Report to the Chairman, Committee on 

Homeland Security, House of 

Representatives 

United States Government Accountability Office

GAO 

February 2009 INFLUENZA 

PANDEMIC 

Sustaining Focus on 

the Nation’s Planning 

and Preparedness 

Efforts 

GAO-09-334 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

February 2009

INFLUENZA PANDEMIC

Sustaining Focus on the Nation’s Planning and 

Preparedness Efforts

Highlights of GAO-09-334, a report to the 

Chairman, Committee on Homeland 

Security, House of Representatives 

GAO has conducted a body of work

over the past several years to help

the nation better prepare for,

respond to, and recover from a 

possible influenza pandemic, which 

could result from a novel strain of 

influenza virus for which there is

little resistance and which 

therefore is highly transmissible 

among humans. GAO’s work has 

pointed out that while the previous

administration had taken a number 

of actions to plan for a pandemic, 

including developing a national 

strategy and implementation plan, 

much more needs to be done.

However, national priorities are 

shifting as a pandemic has yet to 

occur, and other national issues 

have become more immediate and 

pressing. Nevertheless, an

influenza pandemic remains a real 

threat to our nation and the world. 

 

For this report, GAO synthesized 

the results of 11 reports and two 

testimonies issued over the past 3 

years using six key thematic areas:

(1) leadership, authority, and 

coordination; (2) detecting threats 

and managing risks; (3) planning, 

training, and exercising; (4) 

capacity to respond and recover; 

(5) information sharing and 

communication; and (6) 

performance and accountability. 

GAO also updated the status of

recommendations in these reports. 

What GAO Recommends

This report does not make new

recommendations. However, the 

report discusses the status of 

GAO’s prior recommendations on

the nation’s planning and 

preparedness for a pandemic. 

Leadership roles and responsibilities need to be clarified and tested, 

and coordination mechanisms could be better utilized. Shared 

leadership roles and responsibilities between the Departments of Health and 

Human Services (HHS) and Homeland Security (DHS) and other entities are 

evolving, and will require further testing and exercising before they are well

understood. Although there are mechanisms in place to facilitate coordination 

between federal, state, and local governments and the private sector to 

prepare for an influenza pandemic, these could be more fully utilized. 

Efforts are underway to improve the surveillance and detection of 

pandemic-related threats, but targeting assistance to countries at the 

greatest risk has been based on incomplete information. Steps have

been taken to improve international disease surveillance and detection efforts. 

However, information gaps limit the capacity for comprehensive comparisons 

of risk levels by country. 

Pandemic planning and exercising has occurred, but planning gaps

remain. The United States and other countries, as well as states and 

localities, have developed influenza pandemic plans. Yet, additional planning 

needs still exist. For example, the national strategy and implementation plan 

omitted some key elements, and HHS found many major gaps in states’ 

pandemic plans. 

Further actions are needed to address the capacity to respond to and

recover from an influenza pandemic. An outbreak will require additional 

capacity in many areas, including the procurement of additional patient 

treatment space and the acquisition and distribution of medical and other 

critical supplies, such as antivirals and vaccines for an influenza pandemic. 

Federal agencies have provided considerable guidance and pandemicrelated information, but could augment their efforts. Federal agencies, 

such as HHS and DHS, have shared information in a number of ways, such as 

through Web sites and guidance, but state and local governments and private 

sector representatives would welcome additional information on vaccine

distribution and other topics. 

Performance monitoring and accountability for pandemic 

preparedness needs strengthening. Although certain performance 

measures have been established in the National Pandemic Implementation 

Plan to prepare for an influenza pandemic, these measures are not always

linked to results. Further, the plan does not contain information on the 

financial resources needed to implement it. 

GAO has made 23 recommendations in its reports—13 of these have been 

implemented and 10 remain outstanding. Continued leadership focus on 

pandemic preparedness remains vital, as the threat has not diminished. 

To view the full product, including the scope 

and methodology, click on GAO-09-334.

For more information, contact Bernice 

Steinhardt at (202) 512-6543 or 

steinhardtb@gao.gov. 
Contents 

Letter 1

Results in Brief 3 

Background 8

Leadership Roles and Responsibilities Need to Be Clarified and 

Tested, and Coordination Mechanisms Could Be Better Utilized 11 

Efforts Are Underway to Improve the Surveillance and Detection 

of Pandemic-Related Threats in Humans and Animals, but 

Targeting Assistance to Countries at the Greatest Risk Has Been 

Based on Incomplete Information 16 

Pandemic Planning and Exercising Has Occurred in the United 

States and Other Countries, but Planning Gaps Remain 20 

Further Actions Are Needed to Address the Capacity to Respond to 

and Recover from an Influenza Pandemic 27 

Federal Agencies Have Provided Considerable Guidance and 

Pandemic-Related Information, but Could Augment Their Efforts 35 

Performance Monitoring and Accountability for Pandemic 

Preparedness Needs Strengthening 38 

Concluding Observations 40 

Appendix I Open Recommendations from GAO’s Work on an 

Influenza Pandemic as of February 2009 42 

Appendix II Implemented Recommendations from GAO’s Work 

on an Influenza Pandemic as of February 2009 46 

Appendix III GAO Contact and Staff Acknowledgments 50 

Related GAO Products 51 

Figures 

Figure 1: Key Themes of GAO’s Pandemic Strategy 2 

Figure 2: WHO Global Pandemic Phases 10 

Page i GAO-09-334 Pandemic Planning and Preparedness Efforts
Figure 3: Top 15 Recipients of Committed, Country-Specific 

International Avian and Influenza Pandemic Funding as of 

December 2006 19 

Figure 4: HHS Influenza Pandemic Supplemental Appropriations, 

Fiscal Year 2006 30 

Page ii GAO-09-334 Pandemic Planning and Preparedness Efforts
Abbreviations 

APHIS Animal and Plant Health Inspection Service 

CBO Congressional Budget Office 

CDC Centers for Disease Control and Prevention 

DHS Department of Homeland Security 

DOD Department of Defense 

EMAC Emergency Management Assistance 

 Compact 

FAO Food and Agriculture Organization 

FCO Federal Coordinating Officer 

FEB federal executive board

FEMA Federal Emergency Management Agency 

HHS Department of Health and Human Services 

HSC Homeland Security Council 

NGA National Governors Association 

National Pandemic 

Implementation Plan National Strategy for Pandemic Influenza 

 Implementation Plan

National Pandemic Strategy National Strategy for Pandemic Influenza 

NRF National Response Framework 

OIE World Organisation for Animal Health 

OPM Office of Personnel Management 

PFO Principal Federal Official 

SEC Securities and Exchange Commission 

UNSIC United Nations System Influenza 

 Coordinator 

USAID United States Agency for International 

 Development 

USDA United States Department of Agriculture 

WHO World Health Organization 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately. 

Page iii GAO-09-334 Pandemic Planning and Preparedness Efforts
United States Government Accountability Office

Washington, DC 20548 

 

February 26, 2009 

The Honorable Bennie G. Thompson

Chairman 

Committee on Homeland Security 

House of Representatives 

The Honorable Bennie G. Thompson

Chairman 

Committee on Homeland Security 

House of Representatives 

Dear Mr. Chairman: 

As you know, we conducted a body of work over the past several years to 

help the nation better prepare for, respond to, and recover from a possible 

influenza pandemic. Our work has pointed out that while the previous 

administration had taken a number of actions to plan for a pandemic, 

including developing a national strategy and implementation plan, much 

more needs to be done. At the same time, however, national priorities are 

shifting as a pandemic has yet to occur, and the nation’s financial crisis 

and other national issues have become more immediate and pressing. 

Nevertheless, an influenza pandemic remains a real threat to our nation 

and to the world. Strengthening preparedness for large-scale public health

emergencies, such as an influenza pandemic, is one of the 13 urgent issues 

that we identified as among those needing the immediate attention of the 

new administration and Congress during this transition period.1

 As your 

Committee also recently reported, there are opportunities to renew federal 

efforts to protect our country against influenza pandemic in the new 

administration.2

As you know, we conducted a body of work over the past several years to 

help the nation better prepare for, respond to, and recover from a possible 

influenza pandemic. Our work has pointed out that while the previous 

administration had taken a number of actions to plan for a pandemic, 

including developing a national strategy and implementation plan, much 

more needs to be done. At the same time, however, national priorities are 

shifting as a pandemic has yet to occur, and the nation’s financial crisis 

and other national issues have become more immediate and pressing. 

Nevertheless, an influenza pandemic remains a real threat to our nation 

and to the world. Strengthening preparedness for large-scale public health

emergencies, such as an influenza pandemic, is one of the 13 urgent issues 

that we identified as among those needing the immediate attention of the 

new administration and Congress during this transition period.1

 As your 

Committee also recently reported, there are opportunities to renew federal 

efforts to protect our country against influenza pandemic in the new 

administration.2

Given the consequences of a severe influenza pandemic, in 2006 we 

developed a strategy for our work that would help support Congress’s 

decision making and oversight related to pandemic planning. Our strategy 

was built on a large body of work spanning two decades, including reviews 

of government responses to prior disasters such as Hurricanes Andrew 

and Katrina, the devastation caused by the 9/11 terror attacks, efforts to 

address the Year 2000 (Y2K) computer challenges, and assessments of 

public health capacities in the face of bioterrorism and emerging 

infectious diseases such as Severe Acute Respiratory Syndrome (SARS). 

Given the consequences of a severe influenza pandemic, in 2006 we 

developed a strategy for our work that would help support Congress’s 

decision making and oversight related to pandemic planning. Our strategy 

was built on a large body of work spanning two decades, including reviews 

of government responses to prior disasters such as Hurricanes Andrew 

and Katrina, the devastation caused by the 9/11 terror attacks, efforts to 

address the Year 2000 (Y2K) computer challenges, and assessments of 

public health capacities in the face of bioterrorism and emerging 

infectious diseases such as Severe Acute Respiratory Syndrome (SARS). 

 1

GAO’s 2009 Congressional and Presidential Transition Web site: 

http://www.gao.gov/transition_2009.

2

House Committee on Homeland Security,Getting Beyond Getting Ready for Pandemic

Influenza, a report prepared by the majority staff, 111th Cong., 1st sess., January 2009. 

Page 1 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

The strategy was built around six key themes as shown in figure 1. While 

all of these themes are interrelated, our earlier work underscored the 

importance of leadership, authority, and coordination, a theme that 

touches on all aspects of preparing for, responding to, and recovering from

an influenza pandemic. 

Figure 1: Key Themes of GAO’s Pandemic Strategy 

Source: GAO.

Information 

sharing and 

communication

Performance 

and 

accountability

Capacity to 

respond and 

recover

Planning, 

training, 

and 

exercising

Detecting 

threats and 

managing risks

Leadership, 

authority, 

and 

coordination

At your request, this report synthesizes the work thus far completed under 

this strategy. In the past 3 years, we have issued 11 reports and two 

testimonies on influenza pandemic planning, which address these key 

themes. We have made 23 recommendations based on the findings from 

many of these reports and testimonies. Thirteen of these 

recommendations have been acted upon by the responsible federal 

agencies, but while the responsible federal agencies have generally agreed 

with our recommendations, 10 recommendations have not yet been 

implemented. We also have three pandemic-related reviews underway on 

the following topics: (1) the status of implementing the National Strategy 

for Pandemic Influenza Implementation Plan (National Pandemic 

Page 2 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

Implementation Plan); (2) plans to protect the federal workforce in a

pandemic; and (3) the effect of a pandemic on the telecommunications 

capacity needed to sustain critical financial market activities. A list of our 

open and implemented recommendations can be found in appendices I 

and II. While this report makes no new recommendations, we have 

updated the status of recommendations that have not yet been

implemented. A list of our related GAO products that are referenced 

throughout this report is located after appendix III. 

We also collaborated with several state and local audit offices on 

coordinated audits of state and local pandemic planning and consulted 

with audit offices from a number of countries on pandemic-related 

activities through our external partnerships. These countries include 

Austria, Belgium, Cambodia, Canada, Germany, Indonesia, Japan, 

Kazakhstan, Sweden, the United Kingdom, and Vietnam. We have also 

drawn from audits of pandemic planning and exercising conducted by 

audit officials in Portland, Oregon; Kansas City, Missouri; and New York 

state. Finally, we have incorporated recent studies conducted by the 

Congressional Budget Office (CBO), National Governors Association 

(NGA), United Nations System Influenza Coordinator (UNSIC), and the 

World Bank. 

This report is largely based on our prior work, which was conducted in 

accordance with generally accepted government auditing standards. Those 

standards require that we plan and perform the audit to obtain sufficient, 

appropriate evidence to provide a reasonable basis for our findings and 

conclusions based on our audit objectives. We believe that the evidence 

obtained provides a reasonable basis for our findings and conclusions 

based on our audit objectives. 

We have synthesized the results from our pandemic work over the past 

few years by the six key themes in our pandemic strategy, as follows: Results in Brief 

Leadership roles and responsibilities need to be clarified and 

tested, and coordination mechanisms could be better utilized.

Federal government leadership roles and responsibilities for pandemic 

preparedness and response are evolving, and will require further testing 

before the relationships among the many federal leadership positions are 

well understood. Such clarity in leadership is even more crucial now given

the change in administration and the associated transition of senior 

federal officials. Although there are mechanisms in place to facilitate 

coordination between federal, state, and local governments and the private 

Page 3 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

sector to prepare for an influenza pandemic, these could be more fully 

utilized. For example, a system of coordinating councils that facilitates 

planning between government and the private sector for critical 

infrastructure protection could be better used to help resolve key 

challenges to public and private sector coordination. In addition, some 

federal executive boards (FEB), which bring together federal agencies and 

community leaders outside of Washington, D.C., have established 

relationships with state and local governments and community 

organizations that could be useful in pandemic preparedness and 

response. As a result of our recommendations, FEBs were included in the 

National Response Framework (NRF)

3

 in January 2008 as one of the 

regional support structures that have the potential to contribute to the 

development of situational awareness during an emergency.

