GAO 

United States Government Accountability Office

Report to the Chairman, Committee on 

Homeland Security, House of 

Representatives 

INFLUENZA 

PANDEMIC 

Monitoring and 

Assessing the Status 

of the National 

Pandemic 

Implementation Plan 

Needs Improvement 

November 2009 

GAO-10-73 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

November 2009

INFLUENZA PANDEMIC

Monitoring and Assessing the Status of the National 

Pandemic Implementation Plan Needs Improvement 

Highlights of GAO-10-73, a report to the 

Chairman, Committee on Homeland 

Security, House of Representatives 

To oversee agencies’ progress in implementing the Plan’s action items, the 

HSC, which is supported by the White House National Security Staff in this 

administration, convenes regular interagency meetings, asks agencies for 

summaries of progress; and leads the interagency process that monitors the 

progress of the Plan. Officials from the six agencies stated that they monitor 

action items tasked to more than one agency by selecting one or two agencies 

to report a consolidated summary of progress, approved by each responsible 

agency, to the HSC. However, neither the HSC nor the agencies monitor or 

report on the 17 action items intended for nonfederal entities, including, for 

example, action items asking state, local, and tribal entities to ensure their 

preparedness plans address mass immunization, even though the information 

may have been available from other sources, such as the interagency review 

of state pandemic plans led by the Department of Health and Human Services. 

In addition, the Plan does not describe the types of information needed to 

carry out the Plan’s response-related action items, although agencies may 

have operational plans or other existing guidance that would provide this 

information. 

The HSC reported in October 2008 that the majority of the 324 action items 

were designated as complete. However, GAO’s review of 60 action items 

found that it was difficult to determine the actual status of some of the 49 

designated as complete. All of the action items reviewed have both a 

description of activities to be carried out and a measure of performance, 

which the HSC stated that it used to assess completion. However, for more 

than half of the action items considered complete, the measures of 

performance do not fully address all of the activities contained in their 

descriptions. While the HSC’s progress summaries sometimes corrected for 

this by either referring to activities in the action item’s description or some 

other information not reflected in either the measure of performance or 

description, future progress reports would benefit from using measures of 

performance that are more consistent with the action items’ descriptions. 

The Plan is predicated on a type of pandemic different in severity and origin 

than the current H1N1 pandemic, but it is serving as the foundation for the 

response to the outbreak, supplemented by an additional plan tailored 

specifically to the characteristics of the H1N1 pandemic. Nevertheless, the 

National Strategy for Pandemic Influenza and Plan will still be needed for 

future events as most of the action items in the Plan were to be completed by 

May 2009. As recommended in earlier GAO work, but not yet implemented, 

the Plan should be updated to take into account certain missing elements and 

lessons learned from the H1N1 pandemic; the update should also address the 

monitoring and assessment improvements GAO identified in this report. 

The current H1N1 pandemic 

highlights the threat posed to our 

nation by an influenza pandemic. 

The previous administration’s 

Homeland Security Council (HSC) 

issued the Implementation Plan 

for the National Strategy for 

Pandemic Influenza (Plan) in May 

2006 to help address a pandemic. 

GAO was asked to (1) determine 

how the HSC and responsible 

federal agencies monitor the 

progress and completion of the 

Plan’s action items; and (2) assess 

the extent to which selected action 

items have been completed. To do 

this, GAO interviewed officials 

from the HSC and the six federal 

agencies responsible for 

implementing most of the Plan, and 

analyzed a random sample of 60 

action items. While this report does 

not assess the response efforts for 

the H1N1 pandemic, GAO 

continues to monitor the outbreak 

and the federal response. 

What GAO Recommends

GAO makes recommendations to 

the HSC related to the Plan and any 

future updates, including 

developing a monitoring and 

reporting process for action items 

intended for nonfederal entities, 

identifying the types of information 

needed to carry out the responserelated action items, and improving 

how completion is assessed. The 

Principal Deputy Counsel to the 

President stated that the 

administration will consider GAO’s 

recommendations. The HSC also 

provided technical comments. 

Comments from other agencies are 

discussed in the report. 

View GAO-10-73 or key components.

For more information, contact Bernice 

Steinhardt at (202) 512-6543 or 

steinhardtb@gao.gov. 
Page i GAO-10-73 

Contents 

Letter 1

Background 4 

The HSC Monitors Agencies’ Progress on Most Action Items 8 

Status of Some Selected Action Items Considered Complete Was 

Difficult to Determine 15 

Conclusions 23 

Recommendations for Executive Action 24 

Agency Comments and Our Evaluation 24 

Appendix I Objectives, Scope, and Methodology 27 

Appendix II Sample of 60 Selected Action Items in the 

Implementation Plan for the National Strategy for 

Pandemic Influenza 31 

Appendix III Comments from the White House 38 

Appendix IV Comments from the Department of Health and Human 

Services 39 

Appendix V Comments from the Department of Homeland 

Security 42 

Appendix VI GAO Contact and Staff Acknowledgments 44 

Related GAO Products 45 

 National Pandemic Plan 
Tables 

Table 1: The 10 Response-Related Action Items in Our Sample 13 

Table 2: Examples of Selected Action Items Where Measures of 

Performance Fully or Partially Addressed the Plan’s 

Respective Descriptions 17 

Table 3: Examples of Selected Action Items Where the HSC’s 2-

Year Progress Report Summaries Partially Addressed or 

Did Not Address the Plan’s Respective Measures of 

Performance 19 

Figures 

Figure 1: WHO Pandemic Influenza Phases 5 

Figure 2: Elements of the Strategy and Plan 7 

Page ii GAO-10-73 National Pandemic Plan
Abbreviations 

DHS Department of Homeland Security 

DOC Department of Commerce 

DOD Department of Defense 

DOI Department of the Interior 

DOJ Department of Justice 

DOL Department of Labor 

DOS Department of State 

DOT Department of Transportation 

EMS Emergency Medical Services 

ESF Emergency Support Function 

FAO Food and Agriculture Organization 

HHS Department of Health and Human Services 

HSC Homeland Security Council 

NGO nongovernmental organization 

NSS White House National Security Staff 

NVS National Veterinary Stockpile 

OIE World Organisation for Animal Health 

Plan Implementation Plan for the National Strategy for 

 Pandemic Influenza 

REDI Regional Emerging Disease Intervention 

Strategy National Strategy for Pandemic Influenza

Treasury Department of the Treasury 

USAID United States Agency for International Development 

USDA United States Department of Agriculture 

USTR United States Trade Representative 

VA Department of Veterans Affairs 

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-10-73 National Pandemic Plan
Page 1 GAO-10-73 

 

United States Government Accountability Office

Washington, DC 20548 

 

November 24, 2009 

The Honorable Bennie G. Thompson 

Chairman 

Committee on Homeland Security 

House of Representatives 

Dear Mr. Chairman: 

An influenza pandemic remains a real threat to our nation and to the 

world, as we are witnessing during the current H1N1 pandemic, which 

began in spring 2009 and continues today. The previous administration’s 

Homeland Security Council (HSC) took an active approach to the potential 

disaster of an influenza pandemic by, among other things, issuing the 

National Strategy for Pandemic Influenza (Strategy) in November 2005, 

and the Implementation Plan for the National Strategy for Pandemic 

Influenza (Plan) in May 2006.1

 The Strategy lays out high-level goals to 

prepare for and respond to an influenza pandemic, while the Plan is 

intended to support the broad framework and goals articulated in the 

Strategy by outlining specific steps that federal departments and agencies 

should take to achieve the goals. The Plan includes 324 action items, a 

majority of which have measures of performance and associated time 

frames. Both the Strategy and Plan are based on a scenario that assumes a 

severe pandemic originating outside the United States, spreading first 

among animal populations and then transmitted to humans. While the 

current pandemic does not share these characteristics, according to the 

Director of Medical Preparedness Policy for the White House National 

Security Staff (NSS), which supports the HSC in the current 

administration,2

 the Strategy and Plan provide the foundation for an 

additional planning document, the National Framework for 2009-H1N1 

1

The HSC was established in 2001 pursuant to Executive Order 13228 to serve as a 

mechanism for ensuring coordination of homeland security–related activities of executive 

departments and agencies and effective development and implementation of homeland 

security policies. Congress subsequently established the HSC for the purpose of more 

effectively coordinating the policies and functions of the federal government relating to 

homeland security in the Homeland Security Act of 2002. Pub. L. No. 107-296 (Nov. 25, 

2002). 

2

On May 26, 2009, the President announced the full integration of White House staff 

supporting national security and homeland security. The HSC will be maintained as the 

principal venue for interagency deliberations on issues that affect the security of the 

homeland, such as influenza pandemic. 

 National Pandemic Plan 
 

Influenza Preparedness and Response, that was developed this year to 

respond to the H1N1 pandemic. The framework for the 2009 H1N1 

pandemic has not yet been made publicly available. 

In August 2007, we reported that while the development of the Strategy 

and Plan were an important first step in guiding national preparedness, the 

Plan lacked a prescribed process for monitoring and reporting on 

progress, which is one element of the six desirable characteristics of a 

national strategy.3

 To address this and other areas that we had identified, 

we recommended that the HSC establish a specific process and time frame 

for updating the Plan, including lessons learned from exercises and other 

events, such as the 2009 H1N1 pandemic. For this report, you asked us to 

focus on the progress in implementing the action items in the Plan, 

specifically (1) determining how the HSC and the responsible federal 

agencies are monitoring the progress and completion of the Plan’s action 

items; and (2) assessing the extent to which selected action items have 

been completed, whether activity has continued on the selected action 

items reported as complete, and the nature of that work. We did not assess 

the response to the 2009 H1N1 pandemic in this report, but we are 

continuing to monitor the outbreak and the federal government’s 

response. 

To address these objectives, we conducted an in-depth analysis of a 

random sample of 60 action items in the Plan. These 60 action items are 

listed in appendix II. We drew a random sample from the 286 action items 

involving six federal agencies with primary responsibility for ensuring 

completion of the large majority (88 percent) of the 324 action items. 

These six agencies include the Department of Defense (DOD), Department 

of Health and Human Services (HHS), Department of Homeland Security 

(DHS), Department of State (DOS), Department of Transportation (DOT), 

and the Department of Agriculture (USDA).4

 We do not generalize the 

results of our analysis because the particular analytical steps we took 

 

3

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

Federal Leadership Roles and an Effective National Strategy, GAO-07-781 (Washington, 

D.C.: Aug. 14, 2007). 

4

HHS, DHS, and USDA have primary responsibility in implementing a majority of the action 

items in the Plan. 

Page 2 GAO-10-73 National Pandemic Plan
 

across the selected action items varied, and as a result there was no 

common underlying measure on which to generalize the results to all of 

the action items in the Plan. In addition, we did not review all of the action 

items in the Plan in depth because our analyses involved multiple 

assessments for each action item, including the review of large volumes of 

agency documentation in determining the level of evidence for completion 

of the action item. See appendix I for a more detailed discussion of our 

scope and methodology. 

For both objectives, we interviewed officials and obtained documentation 

from the six agencies. We also reviewed the HSC’s 6-month, 1-year, and 2-

year progress reports, and the HSC’s 1-year summary report on the 

implementation of the action items in the Plan. In addition, we interviewed 

a senior HSC official in the previous administration and the Director of 

Medical Preparedness Policy for the NSS in the current administration, 

who is responsible for overseeing the implementation of the Plan. We also 

relied on our prior pandemic work, including a review of whether the 

Strategy and Plan contained all the characteristics of an effective national 

strategy, to inform our analysis.5

 To address the first objective, we 

assessed information from interviews and documentation on how the HSC 

and the selected agencies monitored the progress and completion of all 

action items. We also interviewed representatives from nonfederal entities 

that agency officials had identified as working on specific action items, 

such as the World Organisation for Animal Health (OIE) and the Denver 

Health Medical Center, to determine whether they had been consulted on 

the status of those action items. To address the second objective, we 

analyzed the 49 action items designated as complete in the HSC’s 2-year 

progress report from the random sample of 60 action items, along with 

collected documentation and interviews with selected agency officials and 

a senior HSC official from the prior administration. To describe the extent 

to which action items had been completed, we analyzed information on 

the 49 selected action items in the Plan, the HSC progress reports, and 

documentation on each of the 49 action items. To evaluate the extent of 

work that has continued on the 49 action items in our sample designated 

as complete and the nature of that work, we asked all selected agencies 

with primary responsibility if they had performed additional work and, if 

so, to provide a brief description of the nature of that work. In addition, 

for the 34 selected action items designated as complete in the HSC’s 1-year 

progress report, we analyzed each action item’s summary in the HSC’s 1- 

 

5

GAO-07-781. 

