Influenza Pandemic: Sustaining Focus on the Nation's Planning and Preparedness Efforts
Published: 2009-02-26T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: GAO has conducted a body of work over the past several years to help the nation better prepare for, respond to, and recover from a possible influenza pandemic, which could result from a novel strain of influenza virus for which there is little resistance and which therefore is highly transmissible among humans. GAO's work has pointed out that while the previous administration had taken a number of actions to plan for a pandemic, including developing a national strategy and implementation plan, much more needs to be done. However, national priorities are shifting as a pandemic has yet to occur, and other national issues have become more immediate and pressing. Nevertheless, an influenza pandemic remains a real threat to our nation and the world. For this report, GAO synthesized the results of 11 reports and two testimonies issued over the past 3 years using six key thematic areas: (1) leadership, authority, and coordination; (2) detecting threats and managing risks; (3) planning, training, and exercising; (4) capacity to respond and recover; (5) information sharing and communication; and (6) performance and accountability. GAO also updated the status of recommendations in these reports.
section_title: What GAO Found
paragraphs: Leadership roles and responsibilities need to be clarified and tested, and coordination mechanisms could be better utilized. Shared leadership roles and responsibilities between the Departments of Health and Human Services (HHS) and Homeland Security (DHS) and other entities are evolving, and will require further testing and exercising before they are well understood. Although there are mechanisms in place to facilitate coordination between federal, state, and local governments and the private sector to prepare for an influenza pandemic, these could be more fully utilized. Efforts are underway to improve the surveillance and detection of pandemic-related threats, but targeting assistance to countries at the greatest risk has been based on incomplete information. Steps have been taken to improve international disease surveillance and detection efforts. However, information gaps limit the capacity for comprehensive comparisons of risk levels by country. Pandemic planning and exercising has occurred, but planning gaps remain. The United States and other countries, as well as states and localities, have developed influenza pandemic plans. Yet, additional planning needs still exist. For example, the national strategy and implementation plan omitted some key elements, and HHS found many major gaps in states' pandemic plans. Further actions are needed to address the capacity to respond to and recover from an influenza pandemic. An outbreak will require additional capacity in many areas, including the procurement of additional patient treatment space and the acquisition and distribution of medical and other critical supplies, such as antivirals and vaccines for an influenza pandemic. Federal agencies have provided considerable guidance and pandemicrelated information, but could augment their efforts. Federal agencies, such as HHS and DHS, have shared information in a number of ways, such as through Web sites and guidance, but state and local governments and private sector representatives would welcome additional information on vaccine distribution and other topics. Performance monitoring and accountability for pandemic preparedness needs strengthening. Although certain performance measures have been established in the National Pandemic Implementation Plan to prepare for an influenza pandemic, these measures are not always linked to results. Further, the plan does not contain information on the financial resources needed to implement it.
section_title: What GAO Recommends
paragraphs: GAO has made 23 recommendations in its reports--13 of these have been implemented and 10 remain outstanding. Continued leadership focus on pandemic preparedness remains vital, as the threat has not diminished.

section_title: Letter
paragraphs: As you know, we conducted a body of work over the past several years to  As you know, we conducted a body of work over the past several years to  help the nation better prepare for, respond to, and recover from a possible  help the nation better prepare for, respond to, and recover from a possible  influenza pandemic. Our work has pointed out that while the previous  influenza pandemic. Our work has pointed out that while the previous  administration had taken a number of actions to plan for a pandemic,  administration had taken a number of actions to plan for a pandemic,  including developing a national strategy and implementation plan, much  including developing a national strategy and implementation plan, much  more needs to be done. At the same time, however, national priorities are  more needs to be done. At the same time, however, national priorities are  shifting as a pandemic has yet to occur, and the nation’s financial crisis  shifting as a pandemic has yet to occur, and the nation’s financial crisis  and other national issues have become more immediate and pressing.  and other national issues have become more immediate and pressing.  Nevertheless, an influenza pandemic remains a real threat to our nation  Nevertheless, an influenza pandemic remains a real threat to our nation  and to the world. Strengthening preparedness for large-scale public health  and to the world. Strengthening preparedness for large-scale public health  emergencies, such as an influenza pandemic, is one of the 13 urgent issues  emergencies, such as an influenza pandemic, is one of the 13 urgent issues  that we identified as among those needing the immediate attention of the  that we identified as among those needing the immediate attention of the  new administration and Congress during this transition period. As your  new administration and Congress during this transition period.  administration.
GAO’s 2009 Congressional and Presidential Transition Web site:  http://www.gao.gov/transition_2009.
House Committee on Homeland Security,Getting Beyond Getting Ready for Pandemic  Influenza, a report prepared by the majority staff, 111th Cong., 1st sess., January 2009.
The strategy was built around six key themes as shown in figure 1. While  all of these themes are interrelated, our earlier work underscored the  importance of leadership, authority, and coordination, a theme that  touches on all aspects of preparing for, responding to, and recovering from  an influenza pandemic.
At your request, this report synthesizes the work thus far completed under  this strategy. In the past 3 years, we have issued 11 reports and two  testimonies on influenza pandemic planning, which address these key  themes. We have made 23 recommendations based on the findings from  many of these reports and testimonies. Thirteen of these  recommendations have been acted upon by the responsible federal  agencies, but while the responsible federal agencies have generally agreed  with our recommendations, 10 recommendations have not yet been  implemented. We also have three pandemic-related reviews underway on  the following topics: (1) the status of implementing the National Strategy  for Pandemic Influenza Implementation Plan (National Pandemic  Implementation Plan); (2) plans to protect the federal workforce in a  pandemic; and (3) the effect of a pandemic on the telecommunications  capacity needed to sustain critical financial market activities. A list of our  open and implemented recommendations can be found in appendices I  and II. While this report makes no new recommendations, we have  updated the status of recommendations that have not yet been  implemented. A list of our related GAO products that are referenced  throughout this report is located after appendix III.