Efforts are underway to improve the surveillance and detection of 

pandemic-related threats in humans and animals, but targeting 

assistance to countries at the greatest risk has been based on 

incomplete information. International disease surveillance and 

detection efforts serve as an early warning system that could prevent the 

spread of an influenza pandemic outbreak. The United States and its 

international partners are involved in efforts to improve pandemic 

surveillance, including diagnostic capabilities, so that outbreaks can be 

quickly detected. Yet, international capacity for surveillance has many 

weaknesses, particularly in developing countries. Animal surveillance is 

also a key part of this early warning system. Controlling an outbreak in 

poultry would be instrumental to reducing the risk of a human pandemic. 

While the U.S. Department of Agriculture (USDA) has created a National 

Avian Influenza Surveillance System to link existing avian influenza 

surveillance data from USDA, other federal and state agencies, and 

industry, federal and state officials generally do not know the numbers 

and locations of backyard birds so controlling an outbreak of avian 

influenza among these birds remains particularly difficult. Finally, at the 

time of our 2007 review, assessments by U.S. agencies and international 

organizations were used to target assistance to countries at risk, but the 

information on which those assessments were based was not sufficiently 

 3

Issued in January 2008 by the Department of Homeland Security (DHS) and effective in 

March 2008, the NRF is a guide to how the nation conducts all-hazards incident response 

and replaces the National Response Plan. It focuses on how the federal government is 

organized to support communities and states in catastrophic incidents. The NRF builds 

upon the National Incident Management System, which provides a national template for 

managing incidents. 

Page 4 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

detailed or was incomplete, limiting their value for comprehensive 

comparisons of risk levels by country. 

Pandemic planning and exercising has occurred in the United 

States and other countries, but planning gaps remain. The U.S. 

government has worked with its international partners to develop an 

overall global strategy that is compatible with the U.S. approach. Other 

countries, including Belgium, Japan, Sweden, and the United Kingdom, 

have also developed influenza pandemic plans and frameworks. While the 

National Strategy for Pandemic Influenza (National Pandemic Strategy) 

and National Pandemic Implementation Plan are important first steps in 

guiding national preparedness, important gaps exist that could hinder the 

ability of key stakeholders to effectively execute their responsibilities. For 

example, state and local jurisdictions that will play crucial roles in 

preparing for and responding to a pandemic were not directly involved in

developing the National Pandemic Implementation Plan, even though it 

relies on these stakeholders’ efforts. Further, USDA response plans did not 

identify entities responsible for carrying out tasks associated with an 

outbreak scenario. At the state level, we found that each state has 

developed a pandemic plan and conducted pandemic exercises as required 

by federal pandemic funding guidance. However, according to an 

interagency assessment, on average, states had “many major gaps” in their 

plans, and the Department of Health and Human Services (HHS) has 

recently reported that most states continue to have major gaps in their 

pandemic plans. Officials in states and localities reported that they would

welcome additional guidance from the federal government to help them 

better plan and exercise for an influenza pandemic, for example, on how 

to implement community interventions such as closing schools. In the 

private sector, in response to our recommendation, financial market 

organizations were directed by their federal regulators to ensure that the 

pandemic plans they have in place are adequate to maintain critical 

operations during a severe outbreak.

Further actions are needed to address the capacity to respond to 

and recover from an influenza pandemic. Improving the nation’s 

response capability to catastrophic disasters, such as an influenza 

pandemic, is essential. Following a mass casualty event, health care 

systems would need the ability to adequately care for a large number of 

patients or patients with unusual or highly specialized medical needs. The 

ability of local or regional health care systems to deliver services could be 

compromised, at least in the short term, because the volume of patients 

would far exceed the available hospital beds, medical personnel, 

pharmaceuticals, equipment, and supplies. Further, in natural and manPage 5 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

made disasters, assistance from other states may be used to increase 

capacity, but in a pandemic, states would likely be reluctant to provide 

assistance to each other due to scarce resources and fears of infection. 

The federal government has provided some guidance and funding to help

states plan for additional capacity. For example, the federal government 

provided guidance for states to use when preparing for medical surge and 

on prioritizing target groups for an influenza pandemic vaccine. However, 

an outbreak will require additional capacity in many areas, including the 

procurement of additional patient treatment space and the acquisition and 

distribution of medical and other critical supplies, such as antivirals and 

vaccines for an influenza pandemic.4

 In a severe pandemic, the demand 

would exceed the available hospital bed capacity, which would be further 

challenged by the existing shortages of health care providers and their 

potential high rates of absenteeism. In addition, the availability of 

antivirals and vaccines could be inadequate to meet demand due to limited

production, distribution, and administration capacity. 

Federal agencies have provided considerable guidance and 

pandemic-related information, but could augment their efforts. 

Federal agencies, including HHS and the Department of Homeland 

Security (DHS), have shared pandemic-related information in a number of 

ways, such as through Web sites, guidance, and state summits and 

meetings, and are using established networks, including the FEBs and 

coordinating councils for critical infrastructure protection, to share 

information about pandemic preparedness, response, and recovery. 

Federal agencies have established an influenza pandemic Web site 

(www.pandemicflu.gov) and disseminated pandemic preparedness 

checklists for workplaces, individuals and families, schools, health care, 

community organizations, and state and local governments. However, 

private sector and state and local government officials continue to look for 

additional guidance and clarification from the federal government for 

specific topics, such as state border closures and fatality management. 

Performance monitoring and accountability for pandemic 

preparedness needs strengthening. While the National Pandemic 

Strategy and Implementation Plan identify overarching goals and 

objectives for pandemic planning, the documents are not altogether clear 

 4

Antivirals can prevent or reduce the severity of a viral infection, such as influenza. 

Vaccines are used to stimulate the production of an immune system response to protect the

body from disease. 

Page 6 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

on the roles, responsibilities, and requirements to carry out the plan. Some 

of the action items in the National Pandemic Implementation Plan, 

particularly those that are to be completed by state, local, and tribal 

governments or the private sector, do not identify an entity responsible for 

carrying out the action. Moreover, the National Pandemic Strategy and 

Implementation Plan do not provide information on the financial 

resources needed to implement them, which is one of six characteristics of 

an effective national strategy that we have identified.5

 As a result, the 

documents do not provide a picture of priorities or how adjustments might 

be made in view of resource constraints. In the case of the Department of 

Defense (DOD), although it had instituted reporting requirements for its 

components responsible for implementing action items tasked to DOD in 

the National Pandemic Implementation Plan, there were not similar 

oversight mechanisms in place for other pandemic-related tasks. For 

example, DOD did not require its components to report on their 

development or revision of their continuity of operations plans in 

preparation for an influenza pandemic. 

Strengthening preparedness for large-scale public health emergencies, 

including the possibility of an influenza pandemic, is one of the urgent 

issues that we identified as among those needing the immediate attention 

of the new administration and Congress during this transition period. 

Although much has been done, many challenges remain, with almost half 

the recommendations that we have made over the past 3 years still not 

fully implemented. It will be essential for the administration to test the 

shared leadership roles that have been established between HHS and DHS, 

as these roles and responsibilities continue to evolve, as well as the 

relative roles, responsibilities and authorities for an influenza pandemic 

among the federal government, state and local governments, and the 

private sector. DHS and HHS should, in coordination with other federal 

agencies, continue to work with states and local governments to help them

address identified gaps in their pandemic planning, as well as with the 

private sector through the critical infrastructure coordinating councils. 

Despite other more immediate national priorities, the threat of a severe

influenza pandemic remains, and the administration should maintain 

momentum in preparing the nation. 

 5

The six characteristics of an effective national strategy include: (1) purpose, scope, and

methodology, (2) problem definition and risk assessment, (3) goals, subordinate objectives, 

activities, and performance measures, (4) resources, investments, and risk management, 

(5) organizational roles, responsibilities, and coordination, and (6) integration and 

implementation. 

Page 7 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

Influenza pandemic—caused by a novel strain of influenza virus for which 

there is little resistance and which therefore is highly transmissible among 

humans—continues to be a real and significant threat facing the United 

States and the world. While some scientists and public health experts 

believe that the next influenza pandemic could be caused by a highly 

pathogenic strain of the H5N1 avian influenza virus (also known as “bird 

flu”)6

 that is currently circulating in parts of Asia, Europe, and Africa, it is 

unknown when an influenza pandemic will occur, where it will begin, or 

whether an H5N1 virus or another strain would be the cause. Influenza 

pandemic poses a grave threat to global public health at a time when the 

United Nations’ World Health Organization (WHO) has said that infectious 

diseases are spreading faster than at any time in history. Influenza 

pandemics have spread worldwide within months, and a future pandemic 

is expected to spread even more quickly given modern travel patterns. 

Background 

Unlike incidents that are discretely bounded in space or time (e.g., most 

natural or man-made disasters), an influenza pandemic is not a singular 

event, but is likely to come in waves, each lasting weeks or months, and 

pass through communities of all sizes across the nation and the world 

simultaneously. While a pandemic will not directly damage physical 

infrastructure such as power lines or computer systems, it threatens the 

operation of critical systems by potentially removing the essential 

personnel needed to operate them from the workplace for weeks or 

months. In a severe pandemic, absences attributable to illnesses, the need 

to care for ill family members, and fear of infection may, according to the 

Centers for Disease Control and Prevention (CDC), reach a projected 40

percent during the peak weeks of a community outbreak, with lower rates 

of absence during the weeks before and after the peak.7

 In addition, an 

influenza pandemic could result in 200,000 to 2 million deaths in the 

United States, depending on its severity. 

 6

Avian influenza viruses are classified as either “low pathogenic” or “highly pathogenic” 

based on their genetic features and the severity of the disease they cause in poultry. Highly 

pathogenic avian influenza viruses are associated with high morbidity and mortality in 

poultry. Health experts are concerned that should highly pathogenic H5N1 or another 

subtype, to which humans have no immunity, develop the capacity to spread easily from

person to person, an influenza pandemic could occur in humans. 

7

GAO, Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer Federal

Leadership Roles and an Effective National Strategy, GAO-07-781 (Washington, D.C.: 

August 14, 2007). 

Page 8 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

In addition to the profound human costs in terms of illnesses and deaths, 

the economic and societal repercussions of a pandemic could be 

significant. In its December 2005 report on possible macroeconomic 

effects and policy issues related to a potential influenza pandemic, CBO 

stated that a severe influenza pandemic, similar to the 1918-1919 

pandemic, might cause a decline in U.S. gross domestic product of about 

4.25 percent.

8

 CBO updated its report in July 2006 to include some 

estimates from medical experts that suggest that CBO may have initially 

underestimated the economic impact.9

 The report also noted that these 

medical experts stressed the uncertainty about the exact characteristics of 

the potential virus and suggested that the worst-case scenario could be 

much worse than the severe scenario that CBO considered, especially if 

the H5N1 virus acquires the ability to spread efficiently among humans 

without losing its extreme virulence. In addition, in September 2008, the 

World Bank reported that a severe pandemic could cause a 4.8 percent 

drop in world economic activity, which would cost the world economy 

more than $3 trillion.10

WHO has developed six phases of pandemic alert, each divided into three 

periods, as a system of informing the world of the seriousness of the 

pandemic threat. As seen in figure 2, according to WHO the world is 

currently in Phase 3 where a new influenza virus subtype is causing 

disease in humans, but is not yet spreading efficiently and sustainably 

among humans. 

 8

Congressional Budget Office, A Potential Influenza Pandemic: Possible Macroeconomic 

Effects and Policy Issues (Washington, D.C., December 8, 2005; rev. July 27, 2006). 

9

Congressional Budget Office, A Potential Influenza Pandemic: An Update on Possible 

Macroeconomic Effects and Policy Issues (Washington, D.C., May 22, 2006; rev. July 27, 

2006). 

10Andrew Burns, Dominique van der Mensbrugghe, and Hans Timmer, Evaluating the 

Economic Consequences of Avian Influenza (Washington D.C.: World Bank, September 

2008). 

Page 9 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

Figure 2: WHO Global Pandemic Phases 

Inter-pandemic phase 

New virus in animals, no human 

cases

Pandemic alert 

New virus causes no human cases

Pandemic 

Low risk of human cases 

Higher risk of human cases

No or very limited human-to-human

transmission 

Evidence of increased human-to-human

transmission 

Efficient and sustained human-to-human

transmission 

Evidence of increased human-to-human

transmission 

1

2

3

4

5

6

Source: WHO.

Note: Circle indicates WHO assessment of current global phase. 

The Homeland Security Council (HSC) took an active approach to this 

potential disaster by, among other things, issuing the National Pandemic 

Strategy in November 2005, and the National Pandemic Implementation 

Plan in May 2006. The National Pandemic Strategy is intended to provide a

high-level overview of the approach that the federal government will take 

to prepare for and respond to an influenza pandemic. It also provides 

expectations for nonfederal entities—including state, local, and tribal 

governments; the private sector; international partners; and individuals—

to prepare themselves and their communities. The National Pandemic 

Implementation Plan is intended to lay out broad implementation 

requirements and responsibilities among the appropriate federal agencies 

and clearly define expectations for nonfederal entities. The National 

Pandemic Implementation Plan contains 324 action items related to these 

requirements, responsibilities, and expectations, most of which are to be 

completed before or by May 2009. HSC publicly reported on the status of 

the action items that were to be completed by 6 months, 1 year and 2 years 

in December 2006, July 2007, and October 2008 respectively. HSC 

indicated in its October 2008 progress report that 75 percent of the action

items have been completed. As previously mentioned, we have ongoing 

work assessing the status of implementing this plan. 

Page 10 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

Our prior work evaluating catastrophic event preparedness, response, and 

recovery has shown that in the event of a catastrophic disaster, the 

leadership roles, responsibilities, and lines of authority for the 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 event.

11 However, federal 

government leadership roles and responsibilities for preparing for and 

responding to a pandemic continue to evolve and will require further 

clarification and testing before the relationships of the many leadership 

positions are well understood.12 Such clarity in leadership is even more 

crucial now given the change in administration and the associated 

transition of senior federal officials. 