Page 3 GAO-10-73 National Pandemic Plan
 

and 2-year progress reports for any new information on work conducted in 

that period. 

We conducted this performance audit from July 2008 to November 2009 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. Detailed information on our scope and 

methodology appears in appendix I. A list of related GAO products is also 

included at the end of this report. 

An influenza pandemic is caused by a novel strain of influenza virus for 

which there is little resistance and which therefore is highly transmissible 

among humans. 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. 

Background 

On June 11, 2009, the World Health Organization (WHO) declared a 

pandemic based on the novel influenza A (H1N1) virus currently in wide 

circulation by raising the worldwide pandemic alert level to Phase 6—the 

highest level.6

 Figure 1 shows the WHO phases of a pandemic, 

characterizing Phase 6 as community-level outbreaks in at least one 

country in a different WHO region in addition to the criteria defined in 

Phase 5.7

 This action was a reflection of the spread of the new H1N1 virus, 

not the severity of illness caused by the virus. At that time, more than 70 

 

6

On April 25, 2009, WHO convened a meeting of the Emergency Committee, which is 

composed of international experts in a variety of disciplines, to assess the H1N1 influenza 

cases reported in Mexico and in the United States and declared the 2009 H1N1 a public 

health emergency of international concern. 

7

Phase 5 is characterized by human-to-human spread of the virus into at least two countries 

in one WHO region. 

Page 4 GAO-10-73 National Pandemic Plan
 

countries had reported cases of 2009 H1N1 and there were ongoing 

community-level outbreaks in multiple parts of the world. As of November 

8, 2009, WHO reported over 503,536 confirmed cases and at least 6,260 

deaths, acknowledging, however, that the number of cases was actually 

understated since it is no longer requiring affected countries to count 

individual cases and confirm them through laboratory testing. 

Figure 1: WHO Pandemic Influenza Phases 

Time

Predominantly 

animal 

injections; few 

human 

injections

Sustained 

human to 

human 

transmission

Widespread 

human

infection

Possibility of 

recurrent 

events

Disease activity 

at seasonal 

levels

Phases 1-3

Phase 4

Phases 5-6/

pandemic

Post peak

Post

pandemic

Source: WHO.

Note: Circle indicates WHO assessment of current global phase. 

Similar to the seasonal influenza, the 2009 H1N1 influenza can vary from 

mild to severe. Given ongoing H1N1 activity to date, the Centers for 

Disease Control and Prevention (CDC) stated that it anticipates that there 

will be more cases, more hospitalizations, and more deaths associated 

with this pandemic in the United States in the fall and winter. The novel 

H1N1 virus, in conjunction with regular seasonal influenza viruses, poses 

the potential to cause significant illness with associated hospitalizations 

and deaths during the U.S. influenza season. The United States continues 

to report the largest number of 2009 H1N1 cases of any country 

worldwide, although most people who have become ill have recovered 

without requiring medical treatment. The 2009 H1N1 influenza has been 

reported in all 50 states, the District of Columbia, Guam, American Samoa, 

the Commonwealth of the Northern Mariana Islands, Puerto Rico, and the 

U.S. Virgin Islands. 

Page 5 GAO-10-73 National Pandemic Plan
 

National Planning Efforts 

for an Influenza Pandemic 

As shown in figure 2, the Strategy lays out three high-level goals to prepare 

for and respond to an influenza: (1) stop, slow, or otherwise limit the 

spread of a pandemic to the United States; (2) limit the domestic spread of 

a pandemic and mitigate disease, suffering, and death; and (3) sustain 

infrastructure and mitigate impact on the economy and the functioning of 

society. These goals are underpinned by three pillars that are intended to 

guide the federal government’s approach to a pandemic threat, including: 

(1) preparedness and communication, (2) surveillance and detection, and 

(3) response and containment. Each pillar describes domestic and 

international efforts, animal and human health efforts, and efforts that 

would need to be undertaken at all levels of government and in 

communities. The Plan outlines steps for federal entities and 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. 

Page 6 GAO-10-73 National Pandemic Plan
 

Figure 2: Elements of the Strategy and Plan 

Source: GAO analysis of HSC data.

Pillar 2

Surveillance and 

detection

Pillar 3

Response and 

containment

Pillar 1

Preparedness and 

communication

Functional areas

International efforts

Transportation and borders

Protecting human health

Protecting animal health

Law enforcement, public safety, and 

security

Institutions protecting personnel, 

ensuring continuity of operations

31

17

57

16

14

33

19

25

0 0

20

27

31

10

3 3

9

9

Number of action 

items within each 

functional area

Number of action 

items within each 

functional area

Number of action 

items within each 

functional area

Goal 1

Stop, slow, and

limit spread to

United States

Goal 2

Limit the domestic spread

and mitigate disease,

suffering, and death

Goal 3

Sustain infrastructure and 

mitigate impact on economy 

and functioning of society

Note: Data are from the National Strategy for Pandemic Influenza and the Implementation Plan for 

the National Strategy for Pandemic Influenza. 

Of the 324 action items in the Plan, 144 are related to pillar 1 on 

preparedness and communication; 86 are related to pillar 2 on surveillance 

and detection; and the remaining 94 are related to pillar 3 on response and 

containment. Nearly all of the action items (307 of 324) have a measure of 

performance, and most (287 of 324) of the action items have a time frame 

identified either in the action item’s description, measure of performance, 

or both. Most of the action items in the Plan—those that were not tied to 

response—were expected to have been completed in 3 years, by May 2009. 

Since the issuance of the Plan in May 2006, the HSC publicly reported on 

the status of the action items at 6 months, 1 year, and 2 years in December 

2006, July 2007, and October 2008, respectively. Although this 

Page 7 GAO-10-73 National Pandemic Plan
 

administration has not yet publicly reported on the 3-year status of 

implementing the Plan’s action items, an NSS official stated that the 3-year 

progress report had been in development prior to the 2009 H1N1 

pandemic, and may be released shortly. 

The HSC monitors the status of action items in the Plan tasked to federal 

agencies by convening regular interagency meetings and requesting 

summaries of progress from agencies.8

 According to a former HSC official 

who was involved with monitoring the Plan in the prior administration and 

officials from all of the six agencies, following the development of the 

Plan, the HSC officials convened interagency meetings at the Sub-Policy 

Coordination Committee level (deputy assistant secretary or his or her 

representative) that included discussions on the implementation of action 

items. The former HSC official stated that these meetings are a forum for 

monitoring the status of the Plan’s action items. These meetings were held 

weekly after the release of the Plan and biweekly after the spring of 2008, 

according to the former HSC official. Officials from several of the selected 

agencies stated that the interagency meetings facilitate interagency 

cooperation and coordination on the action items in the Plan. Officials 

also said that these meetings provide a venue to raise and address 

concerns relating to how to implement particular action items, and enable 

them to build relationships with their colleagues in other agencies. In 

addition, the HSC requested that agencies provide the Council with 

periodic summaries of their progress on the action items in preparation for 

the HSC’s progress reports, according to officials from all of the selected 

agencies. 

The HSC Monitors 

Agencies’ Progress on 

Most Action Items 

Officials from the six selected agencies informed us that, in this 

administration, the NSS continues to lead the interagency process used to 

monitor progress of the Plan. Officials from several of the selected 

agencies stated that the NSS continues to hold meetings at the SubInteragency Policy Committee level to monitor efforts related to influenza 

pandemic, with a primary focus on the 2009 H1N1 response. According to 

an NSS official, the NSS has also requested periodic summaries of 

progress from agencies on the action items. 

 

8

As discussed later, the HSC does not monitor action items intended for nonfederal entities. 

Page 8 GAO-10-73 National Pandemic Plan
 

For action items that involve multiple federal agencies, the six agencies 

monitor the action items assigned to them by designating one or two 

agencies to report one consolidated summary of progress for each action 

item to the HSC, according to agency officials. Some action items task 

additional federal agencies with a support role as well. According to 

agency officials, all agencies tasked with responsibility for an action item 

have to approve its summary of progress before it is provided to the HSC. 

The HSC’s 6-month, 1-year, and 2-year progress reports state that the 

action items’ summaries in the reports were prepared by relevant agencies 

and departments. Officials from all six agencies said that the HSC does not 

always require them to submit supporting documentation along with their 

summary of progress to determine if an action item is complete. For 

instance, officials at three of the agencies said that the HSC does not 

require them to submit supporting documentation, while officials from 

two other agencies said that additional information is required by the HSC 

if it is not convinced about the completeness of an action item, or if it is 

unclear that the respective measure of performance was met based on the 

summary of progress. 

For the 112 action items in the Plan that include both federal agencies and 

nonfederal entities, the responsible federal agencies determined how they 

would work with and monitor the nonfederal entities. According to the 

former HSC official, the responsible agencies determined how these action 

items would be implemented, including deciding which nonfederal entities 

they would work with and in what manner they would work with them. 

Among the six agencies we reviewed, five said that they worked with 

nonfederal entities to implement some of the action items in the Plan. For 

example, DOT officials stated that they worked with professional 

associations to develop guidelines and recommendations for Emergency 

Medical Services (EMS) and 9-1-1 call centers, and HHS officials told us 

that they worked with medical experts to develop guidance on mass 

casualty care. We interviewed representatives of nine of these nonfederal 

entities and all of them confirmed that the status of the action items with 

which they were associated had been accurately reported. However, they 

also told us that they had not been asked for input into the summaries of 

progress for the action items with which they were associated and had 

therefore been unable to check the accuracy of the summaries before they 

were reported. 

Page 9 GAO-10-73 National Pandemic Plan
 

The HSC makes the final determination as to whether the Plan’s action 

items are completed, according to the former HSC official and officials 

from the selected agencies. The HSC bases its determination on 

information from federal agencies, and uses the measure of performance 

associated with the action items as criteria for completion, as stated in the 

HSC’s 6-month, 1-year, and 2-year progress reports. Officials from three of 

the selected agencies stated that their agencies advise the HSC as to 

whether they believe an action item is complete when they provide 

summaries of progress to the HSC, while officials from two selected 

agencies stated that they provide summaries of progress to the HSC, and 

the HSC ultimately determines if an action item is complete. An 

interagency group led by the HSC reviews the agencies’ summaries of 

progress to help determine if action items are complete. The former HSC 

official told us that the HSC’s method of assessing whether an action item 

was complete depends on the specific action item. For some action items, 

the former HSC official stated that the summary of progress is reviewed by 

both an interagency group and a technical working group consisting of 

subject-matter experts. 

The HSC Uses Information 

Provided by Agencies to 

Determine Action Item 

Status 

Neither the HSC nor 

Agencies Monitor Action 

Items Intended for 

Nonfederal Entities 

As we reported in August 2007, state and local jurisdictions that will play 

crucial roles in preparing for and responding to a pandemic were not 

directly involved in developing the Plan, even though it relies on these 

stakeholders’ efforts.9

 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. Moreover, the Plan states that in the event of an influenza pandemic, 

the distributed nature and sheer burden of disease across the nation would 

mean that the federal government’s support to any particular community is 

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

state governments and local communities. In our June 2008 report on 

states’ influenza pandemic planning and exercising, officials from selected 

states and localities confirmed that they were not directly involved in 

developing the Plan.10 Further, HHS officials confirmed that the Plan was 

developed by the federal government without any state input. 