We also collaborated with several state and local audit offices on  coordinated audits of state and local pandemic planning and consulted  with audit offices from a number of countries on pandemic-related  activities through our external partnerships. These countries include  Austria, Belgium, Cambodia, Canada, Germany, Indonesia, Japan,  Kazakhstan, Sweden, the United Kingdom, and Vietnam. We have also  drawn from audits of pandemic planning and exercising conducted by  audit officials in Portland, Oregon; Kansas City, Missouri; and New York  state. Finally, we have incorporated recent studies conducted by the  Congressional Budget Office (CBO), National Governors Association  (NGA), United Nations System Influenza Coordinator (UNSIC), and the  World Bank.
This report is largely based on our prior work, which was conducted in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
subsections: section_title: Background
paragraphs: Influenza pandemic—caused by a novel strain of influenza virus for which  there is little resistance and which therefore is highly transmissible among  humans—continues to be a real and significant threat facing the United  States and the world. While some scientists and public health experts  believe that the next influenza pandemic could be caused by a highly  pathogenic strain of the H5N1 avian influenza virus (also known as “bird  flu”) that is currently circulating in parts of Asia, Europe, and Africa, it is  unknown when an influenza pandemic will occur, where it will begin, or  whether an H5N1 virus or another strain would be the cause. Influenza  pandemic poses a grave threat to global public health at a time when the  United Nations’ World Health Organization (WHO) has said that infectious  diseases are spreading faster than at any time in history. Influenza  pandemics have spread worldwide within months, and a future pandemic  is expected to spread even more quickly given modern travel patterns.
Unlike incidents that are discretely bounded in space or time (e.g., most  natural or man-made disasters), an influenza pandemic is not a singular  event, but is likely to come in waves, each lasting weeks or months, and  pass through communities of all sizes across the nation and the world  simultaneously. While a pandemic will not directly damage physical  infrastructure such as power lines or computer systems, it threatens the  operation of critical systems by potentially removing the essential  personnel needed to operate them from the workplace for weeks or  months. In a severe pandemic, absences attributable to illnesses, the need  to care for ill family members, and fear of infection may, according to the  Centers for Disease Control and Prevention (CDC), reach a projected 40  percent during the peak weeks of a community outbreak, with lower rates  of absence during the weeks before and after the peak. In addition, an  influenza pandemic could result in 200,000 to 2 million deaths in the  United States, depending on its severity.
In addition to the profound human costs in terms of illnesses and deaths,  the economic and societal repercussions of a pandemic could be  significant. In its December 2005 report on possible macroeconomic  effects and policy issues related to a potential influenza pandemic, CBO  stated that a severe influenza pandemic, similar to the 1918-1919  pandemic, might cause a decline in U.S. gross domestic product of about  4.25 percent. CBO updated its report in July 2006 to include some  estimates from medical experts that suggest that CBO may have initially  underestimated the economic impact. The report also noted that these  medical experts stressed the uncertainty about the exact characteristics of  the potential virus and suggested that the worst-case scenario could be  much worse than the severe scenario that CBO considered, especially if  the H5N1 virus acquires the ability to spread efficiently among humans  without losing its extreme virulence. In addition, in September 2008, the  World Bank reported that a severe pandemic could cause a 4.8 percent  drop in world economic activity, which would cost the world economy  more than $3 trillion.
WHO has developed six phases of pandemic alert, each divided into three  periods, as a system of informing the world of the seriousness of the  pandemic threat. As seen in figure 2, according to WHO the world is  currently in Phase 3 where a new influenza virus subtype is causing  disease in humans, but is not yet spreading efficiently and sustainably  among humans.
The Homeland Security Council (HSC) took an active approach to this  potential disaster by, among other things, issuing the National Pandemic  Strategy in November 2005, and the National Pandemic Implementation  Plan in May 2006. The National Pandemic Strategy is intended to provide a  high-level overview of the approach that the federal government will take  to prepare for and respond to an influenza pandemic. It also provides  expectations for nonfederal entities—including state, local, and tribal  governments; the private sector; international partners; and individuals— to prepare themselves and their communities. The National Pandemic  Implementation Plan is intended to lay out broad implementation  requirements and responsibilities among the appropriate federal agencies  and clearly define expectations for nonfederal entities. The National  Pandemic Implementation Plan contains 324 action items related to these  requirements, responsibilities, and expectations, most of which are to be  completed before or by May 2009. HSC publicly reported on the status of  the action items that were to be completed by 6 months, 1 year and 2 years  in December 2006, July 2007, and October 2008 respectively. HSC  indicated in its October 2008 progress report that 75 percent of the action  items have been completed. As previously mentioned, we have ongoing  work assessing the status of implementing this plan.
section_title: Leadership Roles and Responsibilities Need to Be Clarified and Tested, and Coordination Mechanisms Could Be Better Utilized
paragraphs: Our prior work evaluating catastrophic event preparedness, response, and  recovery has shown that in the event of a catastrophic disaster, the  leadership roles, responsibilities, and lines of authority for the response at  all levels must be clearly defined and effectively communicated to  facilitate rapid and effective decision making, especially in preparing for  and in the early hours and days after the event. However, federal  government leadership roles and responsibilities for preparing for and  responding to a pandemic continue to evolve and will require further  clarification and testing before the relationships of the many leadership  positions are well understood. Such clarity in leadership is even more  crucial now given the change in administration and the associated  transition of senior federal officials.
Most of these federal leadership roles involve shared responsibilities  between HHS and DHS, and it is not clear how these would work in  practice. According to the National Pandemic Strategy and Plan, the  Secretary of Health and Human Services is to lead the federal medical  response to a pandemic, and the Secretary of Homeland Security will lead  the overall domestic incident management and federal coordination. In  addition, under the Post-Katrina Emergency Management Reform Act of  2006, the Administrator of the Federal Emergency Management Agency  (FEMA) was designated as the principal domestic emergency management  advisor to the President, the HSC, and the Secretary of Homeland Security,  adding further complexity to the leadership structure in the case of a  pandemic. To assist in planning and coordinating efforts to respond to a  pandemic, in December 2006 the Secretary of Homeland Security  predesignated a national Principal Federal Official (PFO) for influenza  pandemic and established five pandemic regions each with a regional PFO  and Federal Coordinating Officers (FCO) for influenza pandemic. PFOs  are responsible for facilitating federal domestic incident planning and  coordination, and FCOs are responsible for coordinating federal resources  support in a presidentially-declared major disaster or emergency.