Leadership Roles and 

Responsibilities Need 

to Be Clarified and 

Tested, and 

Coordination 

Mechanisms Could Be 

Better Utilized 

Most of these federal leadership roles involve shared responsibilities 

between HHS and DHS, and it is not clear how these would work in 

practice. According to the National Pandemic Strategy and Plan, the 

Secretary of Health and Human Services is to lead the federal medical 

response to a pandemic, and the Secretary of Homeland Security will lead 

the overall domestic incident management and federal coordination. In 

addition, under the Post-Katrina Emergency Management Reform Act of 

2006, the Administrator of the Federal Emergency Management Agency

(FEMA) was designated as the principal domestic emergency management 

advisor to the President, the HSC, and the Secretary of Homeland Security, 

adding further complexity to the leadership structure in the case of a 

pandemic.13 To assist in planning and coordinating efforts to respond to a 

pandemic, in December 2006 the Secretary of Homeland Security 

predesignated a national Principal Federal Official (PFO) for influenza 

pandemic and established five pandemic regions each with a regional PFO 

and Federal Coordinating Officers (FCO) for influenza pandemic. PFOs 

are responsible for facilitating federal domestic incident planning and 

coordination, and FCOs are responsible for coordinating federal resources 

support in a presidentially-declared major disaster or emergency. 

However, the relationship of these roles to each other as well as with other 

leadership roles in a pandemic is unclear. Moreover, as we testified in July 

 11GAO, Hurricane Katrina: GAO’s Preliminary Observations Regarding Preparedness, 

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

12GAO, Influenza Pandemic: Opportunities Exist to Clarify Federal Leadership Roles 

and Improve Pandemic Planning, GAO-07-1257T (Washington, D.C.: Sept. 26, 2007). 

13Pub. L. No. 109-295, Title VI. 

Page 11 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

2007, state and local first responders were still uncertain about the need

for both FCOs and PFOs and how they would work together in disaster 

response.14 Accordingly, we recommended in our August 2007 report on 

federal leadership roles and the National Pandemic Strategy that DHS and 

HHS develop rigorous testing, training, and exercises for influenza 

pandemic to ensure that federal leadership roles and responsibilities for a 

pandemic are clearly defined and understood and that leaders are able to 

effectively execute shared responsibilities to address emerging 

challenges.15 In response to our recommendation, HHS and DHS officials 

stated in January 2009 that several influenza pandemic exercises had been

conducted since November 2007 that involved both agencies and other 

federal officials, but it is unclear whether these exercises rigorously tested 

federal leadership roles in a pandemic. 

With respect to control of an outbreak in poultry, which would be 

instrumental to reducing the risk of a human pandemic, both USDA and 

DHS may become involved, depending on the level of the outbreak. USDA 

is responsible for acting to prevent, control, and eradicate foreign animal 

diseases in domestic livestock and poultry, in coordination with a number 

of other entities, including states. The Secretary of Homeland Security 

assumes responsibility for coordinating the federal response under certain

circumstances, such as an outbreak serious enough for the President to 

declare an emergency or a major disaster. In a June 2007 report on USDA’s 

planning for avian influenza, we found that USDA was not planning for 

DHS to assume the lead coordinating role if an outbreak among poultry 

occurred that is sufficient in scope to warrant these declarations. To 

address challenges that limit the national ability to quickly and effectively 

respond to highly pathogenic avian influenza, we recommended that the 

Secretaries of Agriculture and Homeland Security clarify their respective

roles and how they will work together in the event of a declared 

presidential emergency or major disaster, and test the effectiveness of this

coordination during exercises.16 Both USDA and DHS agreed that they 

should develop additional clarity and better define their coordination roles 

in these circumstances, and have taken preliminary steps to do so. For 

 14GAO, Homeland Security: Observations on DHS and FEMA Efforts to Prepare for and

Respond to Major and Catastrophic Disasters and Address Related Recommendations 

and Legislation, GAO-07-1142T (Washington, D.C.: July 31, 2007). 

15GAO-07-781. 

16GAO, Avian Influenza: USDA Has Taken Important Steps to Prepare for Outbreaks, but

Better Planning Could Improve Response, GAO-07-652 (Washington, D.C.: June 11, 2007).

Page 12 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

example, according to USDA and DHS officials, the two agencies meet on

a regular basis to discuss such coordination issues. 

Roles and responsibilities for influenza pandemic preparedness can also 

be unclear within individual federal agencies. In two reports on DOD and 

its combatant commands’ pandemic preparedness efforts, we noted that 

while DOD and the combatant commands had taken numerous actions to 

prepare for a pandemic, roles and responsibilities for pandemic 

preparedness within the department and the commands had not been 

clearly defined or communicated.17 Our September 2006 report on DOD’s 

pandemic preparedness noted that neither the Secretary nor the Deputy 

Secretary of Defense had clearly and fully defined and communicated lead 

and supporting roles and responsibilities with clear lines of authority for 

DOD’s influenza pandemic planning, and we recommended that DOD do 

so. In response, DOD communicated departmentwide that the Deputy 

Secretary of Defense had designated the Assistant Secretary of Defense for 

Homeland Defense and Americas’ Security Affairs, working with the 

Assistant Secretary of Defense for Health Affairs, to lead DOD’s pandemic 

efforts. Similarly, in a June 2007 report, we recommended that DOD take 

steps to clarify U.S. Northern Command’s roles and responsibilities for 

pandemic planning and preparedness efforts.18 In response, DOD clarified 

U.S. Northern Command’s roles and responsibilities in guidance and plans.

In addition to concerns about clarifying federal roles and responsibilities 

for a pandemic and how shared leadership roles would work in practice, 

private sector officials have told us that they are unclear about the 

respective roles and responsibilities of the federal and state governments 

during a pandemic emergency. The National Pandemic Implementation 

Plan states that in the event of an influenza pandemic, the distributed 

nature and sheer burden of the disease across the nation would mean that 

the federal government’s support to any particular community is likely to

 17GAO, Influenza Pandemic: DOD Has Taken Important Actions to Prepare, but 

Accountability, Funding, and Communications Need to be Clearer and Focused

Departmentwide, GAO-06-1042 (Washington, D.C.: Sept, 21, 2006); and GAO, Influenza

Pandemic: DOD Combatant Command’s Preparedness Efforts Could Benefit from More 

Clearly Defined Roles, Resources, and Risk Mitigation, GAO-07-696 (Washington, D.C.: 

June 20, 2007). 

18As operational commanders, DOD’s unified combatant commands are an essential part of 

the department’s influenza pandemic planning. There are currently nine combatant 

commands—five with geographical responsibilities and four with functional 

responsibilities. A sixth geographical combatant command—the U.S. Africa Command—

became operational in October 2008. 

Page 13 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

be limited, with the primary response to a pandemic coming from states 

and local communities. Further, federal and private sector representatives 

we interviewed at the time of our October 2007 report identified several 

key challenges they face in coordinating federal and private sector efforts 

to protect the nation’s critical infrastructure in the event of an influenza 

pandemic.19 One of these was a lack of clarity regarding the roles and 

responsibilities of federal and state governments on issues such as state 

border closures and influenza pandemic vaccine distribution. 

Coordination Mechanisms Mechanisms and networks for collaboration and coordination on 

pandemic preparedness between federal and state governments and the 

private sector exist, but they could be better utilized. In some instances, 

the federal and private sectors are working together through a set of 

coordinating councils, including sector-specific and cross-sector councils.

To help protect the nation’s critical infrastructure, DHS created these 

coordinating councils as the primary means of coordinating government 

and private sector efforts for industry sectors such as energy, food and 

agriculture, telecommunications, transportation and water.20 Our October 

2007 report found that DHS has used these critical infrastructure 

coordinating councils primarily to share pandemic information across 

sectors and government levels rather than to address many of the 

challenges identified by sector representatives, such as clarifying the roles 

and responsibilities between federal and state governments.21 We 

recommended in the October 2007 report that DHS encourage the councils 

 19GAO, Influenza Pandemic: Opportunities Exist to Address Critical Infrastructure

Protection Challenges That Require Federal and Private Sector Coordination, GAO-08-36 

(Washington, D.C.: Oct. 31, 2007). 

20The 18 critical infrastructure and key resource sectors are: food and agriculture; banking 

and finance; chemical; commercial facilities; commercial nuclear reactors, materials, and 

water; dams; defense industrial base; drinking water and water treatment systems; 

emergency services; energy; governmental facilities; information technology; national 

monuments and icons; postal and shipping; public health and healthcare;

telecommunications; transportation systems; and critical manufacturing. Critical 

infrastructure are systems and assets, whether physical or virtual, so vital to the United 

States that their incapacity or destruction would have a debilitating effect on national 

security, national economic security, and national public health or safety, or any 

combination of those matters. Key resources are publicly or privately controlled resources 

essential to minimal operations of the economy or government, including individual targets

whose destruction would not endanger vital systems but could create a local disaster or 

profoundly damage the nation’s morale or confidence. 

21GAO-08-36. 

Page 14 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

to consider and address the range of coordination challenges in a potential 

influenza pandemic between the public and private sectors for critical 

infrastructure. DHS concurred with our recommendation and DHS 

officials informed us in February 2009 that the department is working on 

initiatives to address it, such as developing pandemic contingency plan 

guidance tailored to each of the critical infrastructure sectors, and holding 

a series of “webinars” with a number of the sectors.22

Federal executive boards (FEB) bring together federal agency and 

community leaders in major metropolitan areas outside of Washington, 

D.C., to discuss issues of common interest, including an influenza 

pandemic. The Office of Personnel Management (OPM), which provides 

direction to the FEBs, and the FEBs have designated emergency 

preparedness, security, and safety as an FEB core function. The FEB’s 

emergency support role with its regional focus may make the boards a 

valuable asset in pandemic preparedness and response. As a natural 

outgrowth of their general civic activities and through activities such as 

hosting emergency preparedness training, some of the boards have 

established relationships with, for example, federal, state, and local 

governments; emergency management officials; first responders; and 

health officials in their communities. In a May 2007 report on the FEBs’ 

ability to contribute to emergency operations, we found that many of the 

selected FEBs included in our review were building capacity for influenza 

pandemic response within their member agencies and community 

organizations by hosting influenza pandemic training and exercises.23 We 

recommended that, since FEBs are well positioned within local 

communities to bring together federal agency and community leaders, the 

Director of OPM work with FEMA to formally define the FEBs’ role in 

emergency planning and response. As a result of our recommendation, 

FEBs were included in the National Response Framework (NRF) in 

January 2008 as one of the regional support structures that have the 

potential to contribute to development of situational awareness during an

emergency. OPM and FEMA also signed a memorandum of understanding 

in August 2008 in which FEBs and FEMA agreed to work collaboratively in

carrying out their respective roles in the promotion of the national 

emergency response system. 

 22GAO-08-36. 

23GAO, The Federal Workforce: Additional Steps Needed to Take Advantage of Federal 

Executive Boards’ Ability to Contribute to Emergency Operations, GAO-07-515 

(Washington, D.C.: May 4, 2007). 

Page 15 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

International disease surveillance and detection efforts serve to address 

the threat posed by infectious diseases, such as an influenza pandemic, 

before they develop into widespread outbreaks. Such efforts also provide 

national and international public health authorities with information for 

planning and managing efforts to control diseases such as an influenza 

pandemic. However, as we have reported in the past, domestic and 

international disease surveillance efforts need improvement.24 For 

example, some state public health departments’ initiatives to enhance 

disease reporting have been incomplete, and there is a need for national 

standards and interoperability in information collection and sharing to 

detect outbreaks. Globally, in December 2007 we reported that the United 

States and its international partners are involved in efforts to improve 

global influenza surveillance, including diagnostic capabilities, so that 

pandemic strains can be quickly detected.25 Yet, international capacity for 

influenza surveillance still has many weaknesses, particularly in 

developing countries. For example, some countries experiencing H5N1 

human influenza outbreaks, like Indonesia, had at times not promptly 

shared human virus samples with the international community, thus 

further weakening international surveillance efforts. 

Efforts Are Underway 

to Improve the 

Surveillance and 

Detection of 

Pandemic-Related 

Threats in Humans 

and Animals, but 

Targeting Assistance 

to Countries at the 

Greatest Risk Has 

Been Based on 

Incomplete 

Information 

Efforts are also being made both within the United States and

internationally to improve surveillance and detection for highly pathogenic

avian influenza. As stated earlier, controlling an outbreak in poultry would 

be instrumental to reducing the risk of a human pandemic. Within the 

United States, USDA is taking many important measures to help the nation

prepare for outbreaks of highly pathogenic avian influenza. In a June 2007

report on avian influenza, we stated that USDA had developed several 

surveillance programs to detect highly pathogenic avian influenza, 

including a long-standing voluntary program that systematically tests 

samples of birds from participating poultry operators’ flocks for the virus.26

Further, we also stated that USDA’s Animal and Plant Health Inspection 

Service (APHIS) is working with the Department of the Interior, state 

 24GAO, Emerging Infectious Diseases: Review of State and Federal Disease Surveillance 

Efforts, GAO-04-877 (Washington, D.C.: Sept. 30, 2004) and GAO, Information Technology:

Federal Agencies Face Challenges in Implementing Initiatives to Improve Public Health

Infrastructure, GAO-05-308 (Washington, D.C.: June 10, 2005). 

25GAO, Influenza Pandemic: Efforts Under Way to Address Constraints on Using 

Antivirals and Vaccines to Forestall a Pandemic, GAO-08-92 (Washington, D.C.: Dec. 21,

2007). 

26GAO-07-652. 

Page 16 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

wildlife agencies, and others to increase surveillance of wild birds in 

Alaska and the 48 contiguous states in addition to working with states and 

industry to conduct surveillance of birds at auctions, swap meets, flea 

markets, and public exhibitions. APHIS has also formed the National 

Avian Influenza Surveillance System, designed to link existing avian 

influenza surveillance data from USDA, other federal and state agencies, 

and industry. 