 

9

GAO-07-781. 

10GAO, Influenza Pandemic: Federal Agencies Should Continue to Assist States to 

Address Gaps in Pandemic Planning, GAO-08-539 (Washington, D.C.: June 19, 2008). 

Page 10 GAO-10-73 National Pandemic Plan
 

Although the Plan calls for 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 and how their 

completion will be ensured. While the HSC reported on progress on all of 

the action items involving both federal and nonfederal entities that are 

included in the 2-year progress report, the 17 action items that are 

intended for nonfederal entities are not monitored or reported on by the 

HSC or the six federal agencies we reviewed. According to the former HSC 

official in the prior administration and an NSS official in the current 

administration, the HSC is not in a position to assess progress on these 

action items because the federal government cannot direct nonfederal 

entities to complete them. Therefore, these 17 action items do not contain 

measures of performance against which to measure progress. Although the 

HSC’s 1- and 2-year progress reports stated that the HSC intended to 

continue and intensify its work with nonfederal entities, the 2-year 

progress report does not have any information on work conducted on 

these 17 action items nor is their status reported. Examples of the 17 

action items intended for nonfederal entities include the following: 

• State, local, and tribal pandemic preparedness plans should address 

the implementation and enforcement of isolation and quarantine, the 

conduct of mass immunization programs, and provisions for release or 

exception.11

• States should ensure that pandemic response plans adequately address 

law enforcement and public safety preparedness across the range of 

response actions that may be implemented, and that these plans are 

integrated with authorities that may be exercised by federal agencies 

and other state, local, and tribal governments.12

Although there is no information on these two action items in the HSC’s 2-

year progress report, we reported in June 2008 that HHS had led a 

multidepartment effort to review pertinent parts of states’ influenza 

pandemic plans in 22 priority areas,13 and had provided feedback to states 

in November 2007.14 These priority areas included mass vaccination, law 

 

11Action item 6.3.1.1. 

12Action item 8.1.1.1. 

13Stage 1 of the HHS-led interagency review of state pandemic plans spanned from August 

2006 to January 2007. 

14GAO-08-539. 

Page 11 GAO-10-73 National Pandemic Plan
 

enforcement, and community containment, which includes communitylevel interventions designed to limit the transmission of a pandemic virus 

with emphasis on isolation and quarantine, closing schools, and 

discouragement of large public gatherings, at a minimum. This HHS-led 

review found major gaps in these three areas, which are activities cited in 

the two action items noted above. Since our 2008 report, HHS led a second 

interagency assessment of state influenza pandemic plans,15 which found 

that although states have made important progress toward preparing for 

combating an influenza pandemic, most states still have major gaps in 

their pandemic plans.16 So, for these two action items, HHS had gathered 

information on their status for other purposes and made it publicly 

available on www.flu.gov, but this information was not reported in the 

HSC’s progress reports. 

The Plan Lacks a 

Description of the 

Information Needed to 

Carry Out ResponseRelated Action Items 

The Plan includes response-related action items that have a measure of 

performance or time frame associated with a pandemic or animal 

outbreak. In a response-related section in the HSC’s 2-year progress 

report, the report states that although neither a pandemic nor animal 

outbreak had occurred in the United States as of October 2008, the federal 

government had exercised many of the capabilities called for in these 

action items. 

We found that the Plan does not describe the specific circumstances, such 

as the type or severity of an outbreak or pandemic, under which the 

response-related action items would be undertaken. In addition, for 

response-related action items in which the trigger is not an outbreak or 

pandemic, the Plan does not describe the types of information that would 

be needed in order to make a decision to implement the action items. For 

example, one of the action items, shown in table 1 below, calls for DOS 

and DHS to impose restrictions on travel into the United States as 

appropriate.17 However, a senior DOS official told us that the agency does 

 

15Stage 2 of the HHS-led interagency review of state pandemic plans spanned from January 

2007 to December 2008. 

16GAO, Influenza Pandemic: Sustaining Focus on the Nation’s Planning and 

Preparedness Efforts, GAO-09-334 (Washington, D.C.: Feb. 26, 2009) and Departments 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). 

17Action item 5.3.1.1. 

Page 12 GAO-10-73 National Pandemic Plan
 

not have triggers for when these travel restrictions would be implemented. 

As we have previously reported, in preparing for, responding to, and 

recovering from any catastrophic disaster, roles and responsibilities must 

be clearly defined, effectively communicated, and well understood in 

order to facilitate rapid and effective decision making.18 In an August 2009 

report on U.S. preparations for the 2009 H1N1 pandemic, the President’s 

Council of Advisors on Science and Technology highlighted the need for 

quantitative triggers and recommended that federal agencies adopt 

structured frameworks for key decision making by incorporating 

scenarios and specific trigger points for action.19

Table 1: The 10 Response-Related Action Items in Our Sample 

Action 

item 

number Description Measure of performance 

4.3.6.3. USDA, in coordination with DHS, the United States 

Trade Representative (USTR), and DOS, shall ensure 

that clear and coordinated messages are provided to 

international trading partners regarding animal disease 

outbreak response activities in the United States. 

Within 24 hours of an outbreak, appropriate messages will be 

shared with key animal / animal product trading partners. 

5.3.1.1. DOS and DHS, in coordination with DOT, Department 

of Commerce (DOC), HHS, Department of the Treasury 

(Treasury), and USDA, shall work with foreign 

counterparts to limit or restrict travel from affected 

regions to the United States, as appropriate, and notify 

host government(s) and the traveling public. 

Measures imposed within 24 hours of the decision to do so, 

after appropriate notifications made. 

5.3.4.3. DHS, if needed, will implement contingency plans to 

maintain border control during a period of pandemic 

influenza induced mass migration. 

Contingency plan activated within 24 hours of notification. 

5.3.4.5. DOT shall issue safety-related waivers as needed, to 

facilitate efficient movement of goods and people 

during an emergency, balancing the need to expedite 

services with safety, and states should consider 

waiving state-specific regulatory requirements, such as 

size and weight limits and convoy registration. 

All regulatory waivers as needed balance need to expedite 

services with safety. 

 

18GAO, 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). 

19Executive Office of the President, President’s Council of Advisors on Science and 

Technology, Report to the President on U.S. Preparations for 2009-H1N1 Influenza 

(Washington, D.C.: Aug. 7, 2009). 

Page 13 GAO-10-73 National Pandemic Plan
 

Action 

item 

number Description Measure of performance 

5.3.5.3. DOT, in coordination with DHS; state, local, and tribal 

governments; and the private sector, shall monitor 

system closures, assess effects on the transportation 

system, and implement contingency plans. 

Timely reports transmitted to DHS and other appropriate 

entities, containing relevant, current, and accurate information 

on the status of the transportation sector and impacts resulting 

from the pandemic; when appropriate, contingency plans 

implemented within no more than 24 hours of a report of a 

transportation sector impact or issue. 

5.3.5.4. DOT, in support of DHS and in coordination with other 

emergency support function (ESF) #1 support 

agencies, shall work closely with the private sector and 

state, local, and tribal entities to restore the 

transportation system, including decontamination and 

reprioritization of essential commodity shipments. 

Backlogs or shortages of essential commodities and goods 

quickly eliminated, returning production and consumption to 

prepandemic levels. 

5.3.1.4. DHS, in coordination with DOS, USDA, and the 

Department of the Interior (DOI), shall provide countries 

with guidance to increase scrutiny of cargo and other 

imported items through existing programs, such as the 

Container Security Initiative, and impose country-based 

restrictions or item-specific embargoes. 

Guidance, which may include information on restrictions, is 

provided for increased scrutiny of cargo and other imported 

items, within 24 hours upon notification of an outbreak. 

5.3.2.3. DHS, in coordination with USDA, DOS, DOC, DOI, and 

shippers, shall rapidly implement and enforce cargo 

restrictions for export or import of potentially 

contaminated cargo, including embargo of live birds, 

and notify international partners/shippers. 

Measures implemented within 6 hours of decision to do so. 

7.3.1.2. USDA shall coordinate with DHS and other federal, 

state, local, and tribal officials, animal industry, and 

other affected stakeholders during an outbreak in 

commercial or other domestic birds and animals to 

apply and enforce appropriate movement controls on 

animals and animal products to limit or prevent spread 

of influenza virus. 

Initial movement controls in place within 24 hours of detection 

of an outbreak. 

7.3.2.1. USDA shall activate plans to distribute veterinary 

medical countermeasures and materiel from the 

National Veterinary Stockpile (NVS) to federal, state, 

local, and tribal influenza outbreak responders within 24 

hours of confirmation of an outbreak in animals of 

influenza with human pandemic potential, within 9 

months. 

NVS materiel distributed within 24 hours of confirmation of an 

outbreak. 

Source: HSC. 

Note: Data are from the HSC’s 2-year progress report. 

As of late May 2009, an official from only one of the four selected agencies 

responsible for the 10 response-related action items in our sample, the 

Deputy Associate Director for Security Policy at DOT, stated that the 2009 

H1N1 outbreak had triggered an action item from this group (5.3.5.3) for 

which the agency was responsible. For the remaining nine action items, 

officials from all four agencies noted that none of the action items for 

Page 14 GAO-10-73 National Pandemic Plan
 

which their agency had responsibility were relevant to the H1N1 outbreak 

at that time. 

The Plan states that the operational details on how to carry out actions in 

support of the Strategy will be included in departmental pandemic plans.20

Federal agencies may have operational plans or other existing guidance 

that would specify the information needed to determine whether to 

undertake the response-related action items during a pandemic. However, 

the Plan itself gives no indication of whether these plans or guidance 

actually contain such information, or whether the information that would 

be needed has been determined in advance. 

The HSC reported in October 2008 that about 75 percent of the 324 action 

items in the Plan were designated as complete based on its criteria of 

whether the measures of performance were achieved.21 Among the 60 

action items in our sample, 49 had been designated as complete, 3 

designated as in-progress, and 8 had no reported status.22 For a number of 

reasons, as stated in the following sections, it was difficult to determine 

the actual status of some of the 49 selected action items that were 

designated complete. 

Status of Some 

Selected Action Items 

Considered Complete 

Was Difficult to 

Determine 

Measures of Performance 

Used to Determine Status 

Do Not Always Fully 

Reflect the Descriptions of 

the Action Items 

As discussed earlier, according to the HSC’s progress reports, a 

determination that an action item is complete is based on whether the 

action item’s measure of performance is achieved. Our review found, 

however, that for more than half of the action items considered complete, 

the measures of performance did not fully address all the activities 

contained in their descriptions. In some instances, the HSC used 

information other than the measures of performance to report progress. 

 

20HSC, Implementation Plan for the National Strategy for Pandemic Influenza, 

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

21As of October 2008, the HSC reported that of the 324 action items, 245 were complete, 21 

were in progress, and 58 had no status reported. Of the 58 action items that had no status 

reported, 34 had measures of performance and time frames associated with a pandemic or 

animal outbreak in the United States, 17 were intended for nonfederal entities, 3 were 

directed to the federal government or to agencies and nonfederal entities, 2 had deadlines 

beyond the 2-year reporting time frame, and the remaining 2—action items 5.2.4.10. and 

6.1.6.3.— were not included in the report. 

22Action items with no reported status were either response-related or had time frames 

greater than 24 months. 

Page 15 GAO-10-73 National Pandemic Plan
 

All of the 49 action items designated as complete that we reviewed have 

both a description of activities to be carried out, and a measure of 

performance, which generally is used as an indicator to measure progress 

of completion by responsible parties in carrying out what is specified in its 

respective description. We found that the types of performance measures 

for selected action items varied widely. For instance, measures of 

performance may call for processes to be developed and implemented, 

changes to be effected in foreign countries, or products such as guidance 

or a vaccine to be developed. 