However, the relationship of these roles to each other as well as with other  leadership roles in a pandemic is unclear. Moreover, as we testified in July  2007, state and local first responders were still uncertain about the need  for both FCOs and PFOs and how they would work together in disaster  response. Accordingly, we recommended in our August 2007 report on  federal leadership roles and the National Pandemic Strategy that DHS and  HHS develop rigorous testing, training, and exercises for influenza  pandemic to ensure that federal leadership roles and responsibilities for a  pandemic are clearly defined and understood and that leaders are able to  effectively execute shared responsibilities to address emerging  challenges. In response to our recommendation, HHS and DHS officials  stated in January 2009 that several influenza pandemic exercises had been  conducted since November 2007 that involved both agencies and other  federal officials, but it is unclear whether these exercises rigorously tested  federal leadership roles in a pandemic.
With respect to control of an outbreak in poultry, which would be  instrumental to reducing the risk of a human pandemic, both USDA and  DHS may become involved, depending on the level of the outbreak. USDA  is responsible for acting to prevent, control, and eradicate foreign animal  diseases in domestic livestock and poultry, in coordination with a number  of other entities, including states. The Secretary of Homeland Security  assumes responsibility for coordinating the federal response under certain  circumstances, such as an outbreak serious enough for the President to  declare an emergency or a major disaster. In a June 2007 report on USDA’s  planning for avian influenza, we found that USDA was not planning for  DHS to assume the lead coordinating role if an outbreak among poultry  occurred that is sufficient in scope to warrant these declarations. To  address challenges that limit the national ability to quickly and effectively  respond to highly pathogenic avian influenza, we recommended that the  Secretaries of Agriculture and Homeland Security clarify their respective  roles and how they will work together in the event of a declared  presidential emergency or major disaster, and test the effectiveness of this  coordination during exercises. Both USDA and DHS agreed that they  should develop additional clarity and better define their coordination roles  in these circumstances, and have taken preliminary steps to do so. For  example, according to USDA and DHS officials, the two agencies meet on  a regular basis to discuss such coordination issues.
Roles and responsibilities for influenza pandemic preparedness can also  be unclear within individual federal agencies. In two reports on DOD and  its combatant commands’ pandemic preparedness efforts, we noted that  while DOD and the combatant commands had taken numerous actions to  prepare for a pandemic, roles and responsibilities for pandemic  preparedness within the department and the commands had not been  clearly defined or communicated. Our September 2006 report on DOD’s  pandemic preparedness noted that neither the Secretary nor the Deputy  Secretary of Defense had clearly and fully defined and communicated lead  and supporting roles and responsibilities with clear lines of authority for  DOD’s influenza pandemic planning, and we recommended that DOD do  so. In response, DOD communicated departmentwide that the Deputy  Secretary of Defense had designated the Assistant Secretary of Defense for  Homeland Defense and Americas’ Security Affairs, working with the  Assistant Secretary of Defense for Health Affairs, to lead DOD’s pandemic  efforts. Similarly, in a June 2007 report, we recommended that DOD take  steps to clarify U.S. Northern Command’s roles and responsibilities for  pandemic planning and preparedness efforts. In response, DOD clarified  U.S. Northern Command’s roles and responsibilities in guidance and plans.
In addition to concerns about clarifying federal roles and responsibilities  for a pandemic and how shared leadership roles would work in practice,  private sector officials have told us that they are unclear about the  respective roles and responsibilities of the federal and state governments  during a pandemic emergency. The National Pandemic Implementation  Plan states that in the event of an influenza pandemic, the distributed  nature and sheer burden of the disease across the nation would mean that  the federal government’s support to any particular community is likely to  be limited, with the primary response to a pandemic coming from states  and local communities. Further, federal and private sector representatives  we interviewed at the time of our October 2007 report identified several  key challenges they face in coordinating federal and private sector efforts  to protect the nation’s critical infrastructure in the event of an influenza  pandemic. One of these was a lack of clarity regarding the roles and  responsibilities of federal and state governments on issues such as state  border closures and influenza pandemic vaccine distribution.
Coordination Mechanisms  Mechanisms and networks for collaboration and coordination on  pandemic preparedness between federal and state governments and the  private sector exist, but they could be better utilized. In some instances,  the federal and private sectors are working together through a set of  coordinating councils, including sector-specific and cross-sector councils.  To help protect the nation’s critical infrastructure, DHS created these  coordinating councils as the primary means of coordinating government  and private sector efforts for industry sectors such as energy, food and  agriculture, telecommunications, transportation and water. Our October  2007 report found that DHS has used these critical infrastructure  coordinating councils primarily to share pandemic information across  sectors and government levels rather than to address many of the  challenges identified by sector representatives, such as clarifying the roles  and responsibilities between federal and state governments. We  recommended in the October 2007 report that DHS encourage the councils  to consider and address the range of coordination challenges in a potential  influenza pandemic between the public and private sectors for critical  infrastructure. DHS concurred with our recommendation and DHS  officials informed us in February 2009 that the department is working on  initiatives to address it, such as developing pandemic contingency plan  guidance tailored to each of the critical infrastructure sectors, and holding  a series of “webinars” with a number of the sectors.
Federal executive boards (FEB) bring together federal agency and  community leaders in major metropolitan areas outside of Washington,  D.C., to discuss issues of common interest, including an influenza  pandemic. The Office of Personnel Management (OPM), which provides  direction to the FEBs, and the FEBs have designated emergency  preparedness, security, and safety as an FEB core function. The FEB’s  emergency support role with its regional focus may make the boards a  valuable asset in pandemic preparedness and response. As a natural  outgrowth of their general civic activities and through activities such as  hosting emergency preparedness training, some of the boards have  established relationships with, for example, federal, state, and local  governments; emergency management officials; first responders; and  health officials in their communities. In a May 2007 report on the FEBs’  ability to contribute to emergency operations, we found that many of the  selected FEBs included in our review were building capacity for influenza  pandemic response within their member agencies and community  organizations by hosting influenza pandemic training and exercises. We  recommended that, since FEBs are well positioned within local  communities to bring together federal agency and community leaders, the  Director of OPM work with FEMA to formally define the FEBs’ role in  emergency planning and response. As a result of our recommendation,  FEBs were included in the National Response Framework (NRF) in  January 2008 as one of the regional support structures that have the  potential to contribute to development of situational awareness during an  emergency. OPM and FEMA also signed a memorandum of understanding  in August 2008 in which FEBs and FEMA agreed to work collaboratively in  carrying out their respective roles in the promotion of the national  emergency response system.