However, in the United States, federal and state officials generally do not 

know the numbers and locations of backyard birds so controlling an 

outbreak of highly pathogenic avian influenza among these birds remains 

particularly difficult. We recommended that the Secretary of Agriculture 

work with states to determine how to overcome potential problems 

associated with unresolved issues, such as the difficulty in locating 

backyard birds and disposing of carcasses and materials. USDA agreed 

with our recommendation and efforts are underway. For example, 

according to USDA officials, the agency has developed online tools to help

states make effective decisions about carcass disposal. In addition, USDA 

has created a secure Internet site that contains draft guidance for disease 

response, including highly pathogenic avian influenza, and it includes a 

discussion about many of the unresolved issues. 

International surveillance networks for influenza in birds and other 

animals have also been established and efforts are under way to improve 

data sharing among scientists.27 However, global surveillance of the 

disease among domestic animals has serious shortfalls. The World 

Organisation for Animal Health (OIE) and the Food and Agriculture 

Organization (FAO) collaborate to obtain and confirm information on 

suspected highly pathogenic H5N1 cases. According to the October 2008 

report by the UNSIC and the World Bank on the state of pandemic 

readiness,28 data obtained from national authorities indicate that 75 

percent of countries29 report having a surveillance system that is 

 27GAO-08-92. 

28United Nations System Influenza Coordinator and the World Bank, Responses to Avian

Influenza and State of Pandemic Readiness, Fourth Global Progress Report, (New York, 

N.Y., and Washington, D.C., October 2008). 

29Of the 178 countries that UNSIC surveyed, 148 of those surveyed responded to the entire 

survey for an overall response rate of approximately 83 percent, whereas 30 of those 

surveyed did not respond. 105 countries, or 75 percent of 140 respondents addressing 

surveillance systems, reported having an operational surveillance system capable of

detecting highly pathogenic avian influenza. 

Page 17 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

operational and capable of detecting highly pathogenic avian influenza. In 

addition, estimates of risk for disease transmission from one country to 

another, as well as among regions within countries, are difficult to make 

because of uncertainties about how factors such as trade in poultry and 

other birds and wild bird migration affect the movement of the disease. 

Risk-Based Targeting of 

Assistance to Priority 

Countries

Assessments by U.S. agencies and international organizations identified 

widespread risks of the emergence of influenza pandemic, and the United

States identified priority countries for assistance. Our June 2007 report on

international efforts to assess and respond to an influenza pandemic risk 

noted that the bulk of U.S. and other donors’ country-specific 

commitments had been made to countries that the United States had 

designated as priorities, with funding concentrated among certain of these 

countries. We reported that through 2006, the United States had 

committed about $377 million to improve global preparedness for avian 

and influenza pandemic, 27 percent of the $1.4 billion committed by all 

donors, which is the greatest share of funds of all donors. Since we issued 

our June 2007 report, the UNSIC and the World Bank reported that as of 

April 2008, the United States had committed $629 million, which is 

approximately 31 percent of the $2.05 billion committed by all donors, for 

avian and pandemic influenza efforts. 

Figure 3 shows the distribution of committed global and U.S. funding 

across major recipient countries as of December 2006. Of the top 15 

recipients of committed international funds, 11 were U.S. priority 

countries. More recent data on U.S. funding patterns show similar focuses 

on certain countries, with Indonesia the largest recipient, followed by 

Vietnam and Cambodia. 

Page 18 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

Figure 3: Top 15 Recipients of Committed, Country-Specific International Avian and Influenza Pandemic Funding as of 

December 2006

Source: GAO analysis of data compiled by the World Bank.

Dollars in millions

U.S. Priority Countries

0

10

20

30

40

50

60

70

80

90

100

All other donors

U.S. total

Moldova

Armenia

Azerbaijan

Mexico

Thailand

West Bank

Gaza

Georgia

China

Laos

Cambodia

Romania

Turkey

Nigeria

Indonesia

Vietnam

Notes: More recent data reported by the UNSIC and the World Bank on the distribution of U.S. 

commitments, as of April 30, 2008, show a similar focus on certain countries, with Indonesia the 

largest recipient of U.S. country-specific commitments (about $48 million), followed by Vietnam (about 

$21 million), and Cambodia (about $14 million). 

The World Bank defines a commitment as the result of an agreement between the donor and 

recipient for designated purposes or a firm decision, such as a legislative appropriation, that prevents 

the use of an allocated amount for other purposes.

Totals include funds from donor countries, international organizations, and the World Bank 

administered Avian and Human Influenza Facility.

However, we reported that gaps in available information from other 

countries limited the capacity for comprehensive, well-informed 

Page 19 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

comparisons of risk levels by country.

30 For example, in 2007 we reported 

that the United States Agency for International Development’s (USAID) 

environmental risk assessment of areas at greatest risk for avian influenza 

outbreaks included a limited understanding of the role of poultry trade or 

wild birds. USAID, the Department of State, and the United Nations had 

also gathered information that was not sufficiently detailed or complete 

enough to permit well-informed country comparisons. Despite these 

limitations, the HSC has used available information to designate priority 

countries for assistance. The UNSIC and the World Bank stated in the 2008 

report that reports from national authorities responding to a UNSIC survey 

indicate that 68 percent of countries31 had conducted a risk assessment. As 

we previously reported in June 2007, adopting a risk management 

approach can help manage the uncertainties in an influenza pandemic and 

identify the most appropriate course of action.32 However, the FAO’s 

detailed evaluation concluded that very few countries have a surveillance 

plan that is based on an “elaborated” risk-analysis. 

By their very nature, catastrophic events involve extraordinary levels of 

mass casualties, damage, or disruption that can overwhelm state and local

responders—making sound planning for catastrophic events crucial. 

Strong advance planning, both within and among federal, state, and local 

governments and other organizations, as well as robust training and 

exercise programs to test these plans in advance of a real disaster, are 

essential to best position the nation to prepare for, respond to, and 

recover from major catastrophes such as an influenza pandemic. 

Capabilities are built upon the appropriate combination of people, skills, 

processes, and assets. Ensuring that needed capabilities are available 

requires effective planning and coordination as well as training and 

exercises in which the capabilities are realistically tested, problems 

identified and lessons learned, and subsequently addressed in partnership 

with other federal, state, and local stakeholders. We have also noted that 

Pandemic Planning 

and Exercising Has 

Occurred in the 

United States and 

Other Countries, but 

Planning Gaps 

Remain 

 30GAO, Influenza Pandemic: Efforts to Forestall Onset Are Under Way; Identifying 

Countries at Greatest Risk Entails Challenges, GAO-07-604 (Washington, D.C.: June 20,

2007). 

31Of the 178 countries that UNSIC surveyed, 148 of those surveyed responded to the entire 

survey for an overall response rate of approximately 83 percent, whereas 30 of those 

surveyed did not respond. 95 countries, or approximately 68 percent of 139 respondents 

addressing surveillance systems, had actually conducted a risk assessment. 

32GAO-07-604. 

Page 20 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

an incomplete understanding of roles and responsibilities under the 

National Response Plan has often led to misunderstandings, problems, 

and delays—an area where training could be helpful. Key officials must 

actively and personally participate so that they are better prepared to deal

with real life situations. In addition, as we previously reported on the 

federal response to Hurricane Katrina, lessons learned from exercises 

must be incorporated and used to improve emergency plans.33

Pandemic Planning and 

Exercising in Other

Countries

A number of countries in addition to the United States have developed 

pandemic plans, along with state and local governments, and the private

sector. We reported in June 2007 that the U.S. government has worked 

with its international partners to develop an overall global strategy that is 

compatible with the U.S. approach. These steps included the appointment 

of a UNSIC and periodic global conferences to review progress and refine 

the strategy.

Other countries, including Belgium, Japan, Sweden, and the United 

Kingdom, have developed influenza pandemic plans and frameworks. In 

July 2006, Belgium issued the Belgian pandemic flu preparedness plan 

which provides basic information on various topics such as leadership, 

antivirals, vaccines, surveillance, logistics, and public communication.34

Similar to Belgium’s pandemic plan, Japan used WHO’s six influenza 

pandemic phases in drafting government policies and response efforts in 

its Pandemic Influenza Preparedness Action Plan of the Japanese 

Government issued in November 2005.35 Sweden’s National Audit Office 

reported in its February 2008 audit that Sweden’s Preparedness planning

for pandemic influenza – National Actions is focused only on infection 

control services and the health sector and does not cover the rest of 

society.36 To address this, the government of Sweden agreed to further 

develop its plan by March 2010. Further, the Sweden’s National Audit 

 33GAO, Catastrophic Disasters: Enhanced Leadership, Capabilities, and Accountability 

Controls Will Improve the Effectiveness of the Nation’s Preparedness, Response, and

Recovery System, GAO-06-618 (Washington, D.C.: Sept 6, 2006). 

34Interministerial Influenza Commission, Belgian pandemic flu preparedness plan, 

Version 1 (Belgium: July 2006). 

35Inter-ministerial Avian Influenza Committee, Pandemic Influenza Preparedness Action 

Plan of the Japanese Government (Japan: rev. October 2007). 

36Riksrevisionen, Swedish National Audit Office, Pandemics—Managing Threats to 

Human Health (Sweden: February 2008). 

Page 21 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

Office found that there is very limited knowledge of the extent to which 

municipalities can provide essential services in the event of an influenza 

pandemic. Within the United Kingdom, the government issued The 

National Framework for Responding to an Influenza Pandemic and the 

Scottish National Framework for Responding to an Influenza Pandemic 

in November 2007 and March 2007, respectively. Both frameworks provide 

information and guidance to assist and support public and private 

organizations across all sectors in understanding the nature of the 

challenges and in making the appropriate preparations for an influenza 

pandemic.37

According to a UNSIC global survey, 141 countries, or 97 percent of those 

that responded, have pandemic preparedness plans.38 However, further 

analysis conducted by the UNSIC’s Pandemic Influenza Contingency Team

and other institutions suggested that the quality and comprehensiveness of

these plans continue to vary significantly between countries. UNSIC and 

the World Bank also found that there had been a moderate increase in the

number of countries that have undertaken simulation exercises.39

Specifically, where testing has occurred, 25 percent of respondents (37 of 

145 countries), reported that testing took place at both the national and 

local levels. In addition, 37 percent of respondents (45 of 120 countries) 

have incorporated the lessons learned from simulations into plan 

revisions. 

Federal, State, and Local 

Government Pandemic 

Planning and Exercising 

In our August 2007 report on the National Pandemic Strategy and 

Implementation Plan, we found that while these documents are an 

important first step in guiding national preparedness, they do not fully 

address all six characteristics of an effective national strategy, as 

 37United Kingdom Cabinet Office, National Risk Register (London, U.K.: 2008). 

38Of the 178 countries that UNSIC surveyed, 148 of those surveyed responded to the entire 

survey for an overall response rate of approximately 83 percent, whereas 30 of those 

surveyed did not respond. Of 145 respondents addressing pandemic planning 141 countries, 

or 97 percent, said that they had a pandemic plan in place. Four respondents from Africa 

indicated that they did not have a pandemic plan. 

39A comparison of countries that replied to UNSIC’s surveys in 2007 and 2008 showed that 

34 of 69 respondents reported having conducted a simulation in 2008 that had not done so

in 2007. 

Page 22 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

identified in our work.40 The documents fully address only one of the six 

characteristics, by reflecting a clear description and understanding of 

problems to be addressed. Further, the National Pandemic Strategy and 

Implementation Plan do not address one characteristic at all, containing 

no discussion of what it will cost, where resources will be targeted to 

achieve the maximum benefits, and how it will balance benefits, risks, and 

costs. Moreover, the documents do not provide a picture of priorities or 

how adjustments might be made in view of resource constraints. Although 

the remaining four characteristics are partially addressed, important gaps

exist that could hinder the ability of key stakeholders to effectively 

execute their responsibilities. For example, state and local jurisdictions 

that will play crucial roles in preparing for and responding to a pandemic 

were not directly involved in developing the National Pandemic 

Implementation Plan, even though it relies on these stakeholders’ efforts. 

Stakeholder involvement during the planning process is important to 

ensure that the federal government’s and nonfederal entities’

responsibilities are clearly understood and agreed upon. Further, 

relationships and priorities among actions were not clearly described, 

performance measures were not always linked to results, and insufficient 

information was provided about how the documents are integrated with 

other response related plans, such as the NRF. We recommended that the 

HSC establish a process for updating the National Pandemic 

Implementation Plan and that the updated plan should address these and 

other gaps. HSC did not comment on our recommendation and has not 

indicated if it plans to implement it. 

Concerning federal government planning for an outbreak in animals, we 

reported in 2007 that although USDA had also taken important steps to 

prepare for outbreaks of highly pathogenic avian influenza, there were still 

gaps in its planning. We noted that USDA was drafting response plans for 

highly pathogenic avian influenza and was also working with the HSC and 

other key federal agencies to produce an “interagency playbook” intended 

to clarify how primary federal responders would initially interact to 

respond to six scenarios of detection of highly pathogenic H5N1. USDA 

had also begun preliminary exercises to test aspects of these plans with 

 40The six characteristics of an effective national strategy include: (1) purpose, scope, and 

methodology, (2) problem definition and risk assessment, (3) goals, subordinate objectives, 

activities, and performance measures, (4) resources, investments, and risk management, 

(5) organizational roles, responsibilities, and coordination, and (6) integration and 

implementation. GAO, Combating Terrorism: Evaluation of Selected Characteristics in

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

Page 23 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

federal, state, local, and industry partners. However, USDA response plans 

did not identify the capabilities needed to carry out the tasks associated 

with an outbreak scenario—that is, the entities responsible for carrying 

them out, the resources needed, and the source of those resources. To 

address these gaps, we recommended that the Secretary of Agriculture 

identify these capabilities, use this information to develop a response plan 

that identifies the critical tasks for responding to the selected outbreak 

scenario and, for each task, identifies the responsible entities, the location 

of resources needed, time frames, and completion status, and test these 

capabilities in ongoing exercises to identify gaps and ways to overcome 

those gaps. USDA concurred, and officials told us that it has created a 

draft preparedness and response plan that identifies federal, state, and 

local actions, timelines, and responsibilities for responding to highly 

pathogenic avian influenza, but the plan has not been issued yet. 