As we reported in 2007, most of the Plan’s measures of performance for 

action items are focused on activities, such as disseminating guidance, and 

are not always clearly linked to the goals and objectives described in the 

Strategy and Plan. In these cases, it is difficult to determine whether the 

goals and objectives have been achieved.23 We found that the selected 

action items’ measures of performance addressed the descriptions of their 

respective action items to varying degrees.24 Examples can be seen in 

table 2. 

 

23GAO-07-781. 

24For this analysis, we reviewed the action item’s measure of performance relative to the 

respective description as written in the Plan, and therefore we could not determine the 

intent of the measure or of the description. 

Page 16 GAO-10-73 National Pandemic Plan
 

Table 2: Examples of Selected Action Items Where Measures of Performance Fully or Partially Addressed the Plan’s 

Respective Descriptions 

Action item 

number Plan’s description Plan’s measure of performance 

GAO analysis of relationship 

between Plan’s description and 

measure of performance 

4.2.3.9. DOD, in coordination with HHS, shall prioritize 

international DOD laboratory research efforts 

to develop, refine, and validate diagnostic 

methods to rapidly identify pathogens, within 

18 months. 

Completion of prioritized research 

plan, resources identified, and 

tasks assigned across DOD 

medical research facilities. 

Fully addressed—measure of 

performance includes all 

components specified in its 

respective description. 

6.1.13.6. DOT, in coordination with HHS; DHS; state, 

local, and tribal officials; and other EMS 

stakeholders, shall develop suggested EMS 

pandemic influenza guidelines for statewide 

adoption that address: clinical standards, 

education, treatment protocols, 

decontamination procedures, medical 

direction, scope of practice, legal parameters, 

and other issues, within 12 months. 

EMS pandemic influenza 

guidelines completed. 

Fully addressed—measure of 

performance includes all 

components specified in its 

respective description. 

5.1.1.5. DOD, in coordination with DHS, DOT, the 

Department of Justice (DOJ), and DOS, shall 

conduct an assessment of military support 

related to transportation and borders that may 

be requested during a pandemic and develop a 

comprehensive contingency plan for Defense 

Support to Civil Authorities, within 18 months. 

Defense Support to Civil 

Authorities plan in place that 

addresses emergency 

transportation and border support.

Partially addressed—measure of 

performance excludes a reference 

to an assessment of military 

support related to transportation 

and borders, as specified in its 

respective description. 

9.1.2.2. a DHS, in coordination with states, localities, and 

tribal entities, shall support private sector 

preparedness with education, exercise, 

training, and information-sharing outreach 

programs, within 6 months. 

Preparedness exercises 

established with private sector 

partners in all states and U.S. 

territories. 

Partially addressed—measure of 

performance excludes a reference 

to education, training, and 

information-sharing outreach 

programs for private sector 

preparedness, as specified in its 

respective description. 

Source: GAO analysis of HSC data. 

Data are from the Implementation Plan for the National Strategy for Pandemic Influenza. 

Notes: “Fully addressed” means that the measure of performance contained all of the activities 

specified in the respective description. “Partially addressed” means that the measure of performance 

contained some of the activities specified in the respective description. “Did not address” means that 

the measure of performance did not contain any of the activities specified in the respective 

description. 

a

For action item 9.1.2.2., although the measure of performance partially addressed the respective 

description, the HSC’s 2-year progress summary addressed all of the components identified in the 

description. However, the progress summary did not fully address the measure of performance as it 

excluded a reference to whether the preparedness exercises were established with private sector 

partners in all states and U.S. territories. 

All of the 49 selected action items’ measures of performance either fully or 

partially addressed their respective descriptions. In 23 of the 49 selected 

action items that were designated as complete in the HSC’s 2-year 

progress report, we found that the measures of performance fully 

Page 17 GAO-10-73 National Pandemic Plan
 

addressed the respective descriptions for the action items. For the 

remaining 26 action items, the measures of performance partially 

addressed their respective descriptions. For example, as noted in table 2, 

the description for one of the action items calls for DOD to conduct an 

assessment of military support related to transportation and borders that 

could be requested during a pandemic. While the measure of performance 

did not include this activity, the HSC nevertheless designated the action 

item as complete. 

Our review also found that for 22 of the 49 selected action items 

designated as complete in the HSC’s 2-year progress report, the progress 

summaries fully addressed how the measures of performance were 

achieved, thereby supporting the HSC’s designation of complete for these 

action items. However, for the other 27 selected action items designated as 

complete, the progress summaries did not fully address how the measures 

of performance were achieved. 25 Specifically, in 18 of the 27 selected 

action items, the HSC’s summaries addressed some but not all of the 

activities specified in the respective measures of performance, and for the 

remaining 9 action items, the summaries did not address at all how the 

measures of performance were achieved.26 In these instances, we found 

that the HSC either used the action item’s description, or used information 

that was not reflected in either the description or measure of performance, 

to assess completion. Table 3 below includes two examples where the 

HSC summaries partially addressed or did not address the action item’s 

measure of performance. 

 

25For this analysis, we reviewed the summaries of the status of selected action items in the 

HSC’s 2-year progress report and the action item’s measure of performance in the Plan as 

written. 

26For these nine action items, we analyzed the HSC’s summaries from its 2-year progress 

report to determine whether the HSC used the action item’s descriptions to make its 

determination that they were complete. Our analysis found that the HSC’s summaries from 

its 2-year progress report fully or partially addressed five of the respective action item’s 

descriptions and did not address the four remaining action items’ descriptions. In these 

four cases, it is unclear on what basis the HSC made its determination since the summaries 

did not address either the respective measures of performance or their descriptions. 

Page 18 GAO-10-73 National Pandemic Plan
 

Table 3: Examples of Selected Action Items Where the HSC’s 2-Year Progress Report Summaries Partially Addressed or Did 

Not Address the Plan’s Respective Measures of Performance 

Action item 

number Plan’s description 

Plan’s measure of 

performance 

Summaries of status of 

action items in the HSC’s 

2-year progress report 

(as of October 2008) 

GAO analysis of 

relationship between

the HSC’s summary 

and Plan’s measure 

of performance 

4.2.3.10. DOD shall work with priority 

nations’ military forces to assess 

existing laboratory capacity, rapid 

response teams, and portable 

field assay testing equipment, 

and fund essential commodities 

and training necessary to achieve 

an effective national military 

diagnostic capability, within 18 

months. 

Assessments 

completed, proposals 

accepted, and funding 

made available to 

priority countries. 

The Department of Defense 

performed assessments in all 

priority countries with the 

exception of those where the 

nations’ Ministry of Defense, 

Ministry of Health, or political 

limitations would not allow. DOD 

has worked with and conducted 

training with other nations to 

enhance their lab capability. 

Combatant commands have 

worked with our partners to 

develop and improve infection 

control programs and develop 

training and exercise programs. 

In addition, the military 

laboratories assist regional 

partner nations with testing and 

diagnosis. 

Partially addressed—

The HSC’s summary 

partially addressed the 

measure of 

performance for this 

action item as it did not 

explicitly state that 

proposals were 

accepted, and funding 

was made available to 

priority countries. 

8.1.1.2. DHS, in coordination with DOJ, 

HHS, the Department of Labor 

(DOL), and DOD, shall develop a 

pandemic influenza tabletop 

exercise for state, local, and tribal 

law enforcement / public safety 

officials that they can conduct in 

concert with public health and 

medical partners, and ensure it is 

distributed nationwide within 4 

months. 

Percent of state, local, 

and tribal law 

enforcement / public 

safety agencies that 

have received the 

pandemic influenza 

tabletop exercise. 

A tabletop exercise template has 

been developed for use by public 

health authorities. DHS is 

continuing to work with federal 

partners to develop pandemic 

influenza tabletop exercises for 

state, local, and tribal law 

enforcement / public safety 

officials that can be conducted in 

concert with medical and public 

health entities. 

Did not address—The 

HSC’s summary did 

not address how the 

measure of 

performance was 

achieved because it 

did not include 

information on the 

percentage of various 

law enforcement and 

public safety agencies 

that received the 

tabletop exercises. 

Source: GAO analysis of HSC data. 

Data are from the Implementation Plan for the National Strategy for Pandemic Influenza and HSC’s 

Two-Year Progress Report. 

Notes: “Fully addressed” means that the HSC’s progress summary contained all of the activities 

specified in the action item’s measure of performance. “Partially addressed” means that the HSC’s 

progress summary contained some of the activities specified in the action item’s measure of 

performance. “Did not address” means that the HSC’s progress summary did not contain any of the 

activities specified in action item’s measure of performance. 

Page 19 GAO-10-73 National Pandemic Plan
 

Of the 49 selected action items designated as complete, 11 have measures 

of performance that cannot be accomplished solely by responsible entities 

tasked to work on these action items. Five of these require other 

countries’ assistance while the remaining six require nondesignated 

entities’ participation in order for the action items to be completed. For 

these 11 action items, the responsible federal agencies are not able to 

achieve the measures of performance for these action items on their own, 

but can provide assistance, such as funding and guidance, to encourage 

completion of these action items by others. For example, one of the action 

items below calls for DOS to promote, among other things, rapid reporting 

of influenza cases by other nations; the measure of performance is that all 

high-risk countries improve their capacity for rapid reporting.27 Even 

though this outcome is beyond DOS’s ability to achieve on its own, the 

action item was considered complete, and no explanation was provided. 

Some Selected Action 

Items Were Designated as 

Complete Despite 

Requiring Actions outside 

the Authority of the 

Responsible Entities 

Some examples of the measures of performance that cannot be entirely 

fulfilled by the agencies and organizations in the United States include the 

following: 

• DOS, in coordination with other agencies, shall work on a continuing 

basis through the Partnership and through bilateral and multilateral 

diplomatic contacts to promote transparency, scientific cooperation, 

and rapid reporting of avian and human influenza cases by other 

nations within 12 months. Measure of performance: All high-risk 

countries actively cooperating in improving capacity for transparent, 

rapid reporting of outbreaks.28

• USDA shall provide technical assistance to priority countries to 

increase safety of animal products by identifying potentially 

contaminated animal products, developing screening protocols, 

regulations, and enforcement capacities that conform to the World 

Organisation for Animal Health (OIE) avian influenza standards for 

transboundary movement of animal products, within 36 months. 

Measure of performance: All priority countries have protocols and 

regulations in place or in process.29

 

27Action item 4.2.1.1. 

28Action item 4.2.1.1. 

29Action item 4.2.7.2. 

Page 20 GAO-10-73 National Pandemic Plan
 

We previously reported in June 2007 that DOS officials confirmed that the 

following action item, which was designated as complete in the HSC’s 2-

year progress report, had a measure of performance that was difficult to 

address because the agency did not have the means to accurately estimate 

the effective reach or impact of their efforts on target audiences.30 As a 

result, this action item could only be achieved with the participation from 

nondesignated entities. 

• DOS, in coordination with HHS, the United States Agency for 

International Development (USAID), USDA, DOD, and DHS, shall lead 

an interagency public diplomacy group to develop a coordinated, 

integrated, and prioritized plan to communicate U.S. foreign policy 

objectives relating to our international engagement on avian and 

pandemic influenza to key stakeholders (e.g., the American people, the 

foreign public, nongovernmental organizations, international 

businesses), within 3 months. Measure of performance: Number and 

range of target audiences reached with core public affairs and public 

diplomacy messages, and impact of these messages on public 

responses to avian and pandemic influenza.31

Additional Work Was 

Conducted on Some 

Selected Action Items 

Designated as Complete 

We found that work has continued on some of the selected action items 

the HSC designated as complete, including providing additional guidance, 

training and exercises. In some instances, continued efforts may be 

warranted—for example, when new information or circumstances might 

require an update of guidance. In addition, according to the HSC’s 

progress reports, a determination of “complete” indicates that the measure 

of performance has been achieved but does not necessarily mean that 

work on the action items has ended; the work is ongoing in many cases. 