section_title: Efforts Are Underway to Improve the Surveillance and Detection of Pandemic-Related Threats in Humans and Animals, but Targeting Assistance to Countries at the Greatest Risk Has Been Based on Incomplete Information
paragraphs: International disease surveillance and detection efforts serve to address  the threat posed by infectious diseases, such as an influenza pandemic,  before they develop into widespread outbreaks. Such efforts also provide  national and international public health authorities with information for  planning and managing efforts to control diseases such as an influenza  pandemic. However, as we have reported in the past, domestic and  international disease surveillance efforts need improvement. For  example, some state public health departments’ initiatives to enhance  disease reporting have been incomplete, and there is a need for national  standards and interoperability in information collection and sharing to  detect outbreaks. Globally, in December 2007 we reported that the United  States and its international partners are involved in efforts to improve  global influenza surveillance, including diagnostic capabilities, so that  pandemic strains can be quickly detected. Yet, international capacity for  influenza surveillance still has many weaknesses, particularly in  developing countries. For example, some countries experiencing H5N1  human influenza outbreaks, like Indonesia, had at times not promptly  shared human virus samples with the international community, thus  further weakening international surveillance efforts.
Efforts are also being made both within the United States and  internationally to improve surveillance and detection for highly pathogenic  avian influenza. As stated earlier, controlling an outbreak in poultry would  be instrumental to reducing the risk of a human pandemic. Within the  United States, USDA is taking many important measures to help the nation  prepare for outbreaks of highly pathogenic avian influenza. In a June 2007  report on avian influenza, we stated that USDA had developed several  surveillance programs to detect highly pathogenic avian influenza,  including a long-standing voluntary program that systematically tests  samples of birds from participating poultry operators’ flocks for the virus.  Further, we also stated that USDA’s Animal and Plant Health Inspection  Service (APHIS) is working with the Department of the Interior, state  wildlife agencies, and others to increase surveillance of wild birds in  Alaska and the 48 contiguous states in addition to working with states and  industry to conduct surveillance of birds at auctions, swap meets, flea  markets, and public exhibitions. APHIS has also formed the National  Avian Influenza Surveillance System, designed to link existing avian  influenza surveillance data from USDA, other federal and state agencies,  and industry.
However, in the United States, federal and state officials generally do not  know the numbers and locations of backyard birds so controlling an  outbreak of highly pathogenic avian influenza among these birds remains  particularly difficult. We recommended that the Secretary of Agriculture  work with states to determine how to overcome potential problems  associated with unresolved issues, such as the difficulty in locating  backyard birds and disposing of carcasses and materials. USDA agreed  with our recommendation and efforts are underway. For example,  according to USDA officials, the agency has developed online tools to help  states make effective decisions about carcass disposal. In addition, USDA  has created a secure Internet site that contains draft guidance for disease  response, including highly pathogenic avian influenza, and it includes a  discussion about many of the unresolved issues.
International surveillance networks for influenza in birds and other  animals have also been established and efforts are under way to improve  data sharing among scientists. However, global surveillance of the  disease among domestic animals has serious shortfalls. The World  Organisation for Animal Health (OIE) and the Food and Agriculture  Organization (FAO) collaborate to obtain and confirm information on  suspected highly pathogenic H5N1 cases. According to the October 2008  report by the UNSIC and the World Bank on the state of pandemic  readiness, data obtained from national authorities indicate that 75  percent of countries report having a surveillance system that is  operational and capable of detecting highly pathogenic avian influenza. In  addition, estimates of risk for disease transmission from one country to  another, as well as among regions within countries, are difficult to make  because of uncertainties about how factors such as trade in poultry and  other birds and wild bird migration affect the movement of the disease.
subsections: section_title: Risk-Based Targeting of Assistance to Priority Countries
paragraphs: Assessments by U.S. agencies and international organizations identified  widespread risks of the emergence of influenza pandemic, and the United  States identified priority countries for assistance. Our June 2007 report on  international efforts to assess and respond to an influenza pandemic risk  noted that the bulk of U.S. and other donors’ country-specific  commitments had been made to countries that the United States had  designated as priorities, with funding concentrated among certain of these  countries. We reported that through 2006, the United States had  committed about $377 million to improve global preparedness for avian  and influenza pandemic, 27 percent of the $1.4 billion committed by all  donors, which is the greatest share of funds of all donors. Since we issued  our June 2007 report, the UNSIC and the World Bank reported that as of  April 2008, the United States had committed $629 million, which is  approximately 31 percent of the $2.05 billion committed by all donors, for  avian and pandemic influenza efforts.
Figure 3 shows the distribution of committed global and U.S. funding  across major recipient countries as of December 2006. Of the top 15  recipients of committed international funds, 11 were U.S. priority  countries. More recent data on U.S. funding patterns show similar focuses  on certain countries, with Indonesia the largest recipient, followed by  Vietnam and Cambodia.
However, we reported that gaps in available information from other  countries limited the capacity for comprehensive, well-informed  comparisons of risk levels by country. For example, in 2007 we reported  that the United States Agency for International Development’s (USAID)  environmental risk assessment of areas at greatest risk for avian influenza  outbreaks included a limited understanding of the role of poultry trade or  wild birds. USAID, the Department of State, and the United Nations had  also gathered information that was not sufficiently detailed or complete  enough to permit well-informed country comparisons. Despite these  limitations, the HSC has used available information to designate priority  countries for assistance. The UNSIC and the World Bank stated in the 2008  report that reports from national authorities responding to a UNSIC survey  indicate that 68 percent of countries had conducted a risk assessment. As  we previously reported in June 2007, adopting a risk management  approach can help manage the uncertainties in an influenza pandemic and  identify the most appropriate course of action. However, the FAO’s  detailed evaluation concluded that very few countries have a surveillance  plan that is based on an “elaborated” risk-analysis.