At the state and local levels, we reported in June 2008 that, according to 

CDC, all 50 states and the 3 localities that received federal pandemic funds 

have developed influenza pandemic plans and conducted pandemic 

exercises in accordance with federal funding guidance. All of the 10 

localities that we reviewed had also developed plans and conducted 

exercises. Further, all of the 10 localities and the five states that we 

reviewed had incorporated lessons learned from pandemic exercises into 

their planning.41 However, an HHS-led interagency assessment of states’ 

plans found on average that states had “many major gaps” in their 

influenza pandemic plans in 16 of 22 priority areas, such as school closure 

policies and community containment, which are community-level 

interventions designed to reduce the transmission of a pandemic virus. 

The remaining 6 priority areas were rated as having “a few major gaps.” 

Since we issued our report in June 2008, HHS led another interagency

assessment of state influenza pandemic plans. HHS reported in January 

2009 that, based on this assessment, although states have made important 

progress toward preparing for combating an influenza pandemic, most 

 41We conducted site visits to the five most populous states including California, Florida, 

Illinois, New York, and Texas for a number of reasons, including that these states 

constituted over one-third of the United States population, received over one-third of the

total funding from HHS and DHS that could be used for planning and exercising efforts,

and were likely entry points for individuals coming from another country given that the

states either bordered Mexico or Canada or contained major ports, or both. Within each 

state, we also interviewed officials at 10 localities, which consisted of five urban areas and 

five rural counties. 

Page 24 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

states still have major gaps in their pandemic plans.42 As we had reported 

in June 2008, HHS, in coordination with DHS and other federal agencies,

had convened a series of regional workshops for states in five influenza 

pandemic regions across the country. Because these workshops could be a 

useful model for sharing information and building relationships, we 

recommended that HHS and DHS, in coordination with other federal 

agencies, convene additional meetings with states to address the gaps in 

the states’ pandemic plans. HHS and DHS generally concurred with our 

recommendation, but have not yet held these additional meetings. HHS 

and DHS recently indicated that while no additional meetings are planned

at this time, states will have to continuously update their pandemic plans 

and submit them for review. 

We have also reported on the need for more guidance from the federal

government to help states and localities in their planning. In June 2008, we

reported that although the federal government has provided a variety of

guidance, officials of the states and localities we reviewed told us that they

would welcome additional guidance from the federal government in a 

number of areas, such as community containment, to help them to better 

plan and exercise for an influenza pandemic. State and local officials have

identified similar concerns. An October 2007 Kansas City Auditor’s Office 

report on influenza pandemic preparedness in the city noted that Kansas 

City Health Department officials would like the federal government to 

provide additional guidance on some of the same issues we found, 

including clarifying community interventions such as school closings.43 In 

addition, according to the National Governors Association’s (NGA) 

September 2008 issue brief on states’ pandemic preparedness, states are 

concerned about a wide range of school-related issues, including when to

close schools or dismiss students, how to maintain curriculum continuity 

during closures, and how to identify the appropriate time at which classes 

could resume.44 In addition, NGA reported that states generally have very 

little awareness of the status of disease outbreaks, either in real time or in

 42Departments of Health and Human Services and Homeland Security and other agencies,

Assessment of States’ Operating Plans to Combat Pandemic Influenza: Report to 

Homeland Security Council, (Washington, D.C.: January 2009). 

43City Auditor’s Office, City of Kansas City, Missouri, Performance Audit: Pandemic Flu

Preparedness (October 2007). 

44National Governors Association Center for Best Practices, Issue Brief: Pandemic

Preparedness in the States—An Assessment of Progress and Opportunity (September 

2008). 

Page 25 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

near real time, to allow them to know precisely when to recommend a 

school closure or reopening in a particular area. NGA reported that states 

wanted more guidance in the following areas: (1) workforce policies for 

the health care, public safety, and private sectors; (2) schools; 

(3) situational awareness such as information on the arrival or departure 

of a disease in a particular state, county, or community; (4) public 

involvement; and (5) public-private sector engagement. 

Private Sector Pandemic 

Planning 

The private sector has also been planning for an influenza pandemic, but 

many challenges remain. To better protect critical infrastructure, federal 

agencies and the private sector have worked together across a number of 

sectors to plan for a pandemic, including developing general pandemic 

preparedness guidance, such as checklists for continuity of business 

operations during a pandemic. However, federal and private sector 

representatives have acknowledged that sustaining preparedness and 

readiness efforts for an influenza pandemic is a major challenge, primarily 

because of the uncertainty associated with a pandemic, limited financial 

and human resources, and the need to balance pandemic preparedness 

with other, more immediate, priorities, such as responding to outbreaks of 

foodborne illnesses in the food sector and, now, the effects of the financial 

crisis. 

In our March 2007 report on preparedness for an influenza pandemic in 

one of these critical infrastructure sectors—financial markets—we found

that despite significant progress in preparing markets to withstand 

potential disease pandemics, securities and banking regulators could take

additional steps to improve the readiness of the securities markets.45

Although the seven organizations that we reviewed—which included 

exchanges, clearing organizations, and payment-system processors—were 

working on planning and preparation efforts to reduce the likelihood that 

a worldwide influenza pandemic would disrupt their critical operations, 

only one of the seven had completed a formal plan. To increase the 

likelihood that the securities markets will be able to function during a 

pandemic, we recommended that the Chairman, Federal Reserve; the

Comptroller of the Currency; and the Chairman, Securities and Exchange

Commission (SEC), consider taking additional actions to ensure that 

 45GAO, Financial Market Preparedness: Significant Progress Has Been Made, but

Pandemic Planning and Other Challenges Remain, GAO-07-399 (Washington, D.C.: March 

29, 2007). 

Page 26 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

market participants adequately prepare for a pandemic outbreak. In 

response to our recommendation, the Federal Reserve and the Office of 

the Comptroller of the Currency, in conjunction with the Federal Financial 

Institutions Examination Council, and the SEC directed all banking 

organizations under their supervision to ensure that the pandemic plans 

the financial institutions have in place are adequate to maintain critical 

operations during a severe outbreak. SEC issued similar requirements to 

the major securities industry market organizations. 

Improving the nation’s response capability to catastrophic disasters, such

as an influenza pandemic, is essential. Following a mass casualty event of 

injured or ill victims, health care systems would need the ability to 

adequately care for a large number of patients or patients with unusual or 

highly specialized medical needs. The ability of local or regional health 

care systems to deliver services consistent with established standards of 

care46 could be compromised, at least in the short term, because the 

volume of patients would far exceed the available hospital beds, medical 

personnel, pharmaceuticals, equipment, and supplies. Providing such care 

would require the allocation of scarce resources. 

Further Actions Are 

Needed to Address 

the Capacity to 

Respond to and 

Recover from an 

Influenza Pandemic 

Medical Surge Capacity In contrast to discrete events such as hurricanes and most terrorist 

attacks, the widespread and iterative nature of a pandemic—likely to 

occur in waves as it spreads simultaneously through different

communities and regions—presents continuing challenges in preparing for 

a medical surge in a mass casualty event such as a pandemic. Under such 

conditions, emergency management approaches that have been used in 

the past to increase capacity when responding to other types of disasters, 

such as assistance from other states or the deployment of military 

resources, may not be viable options since these groups may need to hold 

onto resources in order to meet their own needs should they be affected 

by the disease. We reported in June 2007 that state officials informed us 

that the Emergency Management Assistance Compact (EMAC), a 

collaborative arrangement among member states that provides a legal

framework for requesting resources and that has been used in

emergencies such as Hurricane Katrina, would not work in an influenza 

 46A standard of care is the diagnostic and treatment process that a provider should follow

for a certain type of patient or illness, or certain clinical circumstances. It is how similarly 

qualified health care providers would manage the patient’s care under the same or similar 

circumstances. 

Page 27 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

pandemic.47 State officials reported their reluctance to send personnel into 

an infected area, expressed their concern that resources would not be 

available, and believed that personnel would be reluctant to volunteer to 

go to another state. Further, NGA reported in its September 2008 issue 

brief on state pandemic preparedness that EMAC is seen as unreliable 

during a pandemic because states would likely be unwilling to share 

scarce resources or deploy personnel into a location where the disease is 

active and thus expose those individuals to a high-risk environment. 

HHS estimates that in a severe influenza pandemic, almost 10 million 

people would require hospitalization, which would exceed the current 

capacity of U.S. hospitals and necessitate difficult choices regarding 

rationing of resources. HHS also estimates that almost 1.5 million of these 

people would require care in an intensive care unit and about 740,000 

people would require mechanical ventilation. In our September 2008 

report on HHS’s influenza pandemic planning efforts, we reported that 

although HHS has initiated efforts to improve the surge capacity of health

care providers, these efforts will be challenged during a severe pandemic 

because of the widespread nature of such an event, the existing shortages

of health care providers, and the potential high absentee rate of providers. 

Given the uncertain effectiveness of efforts to increase surge capacity, 

HHS has developed guidance to assist health care facilities in planning for 

altered standards of care; that is, for providing care while allocating scarce 

equipment, supplies, and personnel in a way that saves the largest number 

of lives in mass casualty events.48 As we reported in June 2008, 7 out of 20 

states reviewed had adopted or were drafting altered standards of care for 

specific medical issues. Three of the 7 states had adopted some altered 

standards of care guidelines.49 We also found that 18 of the 20 states 

reviewed were selecting alternate care sites, which deliver medical care 

outside of a hospital setting for patients who would normally be treated as 

inpatients. 

 47GAO, Emergency Management Assistance Compact: Enhancing EMAC’s Collaborative 

and Administrative Capacity Should Improve National Disaster Response, GAO-07-854 

(Washington, D.C.: June 29, 2007). 

48GAO, Influenza Pandemic: HHS Needs to Continue Its Actions and Finalize Guidance 

for Pharmaceutical Interventions, GAO-08-671 (Washington, D.C.: Sept. 30, 2008). 

49GAO, Emergency Preparedness: States Are Planning for Medical Surge, but Could

Benefit from Shared Guidance for Allocating Scarce Medical Resources, GAO-08-668 

(Washington, D.C.: June 13, 2008). 

Page 28 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

In addition, we reported that the federal government has provided funding, 

guidance, and other assistance to help states prepare for medical surge in

a mass casualty event, such as an influenza pandemic. Further, the federal 

government has provided guidance for states to use when preparing for 

medical surge, including Reopening Shuttered Hospitals to Expand Surge 

Capacity, which contains a checklist that states can use to identify entities

that could provide more resources in preparing for a medical surge and 

also provided other assistance such as conferences and electronic bulletin

boards for states to use in preparing for medical surge. Some state officials 

reported, however, that they had not begun work on altered standards of 

care guidelines, or had not completed drafting guidelines, because of the

difficulty of addressing the medical, ethical, and legal issues involved. We

recommended that HHS serve as a clearinghouse for sharing among the 

states altered standards of care guidelines developed by individual states

or medical experts. HHS did not comment on the recommendation, and it

has not indicated if it plans to implement it.50 Further, in our June 2008 

report on state and local planning and exercising efforts for an influenza 

pandemic, we found that state and local officials reported that they 

wanted federal influenza pandemic guidance on facilitating medical surge, 

which was also one of the areas that the HHS-led assessment rated as 

having “many major gaps” nationally among states’ influenza pandemic 

plans.51

 50GAO-08-668. 

51GAO-08-539. 

Page 29 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

In fiscal year 2006, Congress appropriated $5.62 billion in supplemental 

funding to HHS for, among other things, (1) monitoring disease spread to 

support rapid response, (2) developing vaccines and vaccine production 

capacity, (3) stockpiling antivirals and other countermeasures, 

(4) upgrading state and local capacity, and (5) upgrading laboratories and 

research at CDC. Figure 4 shows that the majority of this supplemental 

funding—about 77 percent—was allocated for developing antivirals and 

vaccines for a pandemic, and purchasing medical supplies. Also, a portion 

of the funding for state and local preparedness—$170 million—was 

allocated for state antiviral purchases for their state stockpiles.

Antivirals and Vaccine 

Capacity 

Figure 4: HHS Influenza Pandemic Supplemental Appropriations, Fiscal Year 2006 

3%

Medical supplies (personal protective

equipment, ventilators, etc.)

$170

State and local preparednessc

$770

3%

International activitiesa

$179

Antiviralsc

$911

1%

Risk communications

$51

Other domesticb

$276

Vaccine

$3,233

5%

16%

14%

58%

Total $5,590d

Dollars in millions

Source: GAO, HHS.

Notes: Data are from the Department of Health and Human Services, Pandemic Planning Update III: 

A Report from Secretary Michael O. Leavitt (Washington, D.C.: Nov. 13, 2006). 

a

International activities includes: international preparedness, surveillance, response, and research. 

Page 30 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

b

Other domestic includes: surveillance, quarantine, lab capacity, rapid tests. 

c

State and local preparedness includes funding for state subsidies of antiviral drugs. 

d

This chart does not include $30 million in supplemental funding that was transferred to the U.S. 

Agency for International Development. 

According to HHS’s Pandemic Influenza Implementation Plan, HHS 

seeks to ensure the availability of antiviral treatment courses for at least 

25 percent of the U.S. population or at least 81 million treatment courses.52

As of May 2008, both HHS and states had stockpiled a total of 72 million 

treatment courses. Specifically, HHS had stockpiled 44 million courses of 

antivirals for treatment in the HHS-managed Strategic National Stockpile,

which is a national repository of medical supplies that is designed to 

supplement stockpiles from state and local jurisdictions in the event of a 

public health emergency, and had reserved an additional 6 million courses 

from its federally stockpiled antivirals for containment of an initial 

outbreak. HHS also subsidized the purchase of 31 million treatment 

courses by state and local jurisdictions for storage in their own stockpiles,

of which 22 million treatment courses had been stockpiled. 