Our analysis of the 1-year and 2-year progress reports confirmed that there 

was additional work conducted for 20 of the 34 selected action items 

initially designated complete as of the 1-year report.32 For example, one of 

 

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). 

31Action item 4.3.6.1. 

32Our sample included 49 action items designated as complete as of the HSC’s 2-year report. 

However, we only reviewed the 34 of 49 action items designated as complete as of the 

HSC’s 1-year report. The remaining 15 of the 49 action items were not reviewed as they had 

time frames beyond 12 months. 

Page 21 GAO-10-73 National Pandemic Plan
 

the action items called for national spokespersons to coordinate and 

communicate messages to the public.33 The HSC’s 1-year report stated that 

for this action item, which was designated as complete, the federal 

government had engaged various spokespersons by providing training for 

risk communications and supporting community and individual actions to 

reduce illness and death. In the HSC’s 2-year report, the HSC provided new 

information on an influenza pandemic communications plan, which 

included messaging and spokesperson development components and 

numerous regional and local crisis and emergency risk communications 

trainings. In another example, an action item required all hospitals and 

health facilities funded by HHS, DOD, and the Department of Veterans 

Affairs (VA) to develop and publicly disseminate guidance materials on 

infection control.34 In its 1-year report, the HSC provided information on 

guidance documents issued by HHS on hospital infection control and VA’s 

national infection prevention campaign, whereas in its 2-year report, the 

HSC reported on new information related to two DOD guidance 

documents on preparation and response health policy and clinical and 

public health guidelines for the military health system. 

In addition to the supplementary information provided in the HSC’s 2-year 

progress report, the selected agencies informed us that they had 

conducted additional work for 27 of the 49 selected action items that had 

earlier been designated as complete, which included providing additional 

guidance, training, and exercises for an influenza pandemic.35 For 

example, the selected agencies that had primary responsibility for three 

different action items reported that they were continuing to either provide

funding or conduct additional influenza pandemic exercises with states 

and local governments and the private sector to help them better prepa

for an outbreak.

re 

 

36 Officials from HHS also informed us that they were 

conducting additional training to help improve surveillance and laboratory 

diagnostics in priority countries.37 Further, USDA officials stated that they

continued to provide guidance and training materials to countries in the 

33Action item 6.1.3.3. 

34Action item 6.3.2.5. 

35Fifteen of these 27 action items were designated complete as of the HSC’s 1-year report 

and also contained new information that was not highlighted in the HSC’s 2-year report. 

36Action items 6.1.1.3., 7.3.2.1., and 9.1.2.2. 

37Action items 4.2.2.4., 4.2.3.1., and 4.2.3.5. 

Page 22 GAO-10-73 National Pandemic Plan
 

implementation of a national animal vaccination program.38 An official 

from the Food and Agriculture Organization (FAO) also confirmed that 

additional work had continued for this action item in conjunction with the 

World Organisation for Animal Health (OIE) in developing joint strategies 

for highly pathogenic avian influenza. 

In 2007, we recommended that the HSC establish a specific process and 

time frame for updating the Plan to include a number of features we 

identified as important elements of a national strategy, including a process 

for monitoring and reporting on progress. While the Plan’s assumptions 

are not matched to the 2009 H1N1 pandemic, making some of the action 

items less relevant to current circumstances, the process for monitoring 

and reporting on the status of pandemic plans is not particular to any one 

type of pandemic scenario. The lessons learned from developing and 

monitoring the 2006 Plan should be relevant to all future pandemic 

planning efforts. 

Conclusions 

In particular, although the HSC, which is supported by the NSS, has 

monitored progress on the Plan, it has not yet established a process for 

updating the Plan, as previously reported, and we have found additional 

areas for improvement in how the Plan has been monitored and the status 

of action items assessed. For one thing, the NSS and the responsible 

federal agencies have not been monitoring or reporting on action items in 

the Plan intended for state and local governments and other nonfederal 

entities, even though, in some instances, they have information available 

that would allow them to do so, such as the interagency assessment of 

state pandemic plans led by HHS. Given that the Plan states that in a 

pandemic the primary response will come from states and communities, 

this information should be in the progress reports, notwithstanding that it 

may be available in other sources. Similarly, while agency operational 

plans or guidance may provide the information under which the responserelated action items would be undertaken, the Plan itself contains no such 

information. As a result, it is unclear whether the information that would 

be needed to activate the response-related action items in the Plan has 

been identified or worked out in advance. 

 

38Action item 4.1.7.3. 

Page 23 GAO-10-73 National Pandemic Plan
 

The HSC designated about 75 percent of the action items in the Plan as 

completed, as of October 2008. However, based on our review of 49 of the 

245 action items designated as complete, it is difficult to determine the 

actual status of some of the selected action items designated as complete. 

The HSC and the responsible federal agencies generally relied on the 

measures of performance to assess progress in completing the selected 

action items. However, for more than half of the selected action items, we 

found that the measures of performance did not fully reflect all of the 

activities called for in the action items’ descriptions. While the HSC’s 

progress summaries sometimes corrected for this by referring to activities 

in the action item’s description omitted from the measures of 

performance, future progress reports would benefit from using measures 

of performance that are more consistent with the action items’ 

descriptions. This would, in turn, provide a more consistent and complete 

basis for describing progress in implementing the Plan. 

Finally, although the administration has prepared an additional planning 

document tailored specifically to the 2009 H1N1 pandemic, the Strategy 

and Plan will still be needed for future events. Because most of the action 

items were to be completed by May 2009, the Plan should be updated, as 

we earlier recommended, to include all the elements identified in our 2007 

report and to take into account the lessons learned from the 2009 H1N1 

pandemic. As part of the process for monitoring the progress made in 

preparing the nation for an influenza pandemic, the Plan should address 

the monitoring and assessment improvements we identified in this report. 

To improve how progress is monitored and completion is assessed under 

the Plan and in future updates of the Plan, the HSC should instruct the 

NSS to work with responsible federal agencies to 

• develop a monitoring and reporting process for action items that are 

intended for nonfederal entities, such as state and local governments; 

• identify the types of information needed to decide whether to carry out 

the response-related action items; and 

• develop measures of performance that are more consistent with the 

descriptions of the action items. 

We provided a draft of this report to the Homeland Security Council 

(HSC), and to the Secretaries of Agriculture, Defense, Health and Human 

Services, Homeland Security, State, and Transportation for their review 

and comment. 

Recommendations for 

Executive Action 

Agency Comments 

and Our Evaluation 

Page 24 GAO-10-73 National Pandemic Plan
 

In written comments on our draft report, the Principal Deputy Counsel to 

the President, on behalf of the administration, stated that our report is one 

notable source of suggestions for improving national pandemic planning, 

and that the administration would give consideration to our findings and 

recommendations as it continues its work in this area. The HSC also 

provided us with technical comments, which we incorporated as 

appropriate. 

HHS noted in its comments that important questions and analysis that 

underpin our findings and recommendations were not presented or 

addressed in this report, including whether (1) the original Plan was 

adequate, (2) the priorities selected were appropriate, (3) the measures 

selected for monitoring progress were appropriate, and (4) the monitoring 

parameters selected were measurable or even achievable. We agree that 

these are important questions. However, the objectives of this report were 

to (1) determine how the HSC and responsible federal agencies monitor 

the progress and completion of the Plan’s action items and (2) assess the 

extent to which selected action items have been completed. As such, we 

believe that we have in fact addressed the issues raised by HHS in this 

report in our examination of action items and related measures of 

performance, as well as in our prior recommendation that has not yet been 

implemented to incorporate into future updates of the Plan the lessons 

learned from exercises and other events, such as the H1N1 pandemic. 

HHS also provided two other general comments. First, regarding our 

discussion related to the lack of details in the Plan on the information that 

would be used to activate the response-related action items, HHS stated 

that it would be inappropriate to set specific trigger points to activate 

specific responses because an influenza virus has an infinite range of 

potential characteristics, which are not predictable, and that flexibility is 

necessary. HHS further stated that it would be more appropriate to 

discuss the “types” of circumstances and responses that should be planned 

for. We agree that flexibility is necessary to assess the specific 

circumstances under which to implement the response-related action 

items in the Plan, given the changing nature of an influenza virus. We agree 

with HHS that the Plan should discuss the types of circumstances that 

should be planned for in a pandemic. We have made changes to the report 

to clarify this point. 

Second, with respect to our discussion of additional work conducted on 

selected action items designated as complete, HHS noted that 

preparedness is a continuous and iterative improvement process based on 

lessons learned, and that ongoing training and exercises should be 

iterative and adapt to lessons learned. We agree. As we noted in this 

Page 25 GAO-10-73 National Pandemic Plan
 

report, in some instances, continued efforts on action items may be 

warranted—for example, when new information or circumstances might 

require an update of guidance. Our concern, however, is that it is unclear 

what additional work or progress had been made on these action items, 

since the HSC had designated them as complete. 

DHS stated that the information in our report is generally accurate and 

had no substantive comments on the content of the report. DHS further 

stated that while improvements can be made in the Plan as we outlined in 

our report, there has been significant work accomplished in pandemic 

preparedness as a direct result of the Plan. For example, DHS noted that 

significant collaboration at all levels of government and the private sector 

has occurred, which enabled a more efficient and coordinated response 

for the 2009 H1N1 pandemic. 

DOT provided us with technical comments, which we incorporated. DOD, 

DOS, and USDA informed us that they did not have any comments on the 

draft report. The White House, HHS, and DHS provided written comments 

on a draft of this report, which are reprinted in appendixes III, IV, and V, 

respectively. 

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 the HSC, Secretary of 

Agriculture, Secretary of Defense, Secretary of Health and Human 

Services, Secretary of Homeland Security, Secretary of State, Secretary of 

Transportation, and other interested parties. In addition, this report will be 

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. Contact points for 

our Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made major contributions to 

this report are listed in appendix VI. 

Sincerely yours, 

Bernice Steinhardt 

Director, Strategic Issues 

Page 26 GAO-10-73 National Pandemic Plan
Appendix I: Objectives, Scope, and 

Methodology 

Page 27 GAO-10-73 

Appendix I: Objectives, Scope, and 

Methodology 

The objectives of this study were to (1) determine how the Homeland 

Security Council (HSC) and the responsible federal agencies are 

monitoring the progress and completion of the Implementation Plan for 

y for Pandemic Influenza (Plan) action items, and (2) 

 selected action items have been completed, 

action items reported as 

complete, and the nature of that work. We did not assess the response 

efforts for the 2009 H1N1 pandemic in this report, but we continue to 

monitor the outbreak and the federal government’s response. 

To address these objectives, we conducted an in-depth analysis of a 

random sample of 60 action items in the Plan. We drew a random sample 

from the 286 action items involving six federal agencies with primary 

responsibility for ensuring completion of the large majority (88 percent) of 

the 324 action items.1

 These six agencies are the Department of Defense 

(DOD), Department of Health and Human Services (HHS), Department of 

Homeland Security (DHS), Department of State (DOS), Department of 

Transportation (DOT), and the Department of Agriculture (USDA). Of the 

60 action items selected for our sample, the HSC reported that 49 were 

completed, 3 were in progress, and 8 had no status updates in its 2-year 

progress report. The purpose of this random sampling was not to be able 

to generalize our findings to the entire population of 286; rather, it was to 

produce a sample that had a distribution of items generally mirroring that 

of the overall population of 286 using the following variables so that the 

sample would include action items that represented (1) the six agencies 

with primary responsibility for implementing the Plan, (2) the three pillars 

in the Plan,2

 (3) the presence of collaboration between federal agencies 

and nonfederal entities (i.e. state, local, and tribal entities, the private 

sector, international organizations, and nongovernmental organizations), 

and (4) various time frames of when they should be completed, which 

range from within 24 hours of an outbreak to 60 months from the release 

of the Plan in May 2006, among other time frames. We do not generalize 

the results of our analysis because the particular analytical steps we took 

across the selected action items varied and as a result there was no 

 

the National Strateg

assess the extent to which

whether activity has continued on the selected 

1

The Plan includes a total of 324 action items. As noted, we drew a random sample using 

286 of the 324 action items. 