section_title: Pandemic Planning and Exercising Has Occurred in the United States and Other Countries, but Planning Gaps Remain
paragraphs: By their very nature, catastrophic events involve extraordinary levels of  mass casualties, damage, or disruption that can overwhelm state and local  responders—making sound planning for catastrophic events crucial.  Strong advance planning, both within and among federal, state, and local  governments and other organizations, as well as robust training and  exercise programs to test these plans in advance of a real disaster, are  essential to best position the nation to prepare for, respond to, and  recover from major catastrophes such as an influenza pandemic.  Capabilities are built upon the appropriate combination of people, skills,  processes, and assets. Ensuring that needed capabilities are available  requires effective planning and coordination as well as training and  exercises in which the capabilities are realistically tested, problems  identified and lessons learned, and subsequently addressed in partnership  with other federal, state, and local stakeholders. We have also noted that  an incomplete understanding of roles and responsibilities under the  National Response Plan has often led to misunderstandings, problems,  and delays—an area where training could be helpful. Key officials must  actively and personally participate so that they are better prepared to deal  with real life situations. In addition, as we previously reported on the  federal response to Hurricane Katrina, lessons learned from exercises  must be incorporated and used to improve emergency plans.
subsections: section_title: Pandemic Planning and Exercising in Other Countries
paragraphs: A number of countries in addition to the United States have developed  pandemic plans, along with state and local governments, and the private  sector. We reported in June 2007 that the U.S. government has worked  with its international partners to develop an overall global strategy that is  compatible with the U.S. approach. These steps included the appointment  of a UNSIC and periodic global conferences to review progress and refine  the strategy.
Other countries, including Belgium, Japan, Sweden, and the United  Kingdom, have developed influenza pandemic plans and frameworks. In  July 2006, Belgium issued the Belgian pandemic flu preparedness plan  which provides basic information on various topics such as leadership,  antivirals, vaccines, surveillance, logistics, and public communication.  Similar to Belgium’s pandemic plan, Japan used WHO’s six influenza  pandemic phases in drafting government policies and response efforts in  its Pandemic Influenza Preparedness Action Plan of the Japanese  Government issued in November 2005. Sweden’s National Audit Office  reported in its February 2008 audit that Sweden’s Preparedness planning  for pandemic influenza – National Actions is focused only on infection  control services and the health sector and does not cover the rest of  society. To address this, the government of Sweden agreed to further  develop its plan by March 2010. Further, the Sweden’s National Audit  Office found that there is very limited knowledge of the extent to which  municipalities can provide essential services in the event of an influenza  pandemic. Within the United Kingdom, the government issued The  National Framework for Responding to an Influenza Pandemic and the  Scottish National Framework for Responding to an Influenza Pandemic  in November 2007 and March 2007, respectively. Both frameworks provide  information and guidance to assist and support public and private  organizations across all sectors in understanding the nature of the  challenges and in making the appropriate preparations for an influenza  pandemic.
According to a UNSIC global survey, 141 countries, or 97 percent of those  that responded, have pandemic preparedness plans. However, further  analysis conducted by the UNSIC’s Pandemic Influenza Contingency Team  and other institutions suggested that the quality and comprehensiveness of  these plans continue to vary significantly between countries. UNSIC and  the World Bank also found that there had been a moderate increase in the  number of countries that have undertaken simulation exercises.  Specifically, where testing has occurred, 25 percent of respondents (37 of  145 countries), reported that testing took place at both the national and  local levels. In addition, 37 percent of respondents (45 of 120 countries)  have incorporated the lessons learned from simulations into plan  revisions.
section_title: Federal, State, and Local Government Pandemic Planning and Exercising
paragraphs: In our August 2007 report on the National Pandemic Strategy and  Implementation Plan, we found that while these documents are an  important first step in guiding national preparedness, they do not fully  address all six characteristics of an effective national strategy, as  identified in our work. The documents fully address only one of the six  characteristics, by reflecting a clear description and understanding of  problems to be addressed. Further, the National Pandemic Strategy and  Implementation Plan do not address one characteristic at all, containing  no discussion of what it will cost, where resources will be targeted to  achieve the maximum benefits, and how it will balance benefits, risks, and  costs. Moreover, the documents do not provide a picture of priorities or  how adjustments might be made in view of resource constraints. Although  the remaining four characteristics are partially addressed, important gaps  exist that could hinder the ability of key stakeholders to effectively  execute their responsibilities. For example, state and local jurisdictions  that will play crucial roles in preparing for and responding to a pandemic  were not directly involved in developing the National Pandemic  Implementation Plan, even though it relies on these stakeholders’ efforts.  Stakeholder involvement during the planning process is important to  ensure that the federal government’s and nonfederal entities’  responsibilities are clearly understood and agreed upon. Further,  relationships and priorities among actions were not clearly described,  performance measures were not always linked to results, and insufficient  information was provided about how the documents are integrated with  other response related plans, such as the NRF. We recommended that the  HSC establish a process for updating the National Pandemic  Implementation Plan and that the updated plan should address these and  other gaps. HSC did not comment on our recommendation and has not  indicated if it plans to implement it.
Concerning federal government planning for an outbreak in animals, we  reported in 2007 that although USDA had also taken important steps to  prepare for outbreaks of highly pathogenic avian influenza, there were still  gaps in its planning. We noted that USDA was drafting response plans for  highly pathogenic avian influenza and was also working with the HSC and  other key federal agencies to produce an “interagency playbook” intended  to clarify how primary federal responders would initially interact to  respond to six scenarios of detection of highly pathogenic H5N1. USDA  had also begun preliminary exercises to test aspects of these plans with  federal, state, local, and industry partners. However, USDA response plans  did not identify the capabilities needed to carry out the tasks associated  with an outbreak scenario—that is, the entities responsible for carrying  them out, the resources needed, and the source of those resources. To  address these gaps, we recommended that the Secretary of Agriculture  identify these capabilities, use this information to develop a response plan  that identifies the critical tasks for responding to the selected outbreak  scenario and, for each task, identifies the responsible entities, the location  of resources needed, time frames, and completion status, and test these  capabilities in ongoing exercises to identify gaps and ways to overcome  those gaps. USDA concurred, and officials told us that it has created a  draft preparedness and response plan that identifies federal, state, and  local actions, timelines, and responsibilities for responding to highly  pathogenic avian influenza, but the plan has not been issued yet.