In our December 2007 report on using antivirals and vaccines to forestall a 

pandemic, we found that the availability of antivirals and vaccines in a 

pandemic could be inadequate to meet demand due to limited production, 

distribution, and administration capacity.53 As we reported, WHO 

estimated that the quantity of antivirals required to forestall a pandemic 

would be enough treatment courses for 25 percent of the population. In 

addition, there would need to be enough preventative courses to last 20 

days for the remaining 75 percent of the population in the outbreak 

contamination zone. Further, due to the time required to detect the virus 

and develop and manufacture a targeted vaccine for a pandemic, 

pandemic vaccines are likely to play little or no role in efforts to stop or 

contain a pandemic at least in its initial phases. According to a September

2008 CBO report on the United States’ policy regarding pandemic 

vaccines, if an influenza pandemic were to occur today, it would be 

impossible to vaccinate the entire population of about 300 million people 

 52Department of Health and Human Services, Pandemic Influenza Implementation Plan

(November 2006). 

53GAO-08-92. 

Page 31 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

within the following 6 months because current capacity for domestic 

production would be completely inadequate.54

The United States, its international partners, and the pharmaceutical 

industry are investing substantial resources to address constraints on the 

availability and effectiveness of antivirals and vaccines, but some of these 

efforts face limitations. We reported in September 2008 that HHS was 

making large investments in domestic vaccine manufacturing capacity by

supporting vaccine research with contracts that require manufacturers to 

establish vaccine-producing facilities within U.S. borders.55 Through these 

contracts, one U.S. facility has expanded its manufacturing capacity and a 

second facility was recently established in the United States. Further, 

according to a January 2009 report by HHS, the department awarded $120

million to vaccine manufacturers to retrofit their existing U.S. vaccine 

manufacturing facilities for egg-based vaccines56 while also planning to 

build domestic cell-based vaccine57 production facilities within the U.S. by 

awarding approximately $500 million in contracts in fiscal year 2009.58

CBO also reported that HHS is not only encouraging the expansion and 

refurbishing of existing facilities but also funding the development of new 

adjuvants, substances that can be added to influenza vaccines to reduce 

the amount of active ingredient (also called antigen) needed per dose of 

vaccine. By using adjuvants for egg-based and cell-based vaccines, 

domestic manufacturers could produce more doses in existing facilities, 

which means that fewer new facilities would be needed to manufacture 

 54Congressional Budget Office, U.S. Policy Regarding Pandemic-Influenza Vaccines 

(Washington, D.C.: September 2008). 

55GAO-08-671. 

56The standard egg-based technology is essentially the same, whether producing seasonal 

or influenza pandemic vaccines. However, with egg-based technology, an influenza 

pandemic vaccine would require at least 6 months to produce. 

57Cell-based vaccines hold the potential to shorten the time between the identification of a

pandemic virus and full-scale production of the vaccine for the U.S. population. In place of

eggs, cell-based vaccine production uses laboratory-grown cell lines that can host a 

growing virus.

58HHS, Pandemic Planning Update VI: A Report from Secretary Michael O. Leavitt, 

(Washington, D.C.: Jan. 8, 2009). 

Page 32 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

cell-based formulations and smaller stockpiles could be used to protect a 

larger population.59

However, increasing production capacity of vaccines and antivirals will 

take several years, as new facilities are built and necessary materials 

acquired. Also, weaknesses within the international influenza surveillance 

system impede the detection of strains, which could limit the ability to 

promptly administer or develop effective antivirals and vaccines to treat 

and prevent cases of infection to prevent its spread. The delayed use of 

antivirals and the emergence of antiviral resistance in influenza strains 

could limit their effectiveness. In addition, limited support for clinical 

trials could hinder their ability to improve understanding of the use of 

antivirals and vaccines against a pandemic strain. 

In light of this anticipated limitation in supply, HHS released guidance on 

prioritizing target groups for a pandemic vaccine. Because of the 

uncertainties surrounding the availability of a pandemic vaccine, in 

September 2008, we recommended that the Secretary of Health and 

Human Services expeditiously finalize guidance to assist state and local 

jurisdictions to determine how to effectively use limited supplies of 

antivirals, and the pre-pandemic vaccine, which is developed prior to an 

outbreak using strains that have the potential to cause an influenza 

pandemic.60 In December 2008, HHS released final guidance on antiviral 

drug use during an influenza pandemic.61 In addition, HHS officials 

informed us in February 2009 that it is drafting guidance on pre-pandemic 

influenza vaccination. 

In addition to antiviral and vaccine stockpiles for an influenza pandemic 

for the general population, our June 2007 report on avian influenza 

planning concluded that USDA had significant gaps in its planning for 

providing antivirals to individuals responsible for responding to an 

outbreak of highly pathogenic avian influenza.62 USDA has coordinated 

with DHS and other federal agencies to create a National Veterinary 

 59Congressional Budget Office, U.S. Policy Regarding Pandemic-Influenza Vaccines. 

60HHS has launched studies to determine how long the stockpiled pre-pandemic vaccines

remain safe and effective, but in the meanwhile it assumes a 2-year shelf life. 

61HHS, Guidance on Antiviral Drug Use during an Influenza Pandemic (Washington,

D.C.: Dec. 16, 2008). 

62GAO-07-652. 

Page 33 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

Stockpile. This stockpile is intended to be the nation’s repository of animal 

vaccines, personal protective equipment, and other critical veterinary 

products to respond to the most dangerous foreign animal diseases, 

including highly pathogenic avian influenza. However, at the time of the

report, USDA had not yet estimated the amount of antiviral medication 

that it would need in the event of a highly pathogenic avian outbreak or 

resolved how to provide such supplies within the first 24 hours of an 

outbreak. According to Occupational Safety and Health Administration 

guidelines, poultry workers responding to an outbreak of highly 

pathogenic avian influenza should take antiviral medication daily. Further, 

the National Veterinary Stockpile is required to contain sufficient amounts 

of antiviral medication to respond to the most damaging animal diseases 

that affect human health and the economy and has not yet obtained any 

antiviral medication for highly pathogenic avian influenza. However, HHS 

officials told National Veterinary Stockpile officials that the antiviral 

medication in the Strategic National Stockpile was reserved only for use 

during a human pandemic. We therefore recommended that the Secretary 

of Agriculture determine the amount of antiviral medication that USDA 

would need in order to protect animal health responders, given various 

highly pathogenic avian influenza scenarios, and determine how to obtain 

and provide supplies within 24 hours of an outbreak. In commenting on 

our recommendation, USDA officials told us that the National Veterinary

Stockpile now contains enough antiviral medication to protect 3,000 

animal health responders for 40 days. However, USDA officials told us that 

they have yet to determine the number of individuals that would need 

medicine based on a calculation of those exposed to the virus under a 

specific scenario. Further, USDA officials said that a contract for 

additional medication for the stockpile has not yet been secured, which 

would better ensure that medications are available in the event of an 

outbreak of highly pathogenic avian influenza. 

Page 34 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

Our work evaluating public health and natural disaster catastrophe 

preparedness, response, and recovery has shown that insufficient 

collaboration among federal, state, and local governments created 

challenges for sharing public health information and developing 

interoperable communications for first responders. In 2005, we designated

establishing appropriate and effective information-sharing mechanisms to 

improve homeland security as a high-risk area. Over the past several years, 

we have identified potential information-sharing barriers, critical success 

factors, and other key management issues that should be considered to 

facilitate information sharing among and between government entities and 

the private sector. 

Federal Agencies 

Have Provided 

Considerable

Guidance and 

Pandemic-Related 

Information, but 

Could Augment Their 

Efforts

Citizens should be given an accurate portrayal of risk, without overstating 

the threat or providing false assurances of security. Risk communication 

principles have been used in a variety of public warning contexts, from 

alerting the public to severe weather, to less commonplace warnings of 

infectious disease outbreaks. In general, these principles seek to maximize 

public safety by ensuring the public has sufficient information to 

determine what actions to take to prevent or respond to emergencies. 

Appropriately warning the public of threats can help save lives and reduce

costs of disasters. Federal, state and local officials and risk management 

experts who participated in an April 2008 Comptroller General’s forum on 

strengthening the use of risk management principles in homeland security

identified and ranked the challenges in applying these principles. 

Improving risk communication to the public was one of the top three 

challenges identified by the forum participants.63

Our prior work identified several instances when risk communication 

proved less than effective. For example, during the 2004-2005 flu season,

demand for the flu vaccine exceeded supply, and information about future 

vaccine availability was uncertain (as could happen in a future pandemic). 

Although CDC communicated regularly through a variety of media as the 

situation evolved, state and local officials identified several 

communications lessons. These included the need for consistency among 

federal, state, and local communications, the importance of using diverse 

media to reach different audiences, and the importance of disseminating 

clear, updated information when responding to changing circumstances.64

 63GAO, Highlights of a Forum: Strengthening the Use of Risk Management Principles in

Homeland Security, GAO-08-627SP (Washington, D.C.: April 2008). 

64GAO, Influenza Vaccine: Shortages in 2004-05 Season Underscore Need for Better 

Preparation, GAO-05-984 (Washington, D.C.: Sept. 30, 2005).

Page 35 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

Another example, from our October 1999 report on DOD’s anthrax vaccine

immunization program, illustrated the importance of providing accurate 

and sufficient information to personnel. Although DOD and the military 

services used a variety of measures to educate military personnel about 

the program, military personnel wanted more information on the program, 

and over one-half of respondents that participated in our survey said that

the information they received was less than moderately helpful or that 

they did not receive any information.65

The National Pandemic Implementation Plan emphasizes that government 

and public health officials must communicate clearly and continuously 

with the public throughout a pandemic. The plan recognizes that timely, 

accurate, credible, and coordinated messages will be necessary. The 

federal government has undertaken a number of communications efforts 

to provide information on a possible pandemic and how to prepare for it.

HHS (including CDC), DHS, and other federal agencies have provided a 

variety of influenza pandemic information and guidance for states and 

local communities through Web sites and meetings with states. These 

efforts included: 

• establishing an influenza pandemic Web site (www.pandemicflu.gov); 

• including pandemic information on another Web site, Lessons Learned 

Information Sharing System (LLIS) (www.llis.dhs.gov), which is a national 

network of lessons learned and best practices for emergency responders 

and homeland security officials; 

• sponsoring state pandemic summits with all 50 states and additional 

regional state workshops; 

• disseminating pandemic preparedness checklists for workplaces, 

individuals and families, schools, health care, community organizations, 

and state and local governments; and 

• providing additional guidance for the public, such as on pandemic vaccine

targeting and allocation and pre-pandemic community planning.66

 65GAO, Medical Readiness: DOD Continues to Face Challenges in Implementing Its 

Anthrax Vaccine Immunization Program, GAO/T-NSIAD-00-157 (Washington, D.C.: Apr.

13, 2000). 

66Department of Health and Human Services and Department of Homeland Security, 

Guidance on Allocating and Targeting Pandemic Influenza Vaccine (July 23, 2008) and 

Department of Health and Human Services and Centers for Disease Control and 

Prevention, Interim Pre-Pandemic Planning Guidance: Community Strategy for 

Pandemic Influenza Mitigation in the United States (February 2007).

Page 36 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

There are established coordination networks that are being used to 

provide information to state and local governments and to the private 

sector about pandemic planning and preparedness. For example, the FEBs

are charged with providing timely and relevant information to support 

emergency preparedness and response coordination, and OPM expects the 

boards to establish notification networks and communications plans to be 

used in emergency and nonemergency situations. The boards are also 

expected to disseminate relevant information received from OPM and 

other agencies regarding emergency preparedness information and to 

relay local emergency situation information to parties such as OPM, FEB 

members, media, and state and local government authorities. FEB 

representatives generally viewed the boards as an important 

communications link between Washington and the field and among field 

agencies. Each of the selected boards we reviewed reported conducting 

communications activities as a key part of its emergency support service.

In addition, critical infrastructure coordinating councils have been also 

primarily used as a means to share information and develop pandemicspecific guidance across the industry sectors, such as banking and finance 

and telecommunications, and across levels of government. 

However, as noted earlier, state and local officials from all of the states 

and localities we interviewed wanted additional federal influenza 

pandemic guidance from the federal government on specific topics, such

as implementing community interventions, fatality management, and 

facilitating medical surge. Although the federal government has issued 

some guidance, it may not have reached state and local officials or may 

not have addressed the particular concerns or circumstances of the state

and local officials we interviewed. In addition, private sector officials have

told us that they would like clarification about the respective roles and 

responsibilities of the federal and state governments during an influenza 

pandemic emergency, such as in state border closures and influenza 

pandemic vaccine distribution. 

Page 37 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

As indicated earlier, in August 2007 we reported that although the National 

Pandemic Strategy and Implementation Plan identified the overarching 

goals and objectives for pandemic planning, the documents had some 

gaps. Most of the implementation plan’s performance measures consist of 

actions to be completed, such as disseminating guidance, but the measures 

are not always clearly linked with intended results. This lack of clear 

linkages makes it difficult to ascertain whether progress has in fact been 

made toward achieving the national goals and objectives described in the 

National Pandemic Strategy and Implementation Plan. Without a clear 

linkage to anticipated results, these measures of activities do not give an 

indication of whether the purpose of the activity is achieved. For example, 

most of the action items’ performance measures consist of actions to be 

completed, such as guidance developed and disseminated. Further, 18 of 

the action items have no measure of performance associated with them. In 

addition, the National Pandemic Implementation Plan does not establish 

priorities among its 324 action items, which becomes especially important 

as agencies and other parties strive to effectively manage scarce resources 

and ensure that the most important steps are accomplished. This is further 

complicated by the lack of a description of the financial resources needed

to implement the action items, which is one of six characteristics of an 

effective national strategy. 