2

As noted earlier, the National Strategy for Pandemic Influenza has three high-level goals, 

which are underpinned by three pillars that are intended to guide the federal government’s 

approach to a pandemic threat, including: (1) preparedness and communication, (2) 

surveillance and detection, and (3) response and containment. 

 National Pandemic Plan 
Appendix I: Objectives, Scope, and 

Methodology 

Page 28 GAO-10-73 National Pandemic Plan

common underlying measure on which to generalize results to all of th

action items in the Plan. In addition, we did not review all of the a

items in the Plan in depth because our analyses involved multiple 

assessments for each action item, including the review of large volumes of 

agency documentation in determining the level of evidence for completi

of the action item.3

For both objectives, we interviewed officials and obtained documentat

from the six federal agencies. We reviewed the HSC’s 6-month

e 

ction 

on 

ion 

, 1-year, and 

2-year progress reports and the HSC’s 1-year summary report on the 

iewed 

aff 

n 

h 

y 

 

implementation of the action items in the Plan. In addition, we interv

a senior HSC official from the previous administration and the Director of

Medical Preparedness Policy for the White House National Security St

(NSS) in the current administration responsible for overseeing the 

implementation of the Plan. 4

 We also relied on our prior pandemic work 

to inform our analysis. 

To address the first objective on how the HSC and responsible federal 

agencies are monitoring the progress and completion of the Plan’s actio

items, we assessed information from interviews and documentation, suc

as the HSC’s progress reports, on how the HSC and the selected agencies 

monitored the progress and completion of all action items. We also 

requested information from the six agencies on how the NSS is currently 

overseeing the interagency process used for monitoring the 

implementation of action items in the Plan. We also interviewed 

representatives from nine nonfederal entities, such as the World 

Organisation for Animal Health (OIE) and the Denver Health Medical 

Center, which agency officials had identified as working collaborativel

with them on four action items in our sample, and asked these 

representatives whether the agencies asked for information on the 

progress of implementing these action items. In addition, we reviewed the

 

3

In addition, we randomly sampled 11 action items from our sample of 60 that called for 

joint collaboration with nonfederal entities. We interviewed nonfederal entities that federal 

agencies told us they had worked with for 4 of the 11 action items. However, we only 

report this information anecdotally in the report. Additionally, we did not request 

completion of the action item with the nonfederal entities. 

 that 

 

documentation attesting to the presence of collaboration with the federal agencies with 

primary responsibility or the 

4

As noted earlier in the report, on May 26, 2009, the President announced the full 

integration of White House staff supporting national security and homeland security. The 

HSC will be maintained as the principal venue for interagency deliberations on issues

affect the security of the homeland, such as influenza pandemic.
Appendix I: Objectives, Scope, and 

Methodology 

Plan and the HSC’s 2-year progress report to identify specific 

circumstances that would trigger the response-related action items that 

are activated by an animal outbreak or pandemic. We also collecte

information from the four selected agencies that had primary 

responsibility for the 10 response-related action items in our sample 

regarding criteria th

d 

at would trigger these action items.5

s 

f the 49 action items to demonstrate how the 

measures of performance were achieved based on the HSC’s criteria for 

e measures of 

y 

 

To address the second objective, we analyzed the 49 action items in our 

random sample that the HSC’s 2-year progress report designated as 

complete. We also collected documentation and conducted interview

with selected agency officials from the six agencies and a senior HSC 

official from the prior administration. To describe the extent to which 

action items had been completed, we analyzed information on the 49 

selected action items in the Plan, the HSC progress reports, and 

supporting documentation provided by the six agencies with primary 

responsibility for each o

completion. Specifically, we analyzed the 49 selected action items 

designated as complete to assess whether 

1. the measures of performance fully addressed, partially addressed, or 

did not address their respective action item description;6

2. the summaries contained in the HSC’s 2-year progress report fully 

addressed, partially addressed, or did not address how th

performance were achieved;7

 and 

3. the measures of performance could be accomplished solely b

responsible entities that are tasked to work on the action items.8

 

report, 4 action items were designated as complete because the agencies with primary 

responsibility had previously responded to animal outbreaks in other countries and within 

the United States. 

Did 

tivities 

“Fully addressed” means that the HSC’s progress summary contained all of the activities 

s that the 

 of performance. 

5

Of the 10 response-related action items, the HSC designated 4 as complete and 6 had no 

status reported. As stated earlier in the report, according to the HSC’s 2-year progress 

6

“Fully addressed” means that the measure of performance contained all of the activities 

specified in the respective description. “Partially addressed” means that the measure of 

performance contained some of the activities specified in the respective description. “

not address” means that the measure of performance did not contain any of the ac

specified in the respective description. 

7

specified in the action item’s measure of performance. “Partially addressed” mean

HSC’s progress summary contained some of the activities specified in the action item’s 

measure of performance. “Did not address” means that the HSC’s progress summary did 

not contain any of the activities specified in action item’s measure

Page 29 GAO-10-73 National Pandemic Plan
Appendix I: Objectives, Scope, and 

Methodology 

To evaluate the extent of work that has continued on the 49 ac

in our sample that were designated as complete, and the nature of that 

work, we gathered information in two ways. First, we compared the H

1-year and 2-year progress reports for 34 selected action items

designated as complete as of the 1-year report by analyzing each actio

item’s summary in the HSC’s 1- and 2-year progress repor

tion items 

SC’s 

 initially 

n 

ts for any new 

information on work conducted. Second, we asked the six agencies with 

ription 

ork 

ork. 

GAO 

ed 

 and Methods team conducted 

an independent analysis and verification of our assessment by reviewing 

n 

s of 

liation was conducted for a final 

We conducted this performance audit from July 2008 to November 2009 in 

accordance with generally accepted government auditing standards. Those 

e plan and perform the audit to obtain sufficient, 

dit objectives. 

primary responsibility if they had performed additional work after action

items were designated as complete and, if so, to provide a brief desc

of the nature of that work. For 27 of the 49 action items designated as 

complete, the agencies indicated that they had performed additional w

after the action items were designated as complete. For 22 of those 27 

action items, the agencies also specified the nature of the additional w

To ensure consistency and accuracy of our analysis, at least two 

analysts independently analyzed the data we received for the 49 select

action items in our sample designated as complete and then compared

their results. In cases where there were discrepancies, the two analysts 

reconciled their differences for a final response. Additionally, 

methodologists in GAO’s Applied Research

whether the measures of performance addressed its respective descriptio

and whether the HSC summaries addressed how the measure

performance were achieved for all 49 action items designated as complete. 

In cases where there were discrepancies between the analysts’ and 

methodologists’ teams, a joint reconci

response. 

standards require that w

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 au

 

tive 

8

We conducted this analysis by reviewing whether the responsible entities, such as federal 

agencies, tasked to the 49 action items designated as complete could achieve the respec

measures of performance without the assistance of nondesignated entities, such as other 

countries. 

Page 30 GAO-10-73 National Pandemic Plan
Appendix II: Sample of 60 Selected Action 

Items in the Implementation Plan for the 

National Strategy for Pandemic Influenza 

Page 31 GAO-10-73 National Pandemic Plan 

Action item 

number Actions and expectations Measure of performance 

4.1.2.1. The Department of State (

engagement in and followbuild cooperation and cap

internationally, including th

initiatives (inventory of res

pandemic influenza, a regi

Emerging Infectious Disea

Regional Emerging Diseas

the U.S.-China Joint Initiat

Indonesia-Singapore Joint

should develop a strategy 

cooperating with U.S. and

against pandemic influenz

 to 

ey 

DOS) shall ensure strong U.S. government 

up on bilateral and multilateral initiatives to 

acity to fight pandemic influenza 

e Asia-Pacific Economic Cooperation 

ources and regional expertise to fight 

onwide tabletop exercise, a Symposium on 

ses to be held in Beijing in April 2006 and the 

e Intervention (REDI) Center in Singapore), 

ive on Avian Influenza, and the U.S.-

 Avian Influenza Demonstration Project; and 

to expand the number of countries fully 

/or international technical agencies in the fight 

a, within 6 months. 

Finalized action plans that outline goals

be achieved and timeframes in which th

will be achieved. 

4.1.2.2. The Department of Health

REDI Center in Singapore

 and Human Services (HHS) shall staff the 

 within 3 months. 

U.S. government staff provided to REDI 

Center. 

4.1.2.3. The United States Departm

United States Agency for I

Partnership, shall support 

and the World Organisatio

instrument to assess priori

prevention, surveillance, a

veterinary rapid response 

animal surveillance, diagn

countries, within 9 months

unicated to 

a. 

ent of Agriculture (USDA), working with the 

nternational Development (USAID) and the 

the Food and Agriculture Organization (FAO) 

n for Animal Health (OIE) to implement an 

ty countries’ veterinary infrastructure for 

nd control of animal influenza and increase 

capacity by supporting national capacities for 

ostics, training, and containment in at-risk 

. 

Per the OIE’s Performance, Vision and 

Strategy Instrument, assessment tools 

exercised and results comm

the Partnership, and priority countries are 

developing, or have in place, an 

infrastructure capable of supporting their 

national prevention and response plans 

for avian or other animal influenz

4.1.4.2. DOS and HHS, in coordina

programs within 3 months

nongovernmental organiza

Defense (DOD) personnel family members residing and 

traveling abroad, where they may obtain accurate, timely information, 

including risk level assess

decisions and take approp

tion with other agencies, shall implement abroad 

 to inform U.S. citizens, including businesses, 

tion (NGO) personnel, the Department of 

, and military 

Majority of registered U.S. citizens

have access to accurate and current 

information on influenza. 

ments, to enable them to make informed 

riate personal measures. 

4.1.4.3. DOS and HHS shall ensur

federal, state, tribal, and lo

diplomatic personnel and f

to develop methods of obt

diplomatic community withi

government treaty obligati

e that adequate guidance is provided to 

cal authorities regarding the inviolability of 

acilities and shall work with such authorities 

aining voluntary cooperation from the foreign 

n the United States consistent with U.S. 

ons within 6 months. 

Briefing materials and an action plan in 

place for engaging with relevant federal, 

state, tribal, and local authorities. 

4.1.5.3. HHS shall provide technic s for 

stockpiling and use of pandemic influenza vaccines within 6 months. 

All priority countries and partner 

organizations have received relevant 

information on influenza vaccines and 

application strategies. 

al expertise, information, and guideline

4.1.7.2. The Department of Justice (DOJ) and DOS, in coordination with HHS, 

shall consider whether the U.S. Government, in order to benefit from the 

protections of the Defense Appropriations Act, should seek to negotiate 

liability-limiting treaties or 

an international stockpile o

countermeasures, within 6

Review initiated and decision rendered. 

arrangements covering U.S. contributions to 

f vaccine and other medical 

 months. 

Appendix II: Sample of 60 Selected Action 

Items in the Implementation Plan for the 

National Strategy for Pandemic Influenza 
Appendix II: Sample of 60 Selected Action 

Items in the Implementation Plan for the 

National Strategy for Pandemic Influenza 

Page 32 GAO-10-73 National Pandemic Plan

Action item 

number Actions and expectations Measure of performance 

4.1.7.3. USDA, in collaboration with FAO and OIE, shall develop and provide uidelines 

best-practice guidelines and technical expertise to countries that 

express interest in obtaining aid in the implementation of a national 

animal vaccination program, within 4 months. 

Interested countries receive g

and other assistance within 3 months of 

their request. 

4.2.1.1. ing 

al 

d 

ely cooperating 

in improving capacity for transparent, 

rapid reporting of outbreaks. 