At the state and local levels, we reported in June 2008 that, according to  CDC, all 50 states and the 3 localities that received federal pandemic funds  have developed influenza pandemic plans and conducted pandemic  exercises in accordance with federal funding guidance. All of the 10  localities that we reviewed had also developed plans and conducted  exercises. Further, all of the 10 localities and the five states that we  reviewed had incorporated lessons learned from pandemic exercises into  their planning. However, an HHS-led interagency assessment of states’  plans found on average that states had “many major gaps” in their  influenza pandemic plans in 16 of 22 priority areas, such as school closure  policies and community containment, which are community-level  interventions designed to reduce the transmission of a pandemic virus.  The remaining 6 priority areas were rated as having “a few major gaps.”  Since we issued our report in June 2008, HHS led another interagency  assessment of state influenza pandemic plans. HHS reported in January  2009 that, based on this assessment, although states have made important  progress toward preparing for combating an influenza pandemic, most  states still have major gaps in their pandemic plans. As we had reported  in June 2008, HHS, in coordination with DHS and other federal agencies,  had convened a series of regional workshops for states in five influenza  pandemic regions across the country. Because these workshops could be a  useful model for sharing information and building relationships, we  recommended that HHS and DHS, in coordination with other federal  agencies, convene additional meetings with states to address the gaps in  the states’ pandemic plans. HHS and DHS generally concurred with our  recommendation, but have not yet held these additional meetings. HHS  and DHS recently indicated that while no additional meetings are planned  at this time, states will have to continuously update their pandemic plans  and submit them for review.
We have also reported on the need for more guidance from the federal  government to help states and localities in their planning. In June 2008, we  reported that although the federal government has provided a variety of  guidance, officials of the states and localities we reviewed told us that they  would welcome additional guidance from the federal government in a  number of areas, such as community containment, to help them to better  plan and exercise for an influenza pandemic. State and local officials have  identified similar concerns. An October 2007 Kansas City Auditor’s Office  report on influenza pandemic preparedness in the city noted that Kansas  City Health Department officials would like the federal government to  provide additional guidance on some of the same issues we found,  including clarifying community interventions such as school closings. In  addition, according to the National Governors Association’s (NGA)  September 2008 issue brief on states’ pandemic preparedness, states are  concerned about a wide range of school-related issues, including when to  close schools or dismiss students, how to maintain curriculum continuity  during closures, and how to identify the appropriate time at which classes  could resume. In addition, NGA reported that states generally have very  little awareness of the status of disease outbreaks, either in real time or in  near real time, to allow them to know precisely when to recommend a  school closure or reopening in a particular area. NGA reported that states  wanted more guidance in the following areas: (1) workforce policies for  the health care, public safety, and private sectors; (2) schools;   (3) situational awareness such as information on the arrival or departure  of a disease in a particular state, county, or community; (4) public  involvement; and (5) public-private sector engagement.
section_title: Private Sector Pandemic Planning
paragraphs: The private sector has also been planning for an influenza pandemic, but  many challenges remain. To better protect critical infrastructure, federal  agencies and the private sector have worked together across a number of  sectors to plan for a pandemic, including developing general pandemic  preparedness guidance, such as checklists for continuity of business  operations during a pandemic. However, federal and private sector  representatives have acknowledged that sustaining preparedness and  readiness efforts for an influenza pandemic is a major challenge, primarily  because of the uncertainty associated with a pandemic, limited financial  and human resources, and the need to balance pandemic preparedness  with other, more immediate, priorities, such as responding to outbreaks of  foodborne illnesses in the food sector and, now, the effects of the financial  crisis.
In our March 2007 report on preparedness for an influenza pandemic in  one of these critical infrastructure sectors—financial markets—we found  that despite significant progress in preparing markets to withstand  potential disease pandemics, securities and banking regulators could take  additional steps to improve the readiness of the securities markets.  Although the seven organizations that we reviewed—which included  exchanges, clearing organizations, and payment-system processors—were  working on planning and preparation efforts to reduce the likelihood that  a worldwide influenza pandemic would disrupt their critical operations,  only one of the seven had completed a formal plan. To increase the  likelihood that the securities markets will be able to function during a  pandemic, we recommended that the Chairman, Federal Reserve; the  Comptroller of the Currency; and the Chairman, Securities and Exchange  Commission (SEC), consider taking additional actions to ensure that  market participants adequately prepare for a pandemic outbreak. In  response to our recommendation, the Federal Reserve and the Office of  the Comptroller of the Currency, in conjunction with the Federal Financial  Institutions Examination Council, and the SEC directed all banking  organizations under their supervision to ensure that the pandemic plans  the financial institutions have in place are adequate to maintain critical  operations during a severe outbreak. SEC issued similar requirements to  the major securities industry market organizations.
section_title: Further Actions Are Needed to Address the Capacity to Respond to and Recover from an Influenza Pandemic
paragraphs: Improving the nation’s response capability to catastrophic disasters, such  as an influenza pandemic, is essential. Following a mass casualty event of  injured or ill victims, health care systems would need the ability to  adequately care for a large number of patients or patients with unusual or  highly specialized medical needs. The ability of local or regional health  care systems to deliver services consistent with established standards of  care could be compromised, at least in the short term, because the  volume of patients would far exceed the available hospital beds, medical  personnel, pharmaceuticals, equipment, and supplies. Providing such care  would require the allocation of scarce resources.
subsections: section_title: Medical Surge Capacity
paragraphs: In contrast to discrete events such as hurricanes and most terrorist  attacks, the widespread and iterative nature of a pandemic—likely to  occur in waves as it spreads simultaneously through different  communities and regions—presents continuing challenges in preparing for  a medical surge in a mass casualty event such as a pandemic. Under such  conditions, emergency management approaches that have been used in  the past to increase capacity when responding to other types of disasters,  such as assistance from other states or the deployment of military  resources, may not be viable options since these groups may need to hold  onto resources in order to meet their own needs should they be affected  by the disease. We reported in June 2007 that state officials informed us  that the Emergency Management Assistance Compact (EMAC), a  collaborative arrangement among member states that provides a legal  framework for requesting resources and that has been used in  emergencies such as Hurricane Katrina, would not work in an influenza  pandemic. State officials reported their reluctance to send personnel into  an infected area, expressed their concern that resources would not be  available, and believed that personnel would be reluctant to volunteer to  go to another state. Further, NGA reported in its September 2008 issue  brief on state pandemic preparedness that EMAC is seen as unreliable  during a pandemic because states would likely be unwilling to share  scarce resources or deploy personnel into a location where the disease is  active and thus expose those individuals to a high-risk environment.