We also found that some action items, particularly those that are to be

completed by state, local, and tribal governments or the private sector, do 

not identify an entity responsible for carrying out the action. Although the 

plan specifies actions to be carried out by states, local jurisdictions, and 

other entities, including the private sector, it gives no indication of how 

these actions will be monitored, how their completion will be ensured, or 

who will be responsible for making sure that these actions are completed. 

Also, it appears that HSC’s determination of completeness has not been 

accurately applied for all of the action items. Several of the action items 

that were reported by the HSC as being completed were still in progress. 

For example, our June 2007 report on U.S. agencies’ international efforts 

to forestall an influenza pandemic found that eight of the plan’s 

international-related action items included in the HSC’s progress report as 

completed either did not directly address the associated performance 

measure or did not indicate that the completion deadline had been met.67

As stated earlier, we are currently assessing the implementation of the 

plan. 

Performance 

Monitoring and 

Accountability for 

Pandemic 

Preparedness Needs 

Strengthening 

 67GAO-07-604. 

Page 38 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

We have also reported that, although DOD instituted reporting 

requirements for its components responsible for implementing 31 action 

items tasked to DOD in the National Pandemic Implementation Plan, there 

were not similar oversight mechanisms in place for pandemic-related tasks 

that were not specifically part of the National Plan.

68 For example, DOD 

did not require DOD components to report on their development or 

revision of their continuity of operations plans in preparation for 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 influenza pandemic 

planning and preparedness efforts. Additionally, without clear 

departmentwide goals, it would be difficult for all DOD components to 

develop effective plans and guidance. In response to our recommendation, 

DOD designated an official to lead DOD’s pandemic efforts, established a 

Pandemic Influenza Task Force, and communicated this information 

throughout the department. DOD also assigned responsibility to the U.S. 

Northern Command for directing, planning, and synchronizing DOD’s 

global response to an influenza pandemic and disseminated this 

information throughout the department. 

There have been some other instances where performance and 

accountability has been strengthened. The FEBs have recently established 

performance measures for their emergency support role. In our May 2007

report, we recommended that OPM continue its efforts to establish 

performance measures and accountability for the emergency support 

responsibilities of the FEBs before, during, and after an emergency event 

that affects the federal workforce outside Washington, D.C.69 In response 

to our recommendation, the FEB strategic plan for fiscal years 2008 

through 2012 includes operational goals with associated measures for its 

emergency preparedness, security, and employee safety line of business. 

The data intended to support these measures include methods such as 

stakeholder and participant surveys, participant lists, and emergency

preparedness test results. 

In providing funding to states and certain localities to help them to 

prepare for a pandemic, HHS has instituted a number of accountability 

requirements. As described above, HHS received $5.62 billion in 

 68GAO-06-1042. 

69GAO-07-515. 

Page 39 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

supplemental appropriations specifically available for pandemic influenzarelated purposes in fiscal year 2006. As shown in figure 4, a total of $770 

million, or about 14 percent of the supplemental appropriations, went to 

states and localities for preparedness activities. Of the $770 million, $600 

million was specifically provided by Congress for state and local planning 

and exercising. The HHS pandemic funding was administered by CDC and 

required all 50 states and 3 localities to, among other things, develop 

influenza pandemic plans and conduct influenza pandemic exercises. 

According to CDC officials, all 50 states and the localities that received 

direct funding have met these requirements. 

Strengthening preparedness for large-scale public health emergencies, 

including the possibility of an influenza pandemic, is one of the issues that 

we identified as among those needing the urgent attention of the new 

administration and Congress during this transition period. Although much

has been done, many challenges remain, as is evidenced by the fact that 

almost half of the recommendations that we have made over the past 3 

years have still not been fully implemented. Given the change in

administration and the associated transition of senior federal officials, it 

will be essential for this administration to continue to exercise and test the 

shared leadership roles that have been established between HHS and DHS, 

as well as the relative roles, responsibilities, and authorities for a 

pandemic among the federal government, state and local governments and 

the private sector. In the area of critical infrastructure protection, DHS 

should continue to work with other federal agencies and private sector 

members of the critical infrastructure coordinating councils to help 

address the challenges required to coordinate between the federal and 

private sectors before and during a pandemic. These challenges include

clarifying roles and responsibilities of federal and state governments. DHS 

and HHS should also, in coordination with other federal agencies, 

continue to work with states and local governments to help them address 

identified gaps in their pandemic planning. To help improve international

disease surveillance and detection efforts, the United States should 

continue to work with international organizations and other countries to 

help address gaps in available information, which limit the capacity for 

comprehensive, well-informed comparisons of risk levels by countries. 

Continued leadership focus on pandemic preparedness is particularly 

crucial now as the attention on influenza pandemic may be waning as 

attention shifts to other more immediate national priorities. In addition, as 

leadership changes across the executive branch, the new administration 

should recognize that the threat of an influenza pandemic remains 

Concluding 

Observations 

Page 40 GAO-09-334 Pandemic Planning and Preparedness Efforts
 

unchanged and should therefore continue to maintain momentum in 

preparing the nation for a possible influenza pandemic. 

As agreed with your office, we plan no further distribution of this report 

until 30 days from its date, unless you publicly announce its contents 

earlier. At that time, we will send copies to other interested parties. In 

addition, this report is available at no charge on GAO’s Web site at 

http://www.gao.gov. 

If you or your staff have any further questions about this report, please 

contact me at (202) 512-6543 or steinhardtb@gao.gov, or Sarah Veale,

Assistant Director, at (202) 512-6890 or veales@gao.gov. Contact points for 

our Offices of Congressional Relations and Public Affairs may be found on

the last page of this report. Major contributors to this report are listed in 

appendix III. 

Sincerely yours, 

t

Director, Strategic Issues 

Bernice Steinhard

Page 41 GAO-09-334 Pandemic Planning and Preparedness Efforts
Appendix I: Open Recommendations from 

GAO’s Work on an Influenza Pandemic 

as of February 2009 

Title and GAO product number

Summary of open 

recommendations Status 

Influenza Pandemic: HHS Needs to 

Continue Its Actions and Finalize Guidance 

for Pharmaceutical Interventions, 

GAO-08-671, September 30, 2008

The Secretary of Health and 

Human Services should 

expeditiously finalize guidance to 

assist state and local jurisdictions 

to determine how to effectively 

use limited supplies of antivirals 

and pre-pandemic vaccine in a 

pandemic, including prioritizing

target groups for pre-pandemic

vaccine. 

In December 2008, HHS released final guidance 

on antiviral drug use during an influenza pandemic. 

HHS officials informed us that they are drafting the 

guidance on pre-pandemic influenza vaccination. 

Influenza Pandemic: Federal Agencies 

Should Continue to Assist States to Address 

Gaps in Pandemic Planning, 

GAO-08-539, June 19, 2008

The Secretaries of Health and

Human Services and Homeland 

Security should, in coordination 

with other federal agencies, 

convene additional meetings of 

the states in the five federal

influenza pandemic regions to

help them address identified gaps 

in their planning. 

HHS and DHS officials indicated that while no

additional meetings are planned at this time, states 

will have to continuously update their pandemic 

plans and submit them for review. 

Influenza Pandemic: Opportunities Exist to 

Address Critical Infrastructure Protection 

Challenges That Require Federal and 

Private Sector Coordination, 

GAO-08-36, October 31, 2007

The Secretary of Homeland 

Security should work with sectorspecific agencies and lead efforts 

to encourage the government and 

private sector members of the 

councils to consider and help 

address the challenges that will 

require coordination between the 

federal and private sectors 

involved with critical infrastructure 

and within the various sectors, in 

advance of, as well as during, a 

pandemic. 

DHS officials informed us that the department is 

working on initiatives, such as developing 

pandemic contingency plan guidance tailored to 

each of the critical infrastructure sectors, and 

holding a series of “webinars” with a number of the 

sectors. 

Appendix I: Open Recommendations from 

GAO’s Work on an Influenza Pandemic 

as of February 2009 

Page 42 GAO-09-334 Pandemic Planning and Preparedness Efforts
Appendix I: Open Recommendations from 

GAO’s Work on an Influenza Pandemic 

as of February 2009 

Title and GAO product number

Summary of open 

recommendations Status 

Influenza Pandemic: Further Efforts Are 

Needed to Ensure Clearer Federal

Leadership Roles and an Effective National 

Strategy, 

GAO-07-781, August 14, 2007

Influenza Pandemic: Opportunities Exist to 

Clarify Federal Leadership Roles and 

Improve Pandemic Planning, 

GAO-07-1257T, September 26, 2007 

(1) The Secretaries of Homeland 

Security and Health and Human 

Services should work together to 

develop and conduct rigorous 

testing, training, and exercises for 

an influenza pandemic to ensure 

that the federal leadership roles 

are clearly defined and 

understood and that leaders are 

able to effectively execute shared 

responsibilities to address 

emerging challenges. Once the 

leadership roles have been 

clarified through testing, training, 

and exercising, the Secretaries of 

Homeland Security and Health 

and Human Services should 

ensure that these roles are clearly 

understood by state, local, and 

tribal governments; the private 

and nonprofit sectors; and the

international community. 

(1) HHS and DHS officials stated that several 

influenza pandemic exercises had been conducted 

since November 2007 that involved both agencies 

and other federal officials, but it is unclear whether 

these exercises rigorously tested federal

leadership roles in a pandemic. 

(2) The Homeland Security 

Council should establish a specific 

process and time frame for 

updating the National Pandemic 

Implementation Plan. The process 

should involve key nonfederal

stakeholders and incorporate 

lessons learned from exercises 

and other sources. The National 

Pandemic Implementation Plan

should also be improved by 

including the following information 

in the next update: (A) resources 

and investments needed to 

complete the action items and

where they should be targeted, (B) 

a process and schedule for 

monitoring and publicly reporting 

on progress made on completing 

the action items, (C) clearer 

linkages with other strategies and 

plans, and (D) clearer descriptions 

of relationships or priorities among 

action items and greater use of

outcome-focused performance 

measures. 

(2) HSC did not comment on the recommendation 

and has not indicated if it plans to implement it. 

Page 43 GAO-09-334 Pandemic Planning and Preparedness Efforts
Appendix I: Open Recommendations from 

GAO’s Work on an Influenza Pandemic 

as of February 2009 

Title and GAO product number

Summary of open 

recommendations Status 

Avian Influenza: USDA Has Taken Important 

Steps to Prepare for Outbreaks, but Better 

Planning Could Improve Response, 

GAO-07-652, June 11, 2007 

(1) The Secretaries of Agriculture 

and Homeland Security should

develop a memorandum of 

understanding that describes how 

USDA and DHS will work together 

in the event of a declared 

presidential emergency or major 

disaster, or an Incident of National 

Significance, and test the 

effectiveness of this coordination 

during exercises. 

(1) Both USDA and DHS officials told us that they 

have taken preliminary steps to develop additional 

clarity and better define their coordination roles. 

For example the two agencies meet on a regular 

basis to discuss such coordination. 

(2) The Secretary of Agriculture 

should, in consultation with other 

federal agencies, states, and the 

poultry industry identify the 

capabilities necessary to respond 

to a probable scenario or 

scenarios for an outbreak of highly 

pathogenic avian influenza. The 

Secretary of Agriculture should 

also use this information to 

develop a response plan that 

identifies the critical tasks for 

responding to the selected 

outbreak scenario and, for each 

task, identifies the responsible

entities, the location of resources 

needed, time frames, and 

completion status. Finally, the 

Secretary of Agriculture should 

test these capabilities in ongoing 

exercises to identify gaps and

ways to overcome those gaps. 

(2) USDA officials told us that it has created a draft 

preparedness and response plan that identifies 

federal, state, and local actions, timelines, and 

responsibilities for responding to highly pathogenic 

avian influenza, but the plan has not been issued 

yet. 

(3) The Secretary of Agriculture 

should develop standard criteria 

for the components of state 

response plans for highly 

pathogenic avian influenza, 

enabling states to develop more 

complete plans and enabling 

USDA officials to more effectively 

review them. 

(3) USDA told us that it has drafted large volumes 

of guidance documents that are available on a 

secure Web site. However, the guidance is still 

under review and it is not clear what standard 

criteria from these documents USDA officials and 

states should apply when developing and 

reviewing plans. 

(4) The Secretary of Agriculture 

should focus additional work with 

states on how to overcome

potential problems associated with 

unresolved issues, such as the 

difficulty in locating backyard birds 

and disposing of carcasses and 

materials. 

(4) USDA officials have told us that the agency has 

developed online tools to help states make 

effective decisions about carcass disposal. In 

addition, USDA has created a secure Internet site 

that contains draft guidance for disease response, 

including highly pathogenic avian influenza, and it 

includes a discussion about many of the 

unresolved issues. 

Page 44 GAO-09-334 Pandemic Planning and Preparedness Efforts
Appendix I: Open Recommendations from 

GAO’s Work on an Influenza Pandemic 

as of February 2009 

Title and GAO product number

Summary of open 

recommendations Status 

(5) The Secretary of Agriculture 

should determine the amount of 

antiviral medication that USDA

would need in order to protect

animal health responders, given 

various highly pathogenic avian 

influenza scenarios. The 

Secretary of Agriculture should 

also determine how to obtain and 

provide supplies within 24 hours of 

an outbreak. 

(5) USDA officials told us that the National

Veterinary Stockpile now contains enough antiviral 

medication to protect 3,000 animal health 

responders for 40 days. However, USDA has yet 

to determine the number of individuals that would 

need medicine based on a calculation of those 

exposed to the virus under a specific scenario. 

Further, USDA officials told us that a contract for 

additional medication for the stockpile has not yet 

been secured, which would better ensure that 

medications are available in the event of an 

outbreak of highly pathogenic avian influenza.

