Infectious Diseases. 

GAO-03-769T. Washington, D.C.: May 7, 2003. 

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Improved Public Health Response Capacity, but Gaps Remain. 

GAO-03-654T. Washington, D.C.: April 9, 2003. 

Flu Vaccine: Steps Are Needed to Better Prepare for Possible Future 

Shortages. GAO-01-786T. Washington, D.C.: May 30, 2001. 

Flu Vaccine: Supply Problems Heighten Need to Ensure Access for HighRisk People. GAO-01-624. Washington, D.C.: May 15, 2001. 

Influenza Pandemic: Plan Needed for Federal and State Response. 

GAO-01-4. Washington, D.C.: October 27, 2000. 

Global Health: Framework for Infectious Disease Surveillance. 

GAO/NSIAD-00-205R. Washington, D.C.: July 20, 2000. 

(350890) Page 49 GAO-06-1042 Influenza Pandemic
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