HHS estimates that in a severe influenza pandemic, almost 10 million  people would require hospitalization, which would exceed the current  capacity of U.S. hospitals and necessitate difficult choices regarding  rationing of resources. HHS also estimates that almost 1.5 million of these  people would require care in an intensive care unit and about 740,000  people would require mechanical ventilation. In our September 2008  report on HHS’s influenza pandemic planning efforts, we reported that  although HHS has initiated efforts to improve the surge capacity of health  care providers, these efforts will be challenged during a severe pandemic  because of the widespread nature of such an event, the existing shortages  of health care providers, and the potential high absentee rate of providers.  Given the uncertain effectiveness of efforts to increase surge capacity,  HHS has developed guidance to assist health care facilities in planning for  altered standards of care; that is, for providing care while allocating scarce  equipment, supplies, and personnel in a way that saves the largest number  of lives in mass casualty events. As we reported in June 2008, 7 out of 20  states reviewed had adopted or were drafting altered standards of care for  specific medical issues. Three of the 7 states had adopted some altered  standards of care guidelines. We also found that 18 of the 20 states  reviewed were selecting alternate care sites, which deliver medical care  outside of a hospital setting for patients who would normally be treated as  inpatients.
In addition, we reported that the federal government has provided funding,  guidance, and other assistance to help states prepare for medical surge in  a mass casualty event, such as an influenza pandemic. Further, the federal  government has provided guidance for states to use when preparing for  medical surge, including Reopening Shuttered Hospitals to Expand Surge  Capacity, which contains a checklist that states can use to identify entities  that could provide more resources in preparing for a medical surge and  also provided other assistance such as conferences and electronic bulletin  boards for states to use in preparing for medical surge. Some state officials  reported, however, that they had not begun work on altered standards of  care guidelines, or had not completed drafting guidelines, because of the  difficulty of addressing the medical, ethical, and legal issues involved. We  recommended that HHS serve as a clearinghouse for sharing among the  states altered standards of care guidelines developed by individual states  or medical experts. HHS did not comment on the recommendation, and it  has not indicated if it plans to implement it. Further, in our June 2008  report on state and local planning and exercising efforts for an influenza  pandemic, we found that state and local officials reported that they  wanted federal influenza pandemic guidance on facilitating medical surge,  which was also one of the areas that the HHS-led assessment rated as  having “many major gaps” nationally among states’ influenza pandemic  plans.
section_title: Antivirals and Vaccine Capacity
paragraphs: In fiscal year 2006, Congress appropriated $5.62 billion in supplemental  funding to HHS for, among other things, (1) monitoring disease spread to  support rapid response, (2) developing vaccines and vaccine production  capacity, (3) stockpiling antivirals and other countermeasures,   (4) upgrading state and local capacity, and (5) upgrading laboratories and  research at CDC. Figure 4 shows that the majority of this supplemental  funding—about 77 percent—was allocated for developing antivirals and  vaccines for a pandemic, and purchasing medical supplies. Also, a portion  of the funding for state and local preparedness—$170 million—was  allocated for state antiviral purchases for their state stockpiles.
According to HHS’s Pandemic Influenza Implementation Plan, HHS  seeks to ensure the availability of antiviral treatment courses for at least  25 percent of the U.S. population or at least 81 million treatment courses.  As of May 2008, both HHS and states had stockpiled a total of 72 million  treatment courses. Specifically, HHS had stockpiled 44 million courses of  antivirals for treatment in the HHS-managed Strategic National Stockpile,  which is a national repository of medical supplies that is designed to  supplement stockpiles from state and local jurisdictions in the event of a  public health emergency, and had reserved an additional 6 million courses  from its federally stockpiled antivirals for containment of an initial  outbreak. HHS also subsidized the purchase of 31 million treatment  courses by state and local jurisdictions for storage in their own stockpiles,  of which 22 million treatment courses had been stockpiled.
In our December 2007 report on using antivirals and vaccines to forestall a  pandemic, we found that the availability of antivirals and vaccines in a  pandemic could be inadequate to meet demand due to limited production,  distribution, and administration capacity. As we reported, WHO  estimated that the quantity of antivirals required to forestall a pandemic  would be enough treatment courses for 25 percent of the population. In  addition, there would need to be enough preventative courses to last 20  days for the remaining 75 percent of the population in the outbreak  contamination zone. Further, due to the time required to detect the virus  and develop and manufacture a targeted vaccine for a pandemic,  pandemic vaccines are likely to play little or no role in efforts to stop or  contain a pandemic at least in its initial phases. According to a September  2008 CBO report on the United States’ policy regarding pandemic  vaccines, if an influenza pandemic were to occur today, it would be  impossible to vaccinate the entire population of about 300 million people  within the following 6 months because current capacity for domestic  production would be completely inadequate.
The United States, its international partners, and the pharmaceutical  industry are investing substantial resources to address constraints on the  availability and effectiveness of antivirals and vaccines, but some of these  efforts face limitations. We reported in September 2008 that HHS was  making large investments in domestic vaccine manufacturing capacity by  supporting vaccine research with contracts that require manufacturers to  establish vaccine-producing facilities within U.S. borders. Through these  contracts, one U.S. facility has expanded its manufacturing capacity and a  second facility was recently established in the United States. Further,  according to a January 2009 report by HHS, the department awarded $120  million to vaccine manufacturers to retrofit their existing U.S. vaccine  manufacturing facilities for egg-based vaccines while also planning to  build domestic cell-based vaccine production facilities within the U.S. by  awarding approximately $500 million in contracts in fiscal year 2009.
CBO also reported that HHS is not only encouraging the expansion and  refurbishing of existing facilities but also funding the development of new  adjuvants, substances that can be added to influenza vaccines to reduce  the amount of active ingredient (also called antigen) needed per dose of  vaccine. By using adjuvants for egg-based and cell-based vaccines,  domestic manufacturers could produce more doses in existing facilities,  which means that fewer new facilities would be needed to manufacture  cell-based formulations and smaller stockpiles could be used to protect a  larger population.