Source: GAO 

Page 45 GAO-09-334 Pandemic Planning and Preparedness Efforts
Appendix II: Implemented Recommendations 

from GAO’s Work on an Influenza Pandemic

as of February 2009 

GAO report Recommendation Actions taken

Influenza Pandemic: DOD Combatant 

Commands’ Preparedness Efforts 

Could Benefit from More Clearly 

Defined Roles, Resources, and Risk 

Mitigation, 

GAO-07-696, June 20, 2007 

(1) The Secretary of Defense should 

instruct the Assistant Secretary of Defense 

for Homeland Defense and Americas’ 

Security Affairs to issue guidance that 

specifies which of the tasks assigned to 

DOD in the plan and other pandemic 

planning tasks apply to the individual 

combatant commands, military services, 

and other organizations within DOD, as 

well as what constitutes fulfillment of these 

actions. 

(1) The 14 national implementation plan tasks 

assigned to the Joint Staff as the lead 

organization within DOD, which includes tasks to 

be performed by the combatant commands, have 

been completed. According to DOD, the 

department’s Global Pandemic Influenza Planning 

Team developed recommendations for the 

division of responsibilities, which were included in 

U.S. Northern Command’s global synchronization 

plan for pandemic influenza. Additionally, DOD 

assigned pandemic influenza-related tasks to the 

combatant commands in its 2008 Joint Strategic 

Capabilities Plan. 

(2) The Secretary of Defense should 

instruct the Assistant Secretary of Defense 

for Homeland Defense and Americas’ 

Security Affairs to issue guidance that 

specifies U.S. Northern Command’s roles 

and responsibilities as global synchronizer 

relative to the roles and responsibilities of 

the various organizations leading and 

supporting the department’s influenza 

pandemic planning. 

(2) Revisions to DOD’s 2008 Joint Strategic 

Capabilities Plan, as well as guidance from the 

Secretary of Defense during a periodic review of 

U.S. Northern Command’s pandemic influenza 

global synchronization plan, clarified and better 

defined U.S. Northern Command’s role as global 

synchronizer. 

(3) The Secretary of Defense should 

instruct the Assistant Secretary of Defense 

for Homeland Defense and Americas’ 

Security Affairs to work with the Under 

Secretary of Defense (Comptroller) to 

identify the sources and types of resources 

combatant commands need to accomplish 

their influenza pandemic planning and 

preparedness activities. 

(3) DOD, through U.S. Northern Command as the 

global synchronizer for pandemic influenza 

planning, collected information from the 

combatant commands on funding requirements 

related to pandemic influenza preparedness and 

submitted this information through DOD’s formal 

budget and funding process. Through this 

process, five of the combatant commands (U.S. 

Northern Command, U.S. European Command, 

U.S. Pacific Command, U.S. Central Command, 

and U.S. Transportation Command) obtained

about $25 million for fiscal years 2009 through 

2013 for pandemic influenza planning and 

exercises. Future pandemic influenza-related

funding requirements will be addressed through 

DOD’s established budget process. 

Appendix II: Implemented Recommendations 

from GAO’s Work on an Influenza Pandemic 

as of February 2009 

Page 46 GAO-09-334 Pandemic Planning and Preparedness Efforts
Appendix II: Implemented Recommendations 

from GAO’s Work on an Influenza Pandemic

as of February 2009 

GAO report Recommendation Actions taken

(4) The Secretary of Defense should 

instruct the Joint Staff to work with the 

combatant commands to develop options 

to mitigate the effects of factors that are 

beyond the combatant commands’ control. 

(4) The combatant commands are increasingly 

inviting representatives from the United Nations, 

including the World Health Organization and the 

Food and Agriculture Organization; host and

neighboring nations; and other federal 

government agencies to exercises and 

conferences to share information and fill 

information gaps. Additionally, U.S. Northern 

Command and U.S. Pacific Command, along with 

the military services and installations, are 

increasingly working and planning with state, 

local, and tribal representatives. DOD views 

updating and reviewing plans to ensure that they 

are current as a continuous process driven by

changes in policy, science, and environmental 

factors. 

Financial Market Preparedness: 

Significant Progress Has Been Made, 

but Pandemic Planning and Other 

Challenges Remain, 

GAO-07-399, March 29, 2007 

The Chairman, Federal Reserve, the 

Comptroller of the Currency, and the 

Chairman, Securities and Exchange 

Commission, should consider taking 

additional actions to ensure that market 

participants adequately prepare for an 

outbreak, including issuing formal 

expectations that business continuity plans 

for a pandemic should include measures 

likely to be effective even during severe

outbreaks, and setting a date by which 

market participants should have such 

plans. 

In December 2007, the Federal Reserve, in 

conjunction with the Federal Financial Institutions 

Examination Council, issued an Interagency

Statement on Pandemic Planning to each Federal 

Reserve Bank and to all banking organizations 

supervised by the Federal Reserve. The 

statement directed those banks to ensure the 

pandemic plans they have in place are adequate 

to maintain critical operations during a severe 

outbreak. In December 2007, the Office of the 

Comptroller of the Currency, in conjunction with 

the Federal Financial Institutions Examination

Council, also issued an Interagency Statement on 

Pandemic Planning to the national banks, 

outlining the same requirements for pandemic

plans as the guidance issued by the Federal 

Reserve. In July and August of 2007, the 

Securities and Exchange Commission’s Market 

Regulation Division issued letters to the major 

clearing organizations and exchanges—those

covered by the Commission’s 2003 Policy 

Statement on Business Continuity Planning for 

Trading Markets—that directed these 

organizations to confirm by year-end 2007 that 

their pandemic plans are adequate to maintain 

critical operations during a severe outbreak. 

The Federal Workforce: Additional 

Steps Needed to Take Advantage of 

Federal Executive Boards’ Ability to 

Contribute to Emergency Operations, 

GAO-07-515, May 4, 2007 

(1) OPM should initiate discussion with the 

Department of Homeland Security and 

other responsible stakeholders to consider 

the feasibility of integrating the federal

executive board’s (FEB) emergency 

support responsibilities into the established 

emergency response framework, such as 

the National Response Plan. 

(1) In January 2008, the FEBs were included in 

the National Response Framework section on 

regional support structures that have the potential 

to contribute to development of situational 

awareness during an emergency. In addition, in 

August 2007, the FEBs were integrated into the 

National Continuity Policy Implementation Plan 

issued by the White House Homeland Security 

Council. 

Page 47 GAO-09-334 Pandemic Planning and Preparedness Efforts
Appendix II: Implemented Recommendations 

from GAO’s Work on an Influenza Pandemic

as of February 2009 

GAO report Recommendation Actions taken

(2) OPM should continue its efforts to 

establish performance measures and 

accountability for the emergency support 

responsibilities of the FEBs before, during, 

and after an emergency event that affects 

the federal workforce outside Washington, 

D.C. 

(2) The FEB strategic plan for fiscal years 2008 

through 2012 includes operational goals with

associated measures for its emergency 

preparedness, security, and employee safety line 

of business. The data intended to support these 

measures includes methods such as stakeholder 

and participant surveys, participant lists, and 

emergency preparedness test results. 

(3) OPM, as part of its strategic planning 

process for the FEBs, should develop a 

proposal for an alternative to the current 

voluntary contribution mechanism that 

would address the uncertainty of funding 

sources for the boards. 

(3) In November 2008, OPM submitted a 

legislative proposal to provide for interagency

funding of FEB operations nationwide. 

(4) OPM should work with FEMA to 

develop a memorandum of understanding, 

or some similar mechanism that formally 

defines the FEB role in emergency 

planning and response. 

(4) In addition to integrating the FEBs into 

national emergency plans, FEMA and OPM 

signed a memorandum of agreement on August 

1, 2008. Among other things, the memorandum 

states that the federal executive boards and 

FEMA will work together in carrying out their 

respective roles in the promotion of the National 

Incident Management System and the National 

Response Framework. 

Influenza Pandemic: DOD Has Taken 

Important Actions to Prepare, but 

Accountability, Funding, and 

Communications Need to be Clearer 

and Focused Departmentwide, 

GAO-06-1042, September 21, 2006 

(1) The Secretary of Defense should 

instruct the Assistant Secretary of Defense 

for Homeland Defense, as the individual 

accountable for DOD’s influenza pandemic 

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 

influenza pandemic 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. 

(1) The Deputy Secretary of Defense verbally

designated the Assistant Secretary of Defense for 

Homeland Defense, working with the Assistant 

Secretary of Defense for Health Affairs, to lead 

DOD’s pandemic influenza efforts and established 

a Pandemic Influenza Task Force. This 

information was communicated throughout the 

department when the Principal Deputy to the 

Assistant Secretary of Defense for Homeland

Defense and Americas’ Security Affairs issued

DOD’s Implementation Plan for Pandemic 

Influenza within the department in a July 2006

memo. Additionally, U.S. Northern Command was 

designated as the lead combatant command for 

directing, planning, and synchronizing DOD’s 

global response to an influenza pandemic; this

information was disseminated throughout the

department in November 2006. 

(2) The Secretary of Defense should 

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 and 

controls to ensure that needed funding for 

DOD’s influenza pandemic preparedness 

efforts is tied to the department’s goals. 

(2) The Office of the Under Secretary of Defense 

(Comptroller) is utilizing established protocols for 

programming funds related to pandemic influenza 

preparedness for DOD. Funding requests for

preparedness efforts were submitted as part of 

the department’s fiscal year 2009 integrated 

program and budget review, and long-term 

funding requests will be included in future budget 

requests. 

Page 48 GAO-09-334 Pandemic Planning and Preparedness Efforts
Appendix II: Implemented Recommendations 

from GAO’s Work on an Influenza Pandemic

as of February 2009 

GAO report Recommendation Actions taken

(3) The Secretary of Defense should 

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. 

(3) In August 2007, DOD issued additional 

guidance related to the distribution of its vaccine 

and antiviral stockpiles in the event of an 

influenza pandemic. 

(4) The Secretary of Defense should 

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. 

(4) DOD has updated its publicly available 

pandemic influenza Web site, to include links to 

the Military Vaccine Agency, which provides

information on the risks and side effects of 

vaccines. 

Source: GAO 

Page 49 GAO-09-334 Pandemic Planning and Preparedness Efforts
Appendix III: GAO

A

 Contact and Staff 

cknowledgments 

Page 50 GAO-09-334 

Appendix III: GAO Contact and Staff 

Acknowledgments 

Bernice Steinhardt, (202) 512-6543 or steinhardtb@gao.gov

In addition to the contact named above, major contributors to this report 

include Sarah Veale, Assistant Director; Maya Chakko; Susan Sato; Mark 

Ryan; Kara Marshall; and members of GAO’s Pandemic Working Group. 

GAO Contact 

Staff 

Acknowledgments 

Pandemic Planning and Preparedness Efforts
Related GAO Products Related GAO Products 

Veterinarian Workforce: Actions Are Needed to Ensure Sufficient 

Capacity for Protecting Public and Animal Health. GAO-09-178. 

Washington, D.C.: February 4, 2009. 

Influenza Pandemic: HHS Needs to Continue Its Actions and Finalize 

Guidance for Pharmaceutical Interventions. GAO-08-671. Washington,

D.C.: September 30, 2008. 

Influenza Pandemic: Federal Agencies Should Continue to Assist States 

to Address Gaps in Pandemic Planning. GAO-08-539. Washington, D.C.: 

June 19, 2008. 

Emergency Preparedness: States Are Planning for Medical Surge, but 

Could Benefit from Shared Guidance for Allocating Scarce Medical 

Resources. GAO-08-668. Washington, D.C.: June 13, 2008. 

Influenza Pandemic: Efforts Under Way to Address Constraints on 

Using Antivirals and Vaccines to Forestall a Pandemic. GAO-08-92. 

Washington, D.C.: December 21, 2007. 

Influenza Pandemic: Opportunities Exist to Address Critical 

Infrastructure Protection Challenges That Require Federal and Private 

Sector Coordination. GAO-08-36. Washington, D.C.: October 31, 2007. 

Influenza Pandemic: Federal Executive Boards’ Ability to Contribute to 

Pandemic Preparedness. GAO-07-1259T. Washington, D.C.: September 28, 

2007. 

Influenza Pandemic: Opportunities Exist to Clarify Federal Leadership

Roles and Improve Pandemic Planning. GAO-07-1257T. Washington, D.C.: 

September 26, 2007. 

Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer 

Federal Leadership Roles and an Effective National Strategy. 

GAO-07-781. Washington, D.C.: August 14, 2007. 

Emergency Management Assistance Compact: Enhancing EMAC’s 

Collaborative and Administrative Capacity Should Improve National 

Disaster Response. GAO-07-854. Washington, D.C.: June 29, 2007. 

Influenza Pandemic: DOD Combatant Commands’ Preparedness Efforts 

Could Benefit from More Clearly Defined Roles, Resources, and Risk 

Mitigation. GAO-07-696. Washington, D.C.: June 20, 2007. 

Page 51 GAO-09-334 Pandemic Planning and Preparedness Efforts
Related GAO Products 

Influenza Pandemic: Efforts to Forestall Onset Are Under Way; 

Identifying Countries at Greatest Risk Entails Challenges. GAO-07-604. 

Washington, D.C.: June 20, 2007. 

Avian Influenza: USDA Has Taken Important Steps to Prepare for 

Outbreaks, but Better Planning Could Improve Response. GAO-07-652. 

Washington, D.C.: June 11, 2007. 

The Federal Workforce: Additional Steps Needed to Take Advantage of 

Federal Executive Boards’ Ability to Contribute to Emergency 

Operations. GAO-07-515. Washington, D.C.: May 4, 2007. 

Financial Market Preparedness: Significant Progress Has Been Made, 

but Pandemic Planning and Other Challenges Remain. GAO-07-399. 

Washington, D.C.: March 29, 2007. 

Influenza Pandemic: DOD Has Taken Important Actions to Prepare, but 

Accountability, Funding, and Communications Need to be Clearer and 

Focused Departmentwide. GAO-06-1042. Washington, D.C.: September 21, 

2006. 

Catastrophic Disasters: Enhanced Leadership, Capabilities, and 

Accountability Controls Will Improve the Effectiveness of the Nation’s 

Preparedness, Response, and Recovery System. GAO-06-618. Washington, 

D.C.: September 6, 2006. 

(450724) Page 52 GAO-09-334 Pandemic Planning and Preparedness Efforts
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