DOS, in coordination with other agencies, shall work on a continu

basis through the Partnership and through bilateral and multilater

diplomatic contacts to promote transparency, scientific cooperation, an

rapid reporting of avian and human influenza cases by other nations 

within 12 months. 

All high-risk countries activ

4.2.1.5. tariat to 

al 

Expansion of the network to regions not 

currently part of the network. 

HHS shall support the World Health Organization (WHO) Secre

enhance the early detection, identification and reporting of infectious 

disease outbreaks through the WHO’s Influenza Network and Glob

Outbreak and Alert Response Network within 12 months. 

4.2.2.4. iority infectious 

illance, applied 

50 physicians and public health workers 

e surveillance applied 

HHS shall enhance surveillance and response to high pr

disease, including influenza with pandemic potential, by training 

physicians and public health workers in disease surve

epidemiology and outbreak response at its Global Disease Detection 

Response Centers in Thailand and China and at the U.S.-China 

Collaborative Program on Emerging and Re-Emerging Infectious 

Diseases, within 12 months. 

living in priority countries receive training 

in diseas

epidemiology and outbreak response. 

4.2.2.7. 

s 

DOD, in coordination with DOS and with the cooperation of the host ” 

nation, shall assist with influenza surveillance of host nation population

in accordance with existing treaties and international agreements, within 

24 months. 

Medical surveillance “watchboard

expanded to include host nations. 

4.2.3.1. HHS shall develop and implement laboratory diagnostics training 25 laboratory scientists trained in 

programs in basic laboratory techniques related to influenza sample 

preparation and diagnostics in priority countries within 9 months. 

influenza sample preparation and 

diagnostics. 

4.2.3.5. or 

2 months. 

es have 

improved human diagnostic laboratory 

capacity. 

HHS and USAID shall work with the WHO Secretariat and private sect

partners, through existing bilateral agreements, to provide support for 

human health diagnostic laboratories by developing and giving 

assistance in implementing rapid international laboratory diagnostics 

protocols and standards in priority countries, within 1

75 percent of priority countri

4.2.3.9. DOD, in coordination with HHS, shall prioritize international DOD 

laboratory research efforts to develop, refine, and validate diagnostic 

methods to rapidly identify pathogens, within 18 months. 

Completion of prioritized research plan, 

resources identified, and tasks assigned 

across DOD medical research facilities. 

4.2.3.10. g 

ortable field assay 

, 

Assessments completed, proposals 

accepted, and funding made available to 

DOD shall work with priority nations’ military forces to assess existin

laboratory capacity, rapid response teams, and p

testing equipment, and fund essential commodities and training 

necessary to achieve an effective national military diagnostic capability

within 18 months. 

priority countries. 

4.2.5.1. HHS and USAID shall develop, in coordination with the WHO y WHO and other 

Secretariat and other donor countries, rapid response protocols for use

in responding quickly to credible reports of human-to-human 

transmission that may indicate the beginnings of an influenza pandemic, 

within 12 months. 

Adoption of protocols b

stakeholders. 
Appendix II: Sample of 60 Selected Action 

Items in the Implementation Plan for the 

National Strategy for Pandemic Influenza 

Action item 

number Actions and expectations Measure of performance 

4.2.7.2. USDA shall provide technical assistance to priority countries to increas

safety of animal products by identifying potentially contaminated a

products, developing screening protocols, regulations, and enforcem

capacities that conform to OIE avian influenza s

e 

nimal 

ent 

tandards for 

transboundary movement of animal products, within 36 months. 

All priority countries have protocols and 

regulations in place or in process. 

4.3.6.1. 

mmunicate U.S. foreign policy objectives relating to 

rs and public 

diplomacy messages, and impact of these 

messages on public responses to avian 

DOS, in coordination with HHS, USAID, USDA, DOD, and the 

Department of Homeland Security (DHS), shall lead an interagency 

public diplomacy group to develop a coordinated, integrated, and 

prioritized plan to co

our international engagement on avian and pandemic influenza to key 

stakeholders (e.g., the American people, the foreign public, NGOs, 

international businesses),within 3 months. 

Number and range of target audiences

reached with core public affai

and pandemic influenza. 

4.3.6.3. USDA, in coordination with DHS, the United States Trade Within 24 hours of an outbreak, 

Representative (USTR), and DOS, shall ensure that clear and 

coordinated messages are provided to international trading partners 

regarding animal disease outbreak response activities in the United 

States. 

appropriate messages will be shared with

key animal/animal product trading 

partners. 

5.1.1.5. 

pport 

orders that may be requested during a 

e 

Defense Support to Civil Authorities plan 

in place that addresses emergency 

transportation and border support. 

DOD, in coordination with DHS, the Department of Transportation

(DOT), DOJ, and DOS, shall conduct an assessment of military su

related to transportation and b

pandemic and develop a comprehensive contingency plan for Defens

Support to Civil Authorities, within 18 months. 

5.1.4.2. 

onnel Management, and DOS, shall disseminate 

 with 

l 

100 percent of workforce has or has 

access to information on pandemic 

ective 

DHS, in coordination with DOT, the Department of Labor (DOL), the 

Office of Pers

workforce protection information to stakeholders, conduct outreach

stakeholders, and implement a comprehensive program for all Federa

transportation and border staff within 12 months. 

influenza risk and appropriate prot

measures. 

5.2.4.7. DHS, DOT, and HHS, in coordination with transportation and border 

stakeholders, and appropriate state and local health authorities, shall 

develop aviation, land border, and maritime entry and exit protocols 

and/or screening protocols, and education materials for non-medical, 

front-line screeners and officers to identify potentially infected persons

or cargo, within 10 months. 

Protocols and training materials 

developed and disseminated. 

5.2.4.8. DHS and HHS, in coordination with DOT, DOJ, and appropriate State 

and local health authorities, shall develop detection, diagnosis, 

quarantine, isolation, emergency medical services (EMS) transport, 

rts 

ho 

reporting, and enforcement protocols and education materials for 

travelers, and undocumented aliens apprehended at and between po

of entry, who have signs or symptoms of pandemic influenza or w

may have been exposed to influenza, within 10 months. 

Protocols developed and distributed to all 

ports of entry. 

5.2.5.2. on with DHS, the Department of the Interior (DOI), 

and 

USDA, in coordinati Revised process for withdrawing permits 

and HHS, shall review the process for withdrawing permits for 

importation of live avian species or products and identify ways to 

increase timeliness, improve detection of high-risk importers, 

increase outreach to importers and their distributors, within 6 months. 

of high-risk importers. 

5.2.5.3. on with DOI, DHS, shall enhance protocols at air, 

land, and sea ports of entry to identify and contain animals, animal 

products, and/or cargo that may harbor viruses with pandemic potential 

and review procedures to quickly impose restrictions, within 6 months. 

Risk based protocols established and in 

use. 

USDA, in coordinati

Page 33 GAO-10-73 National Pandemic Plan
Appendix II: Sample of 60 Selected Action 

Items in the Implementation Plan for the 

National Strategy for Pandemic Influenza 

Action item 

number Actions and expectations Measure of performance 

5.2.5.6. USDA, DHS, and DOI, in coordination with DOS, HHS, and the 

Department of Commerce (DOC), shall conduct outreach and expand 

education campaigns for the public, agricultural stakeholders, wildlife 

trade community, and cargo and animal importers/exporters on imp

and export regulations and influenza disease risks, within 12 mon

ort 

ths. 

regulations and penalties for noncompliance. 

100 percent of key stakeholders are 

aware of current import and export 

5.3.1.1. DOS and DHS, in coordination with DOT, DOC, HHS, the Depa

the Treasury (Treasury), and USDA, shall work with foreign counterp

to limit or restrict travel from affected regions to the United States, 

appropriate, and notify host government(s) and the traveling public. 

rtment of 

arts 

as 

Measures imposed within 24 hours of the 

decision to do so, after appropriate 

notifications made. 

5.3.1.4. 

tainer Security Initiative, and 

es. 

ude information 

on restrictions, is provided for increased 

scrutiny of cargo and other imported 

cation of 

DHS, in coordination with DOS, USDA and DOI, shall provide countries

with guidance to increase scrutiny of cargo and other imported items

through existing programs, such as the Con

impose country-based restrictions or item-specific embargo

Guidance, which may incl

items, within 24 hours upon notifi

an outbreak. 

5.3.2.3. ll 

of 

ntaminated cargo, including embargo of live birds, and 

urs of 

 do so. 

DHS, in coordination with USDA, DOS, DOC, DOI, and shippers, sha

rapidly implement and enforce cargo restrictions for export or import 

potentially co

notify international partners/shippers. 

Measures implemented within 6 ho

decision to

5.3.4.3. DHS, if needed, will implement contingency plans to maintain border 

control during a period of pandemic influenza induced mass migration. 

Contingency plan activated within 24

hours of notification. 

5.3.4.5. DOT shall issue safety-related waivers as needed, to facilitate efficient All regulatory waivers as needed balance 

movement of goods and people during an emergency, balancing the 

need to expedite services with safety, and states should consider 

waiving state-specific regulatory requirements, such as size and weight 

limits and convoy registration. 

need to expedite services with safety.

5.3.5.3. bal governments, and Timely reports transmitted to DHS and 

ng 

transportation sector and impacts 

resulting from the pandemic; when 

appropriate, contingency plans 

implemented within no more than 24 

r issue. 

DOT, in coordination with DHS, state, local, and tri

the private sector, shall monitor system closures, assess effects on the 

transportation system, and implement contingency plans. 

other appropriate entities, containi

relevant, current, and accurate 

information on the status of the

hours of a report of a transportation 

sector impact o

5.3.5.4. 

f 

Backlogs or shortages of essential 

commodities and goods quickly 

eliminated, returning production and 

consumption to prepandemic levels. 

DOT, in support of DHS and in coordination with other emergency 

support function (ESF) #1 support agencies, shall work closely with the 

private sector and state, local, and tribal entities to restore the 

transportation system, including decontamination and reprioritization o

essential commodity shipments. 

6.1.1.3. DHS, in coordination with HHS, DOJ, DOT, and DOD, shall be prepared

to provide emergency response element training (e.g., incident 

management, triage, security, and communications) and exercise 

assistance upon request of state, local, and tribal communities and 

public health entities within 6 months. 

Percentage of requests for training and 

assistance fulfilled. 

Page 34 GAO-10-73 National Pandemic Plan
Appendix II: Sample of 60 Selected Action 

Items in the Implementation Plan for the 

National Strategy for Pandemic Influenza 

Action item 

number Actions and expectations Measure of performance 

6.1.2.2. HHS, in coordination with DHS, DOD, and the Department of Ve

Affairs (VA), shall develop a joint strategy defining the objectives, 

conditions, and mechanisms for deployment under which the National 

Disaster Medical System assets, U.S. Public Health Service 

Commissioned Corps, Epidemic Intelligence Service officers, and 

terans 

mic. 

DOD/VA health care personnel and public health officers would be 

deployed during a pandemic, within 9 months. 

Interagency strategy completed and 

tested for the deployment of federal

medical personnel during a pande

6.1.3.1. 

blic 

nths. 

y and emergency 

response materials completed and 

HHS, in coordination with DHS, DOS, DOD, VA, and other federal 

partners, shall develop, test, and implement a federal government pu

health emergency communications plan (describing the government’s 

strategy for responding to a pandemic, outlining U.S. international 

commitments and intentions, and reviewing containment measures that 

the government believes will be effective as well as those it regards as 

likely to be ineffective, excessively costly, or harmful) within 6 mo

Containment strateg

published on www.pandemicflu.gov; 

communications plan implemented. 

6.1.3.3. HHS, in coordination with DHS, DOD, and the VA, and in collaboration 

with state, local, and tribal health agencies and the academic 

community, shall select and retain opinion leaders and medical experts 

to serve as credible spokespersons to coordinate and effectively 

communicate important and informative messages to the public, within 6 

months. 

National spokespersons engaged in 

communications campaign. 

6.1.4.2. 

edical 

DOT, in cooperation with HHS, DHS, and DOC, shall develop model loped and 

protocols for 9-1-1 call centers and public safety answering points that 

address the provision of information to the public, facilitate caller 

screening, and assist with priority dispatch of limited emergency m

services, within 12 months. 

Model protocols deve

disseminated to 9-1-1call centers and 

public safety answering points. 

6.1.8.1. ceutical industry toward the goal of 

. 

Domestic vaccine manufacturing capacity 

of 

a 

HHS shall work with the pharma

developing, within 60 months, domestic vaccine production capacity 

sufficient to provide vaccine for the entire U.S. population within 6 

months after the development of a vaccine reference strain

in place to produce 300 million courses 

vaccine within 6 months of development 

of a vaccine reference strain during 

pandemic. 

6.1.13.6. DOT, in coordination with HHS, DHS, state, local, and tribal officials and 

other EMS stakeholders, shall develop suggested EMS pandemic 

influenza guidelines for statewide adoption that address: clinical 

standards, education, treatment protocols, decontamination procedures, 

medical direction, scope of practice, legal parameters, and other issues, 

within 12 months. 

EMS pandemic influenza guidelines

completed. 

6.1.13.9.

s for conducting vaccine- and 

nd 

developed. 

HHS, in coordination with DOD, VA, and in collaboration with state, 

territorial, tribal, and local partners, shall develop/refine mechanisms to: 

(1) track adverse events following vaccine and antiviral administration; 

(2) ensure that individuals obtain additional doses of vaccine, if 

necessary; and (3) define protocol

antiviral-effectiveness studies during a pandemic, within 18 months. 

Mechanism(s) to track vaccine and 

antiviral medication coverage and 

adverse events developed; vaccine- a

antiviral-effectiveness study protocols

6.1.14.3. 

res 

and characteristics of the virus 

within 9 months. 

rocess in place for 

evaluating and adjusting prepandemic 

recommendations of groups receiving 

priority access to medical 

countermeasures. 

HHS, in coordination with DHS and sector-specific agencies, DOS,

DOD, DOL, and VA, shall establish a strategy for shifting priorities 

based on at-risk populations, supplies and efficacy of countermeasu

against the circulating pandemic strain, 

Clearly articulated p

Page 35 GAO-10-73 National Pandemic Plan
Appendix II: Sample of 60 Selected Action 

Items in the Implementation Plan for the 

National Strategy for Pandemic Influenza 

Action item 

number Actions and expectations Measure of performance 

6.1.16.2.

 cellnths. 

ty.

HHS shall support the renovation of existing U.S. manufacturing 

facilities that produce other Food and Drug Administration licensed

based vaccines or biologics and the establishment of new domestic cellbased influenza vaccine manufacturing facilities, within 36 mo

Contracts awarded for renovation or 

establishment of domestic cell-based

influenza vaccine manufacturing capaci

6.1.17.3. care New grants and contracts awarded to 

researchers to develop and evaluate new 

diagnostics. 

HHS, in coordination with DHS, shall develop and test new point-ofand laboratory-based rapid influenza diagnostics for screening and 

surveillance, within 18 months. 

6.2.1.1. HHS shall provide guidance to public health and clinical laboratories on 

the different types of diagnostic tests and the case definitions to use for 

influenza at the time of each pandemic phase. Guidelines for the curren

pandemic alert phase will be disseminated within 3 months. 

t 

v 

1 

a 

subtypes. 

Dissemination on www.pandemicflu.go

and through other channels of guidance 

on the use of diagnostic tests for H5N

and other potential pandemic influenz

6.2.2.8. Guidance provided to states and tribal 

f the 

ies and 

Disasters system for implementation at 

the local level. 

HHS, in coordination with DHS, DOD, and VA, and in collaboration with 

state, local, and tribal authorities, shall be prepared to collect, analyze, 

integrate, and report information about the status of hospitals and health

care systems, healthcare critical infrastructure, and medical materiel 

requirements, within 12 months. 

entities on the use and modification o

components of the National Hospital 

Available Beds for Emergenc

6.3.2.5. All HHS-, DOD-, and VA-funded hospitals and health facilities shall Guidance materials on infection control 

develop, test, and be prepared to implement infection control campaigns 

for pandemic influenza, within 3 months. 

developed and disseminated on 

www.pandemicflu.gov and through other 

channels. 

6.3.3.1. 

plains steps individuals can take to 

ing 

Guidance disseminated 

onwww.pandemicflu.gov and through VA 

HHS, in coordination with DHS, VA, and DOD, shall develop and 

disseminate guidance that ex

decrease their risk of acquiring or transmitting influenza infection dur

a pandemic, within 3 months. 

and DOD channels. 

7.1.5.1. ian 

er to 

improve information on biosecurity distributed to local animal owners, the most useful 

mit 

read, of avian influenza 

viruses in domestic and captive animal 

populations. 

USDA and DOI shall perform research to understand better how av

influenza viruses circulate and are transmitted in nature, in ord

producers, processors, markets, auctions, wholesalers, distributors, 

retailers, and dealers, as well as wildlife management agencies, 

rehabilitators, and zoos, within 18 months. 

Completed research studies provide new 

information, or validate current 

information, on

biosecurity measures to be taken to 

effectively prevent introduction, and li

or prevent sp

7.1.5.4. USDA shall perform research to improve vaccines and mass An effective avian influenza vaccine that 

immunization techniques for use against influenza in domestic birds 

within 36 months. 

can be delivered simultaneously to 

multiple birds ready for commercial 

development. 

7.2.1.1. 

ticularly 

c 

ild bird samples collected 

and influenza virus testing results. 

DOI and USDA shall collaborate with state wildlife agencies, 

universities, and others to increase surveillance of wild birds, par

migratory water birds and shore birds, in Alaska and other appropriate

locations elsewhere in the United States and its territories, to detect 

influenza viruses with pandemic potential, including highly pathogeni

avian influenza H5N1, and establish baseline data for wild birds, within 

12 months. 

Reports detailing geographically 

appropriate w

7.2.1.2. all collaborate to develop and distribute information to 

state and tribal entities on the detection, identification, and reporting of 

influenza viruses in wild bird populations, within 6 months. 

ted and a report 

available describing the type, amount, 

and audiences for the information. 

USDA and DOI sh Information distribu

Page 36 GAO-10-73 National Pandemic Plan
Appendix II: Sample of 60 Selected Action 

Items in the Implementation Plan for the 

National Strategy for Pandemic Influenza 

Action item 

number Actions and expectations Measure of performance 

7.2.1.3. USDA shall work with state and tribal entities, and industry groups

perform surveys of game birds and waterfowl raised in captivity, and 

implement surveillance of birds at auctions, swap meets, flea markets, 

and public exhibitions, within 12 months. 

, to e 

least five states or tribal entities believed 

za 

Samples collected at 50 percent of th

largest auctions, swap meets, flea 

markets, and public exhibitions held in at 

to be at highest risk for an avian influen

introduction. 

7.3.1.2. USDA shall coordinate with DHS and other federal, state, local, and ent controls in place within 

tribal officials, animal industry, and other affected stakeholders during 

an outbreak in commercial or other domestic birds and animals to apply 

and enforce appropriate movement controls on animals and animal 

products to limit or prevent spread of influenza virus. 

Initial movem

24 hours of detection of an outbreak. 

7.3.2.1. USDA shall activate plans to distribute veterinary medical iel distributed within 24 hours 

countermeasures and materiel from the National Veterinary Stockpile 

(NVS) to federal, state, local, and tribal influenza outbreak responders 

within 24 hours of confirmation of an outbreak in animals of influenza 

with human pandemic potential, within 9 months. 

NVS mater

of confirmation of an outbreak. 

8.1.1.2. S, DOL, and DOD, shall develop a 

pandemic influenza tabletop exercise for state, local, and tribal law 

ith 

blic safety agencies that 

DHS, in coordination with DOJ, HH

enforcement/public safety officials that they can conduct in concert w

public health and medical partners, and ensure it is distributed 

nationwide within 4 months. 

Percent of state, local, and tribal law 

enforcement/pu

have received the pandemic influenza 

tabletop exercise. 

8.3.2.2. DHS, in coordination with DOJ, DOD, DOT, HHS, and other appropriate 

ning 

, fire, 

 plans (validated by 

federal sector-specific agencies, shall engage in contingency plan g EMS, fire, 

and related exercises to ensure they are prepared to sustain EMS

emergency management, public works, and other emergency response 

functions during a pandemic, within 6 months. 

Completed

exercise(s)) for supportin

emergency management, public works, 

and other emergency response functions. 

9.1.2.2. DHS, in coordination with states, localities and tribal entities, shall 

support private sector preparedness with education, exercise, training, 

and information sharing outreach programs, within 6 months. 

Preparedness exercises established with 

private sector partners in all states and 

U.S. territories. 

9.3.1.2. 

status 

n these essential services, 

and aid in sharing real-time impact information, monitoring actions, and 

prioritizing national support efforts for preparedness, response, and 

DHS shall develop and operate a national-level monitoring and 

information sharing system for core essential services to provide 

updates to critical infrastructure dependent o

recovery of critical infrastructure sectors within 12 months. 

National-level critical infrastructure 

monitoring and information-sharing 

system established and operational. 

Source: HSC. 

Data are from the Implementation Plan for the Nation

324 action items, of rity 

te, 3 as in pr As we 

l 

t w

al Strategy for Pandemic Influenza. 

Notes: As stated earlier, we reviewed 60 of the

Council (HSC) designated 49 as comple

pointed out, our analysis highlighted a number of rea

status for some of the 49 selected action items tha

 which the Homeland Secu

ogress, and 8 with no reported status. 

sons why it was difficult to determine the actua

ere designated as complete. 

Page 37 GAO-10-73 National Pandemic Plan
Appendix III: Comments from the 

White House 

Page 38 GAO-10-73 

Appendix III: Comments from the 

White House 

 National Pandemic Plan 
Appendix IV: Comments from the Department Appendix IV: Comments from the of Health and Human Services 

Department of Health and Human Services 

Note: Page numbers in 

the draft report may differ 

from those in this report. 

Page 39 GAO-10-73 National Pandemic Plan
Appendix IV: Comments from the Department 

of Health and Human Services 

Page 40 GAO-10-73 National Pandemic Plan
Appendix IV: Comments from the Department 

of Health and Human Services 

Page 41 GAO-10-73 National Pandemic Plan
Appendix V: Comments from the 

Department of Homeland Security 

Page 42 GAO-10-73 

Appendix V: Comments from the 

Department of Homeland Security 

 National Pandemic Plan 
Appendix V: Comments from the 

Department of Homeland Security 

Page 43 GAO-10-73 National Pandemic Plan
Appendix VI: GAO Contact and Staff 

Acknowledgments 

Page 44 GAO-10-73 National Pandemic Plan 

Bernice Steinhardt, (202) 512-6543 or steinhardtb@gao.gov 

In addition to the contact named above, Sarah Veale, Assistant Director; 

Maya Chakko; Susan Sato; David Fox; Melissa Kornblau; Kara Marshall; 

Mark Ryan; David Dornisch; Andrew Stavisky; and members of GAO’s 

Pandemic Working Group made key contributions to this report. 

Appendix VI: GAO Contact and Staff 

Acknowledgments 

Page 44 GAO-10-73 

Appendix VI: GAO Contact and Staff 

Bernice Steinhardt, (202) 512-6543 or steinhardtb@gao.gov 

In addition to the contact named above, Sarah Veale, Assistant Director; 

Maya Chakko; Susan Sato; David Fox; Melissa Kornblau; Kara Marshall; 

Mark Ryan; David Dornisch; Andrew Stavisky; and members of GAO’s 

Pandemic Working Group made key contributions to this report. 

Acknowledgments 

GAO Contact 

Staff 

Acknowledgments 
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(450696) Page 47 GAO-10-73 Nat
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