However, increasing production capacity of vaccines and antivirals will  take several years, as new facilities are built and necessary materials  acquired. Also, weaknesses within the international influenza surveillance  system impede the detection of strains, which could limit the ability to  promptly administer or develop effective antivirals and vaccines to treat  and prevent cases of infection to prevent its spread. The delayed use of  antivirals and the emergence of antiviral resistance in influenza strains  could limit their effectiveness. In addition, limited support for clinical  trials could hinder their ability to improve understanding of the use of  antivirals and vaccines against a pandemic strain.
In light of this anticipated limitation in supply, HHS released guidance on  prioritizing target groups for a pandemic vaccine. Because of the  uncertainties surrounding the availability of a pandemic vaccine, in  September 2008, we recommended that the Secretary of Health and  Human Services expeditiously finalize guidance to assist state and local  jurisdictions to determine how to effectively use limited supplies of  antivirals, and the pre-pandemic vaccine, which is developed prior to an  outbreak using strains that have the potential to cause an influenza  pandemic. In December 2008, HHS released final guidance on antiviral  drug use during an influenza pandemic. In addition, HHS officials  informed us in February 2009 that it is drafting guidance on pre-pandemic  influenza vaccination.
In addition to antiviral and vaccine stockpiles for an influenza pandemic  for the general population, our June 2007 report on avian influenza  planning concluded that USDA had significant gaps in its planning for  providing antivirals to individuals responsible for responding to an  outbreak of highly pathogenic avian influenza. USDA has coordinated  with DHS and other federal agencies to create a National Veterinary  Stockpile. This stockpile is intended to be the nation’s repository of animal  vaccines, personal protective equipment, and other critical veterinary  products to respond to the most dangerous foreign animal diseases,  including highly pathogenic avian influenza. However, at the time of the  report, USDA had not yet estimated the amount of antiviral medication  that it would need in the event of a highly pathogenic avian outbreak or  resolved how to provide such supplies within the first 24 hours of an  outbreak. According to Occupational Safety and Health Administration  guidelines, poultry workers responding to an outbreak of highly  pathogenic avian influenza should take antiviral medication daily. Further,  the National Veterinary Stockpile is required to contain sufficient amounts  of antiviral medication to respond to the most damaging animal diseases  that affect human health and the economy and has not yet obtained any  antiviral medication for highly pathogenic avian influenza. However, HHS  officials told National Veterinary Stockpile officials that the antiviral  medication in the Strategic National Stockpile was reserved only for use  during a human pandemic. We therefore recommended that the Secretary  of Agriculture determine the amount of antiviral medication that USDA  would need in order to protect animal health responders, given various  highly pathogenic avian influenza scenarios, and determine how to obtain  and provide supplies within 24 hours of an outbreak. In commenting on  our recommendation, USDA officials told us that the National Veterinary  Stockpile now contains enough antiviral medication to protect 3,000  animal health responders for 40 days. However, USDA officials told us that  they have yet to determine the number of individuals that would need  medicine based on a calculation of those exposed to the virus under a  specific scenario. Further, USDA officials said that a contract for  additional medication for the stockpile has not yet been secured, which  would better ensure that medications are available in the event of an  outbreak of highly pathogenic avian influenza.
section_title: Federal Agencies Have Provided Considerable Guidance and Pandemic-Related Information, but Could Augment Their Efforts
paragraphs: Our work evaluating public health and natural disaster catastrophe  preparedness, response, and recovery has shown that insufficient  collaboration among federal, state, and local governments created  challenges for sharing public health information and developing  interoperable communications for first responders. In 2005, we designated  establishing appropriate and effective information-sharing mechanisms to  improve homeland security as a high-risk area. Over the past several years,  we have identified potential information-sharing barriers, critical success  factors, and other key management issues that should be considered to  facilitate information sharing among and between government entities and  the private sector.
Citizens should be given an accurate portrayal of risk, without overstating  the threat or providing false assurances of security. Risk communication  principles have been used in a variety of public warning contexts, from  alerting the public to severe weather, to less commonplace warnings of  infectious disease outbreaks. In general, these principles seek to maximize  public safety by ensuring the public has sufficient information to  determine what actions to take to prevent or respond to emergencies.  Appropriately warning the public of threats can help save lives and reduce  costs of disasters. Federal, state and local officials and risk management  experts who participated in an April 2008 Comptroller General’s forum on  strengthening the use of risk management principles in homeland security  identified and ranked the challenges in applying these principles.  Improving risk communication to the public was one of the top three  challenges identified by the forum participants.
Our prior work identified several instances when risk communication  proved less than effective. For example, during the 2004-2005 flu season,  demand for the flu vaccine exceeded supply, and information about future  vaccine availability was uncertain (as could happen in a future pandemic).  Although CDC communicated regularly through a variety of media as the  situation evolved, state and local officials identified several  communications lessons. These included the need for consistency among  federal, state, and local communications, the importance of using diverse  media to reach different audiences, and the importance of disseminating  clear, updated information when responding to changing circumstances.
Another example, from our October 1999 report on DOD’s anthrax vaccine  immunization program, illustrated the importance of providing accurate  and sufficient information to personnel. Although DOD and the military  services used a variety of measures to educate military personnel about  the program, military personnel wanted more information on the program,  and over one-half of respondents that participated in our survey said that  the information they received was less than moderately helpful or that  they did not receive any information.
The National Pandemic Implementation Plan emphasizes that government  and public health officials must communicate clearly and continuously  with the public throughout a pandemic. The plan recognizes that timely,  accurate, credible, and coordinated messages will be necessary. The  federal government has undertaken a number of communications efforts  to provide information on a possible pandemic and how to prepare for it.  HHS (including CDC), DHS, and other federal agencies have provided a  variety of influenza pandemic information and guidance for states and  local communities through Web sites and meetings with states. These  efforts included:    establishing an influenza pandemic Web site (www.pandemicflu.gov);  including pandemic information on another Web site, Lessons Learned  Information Sharing System (LLIS) (www.llis.dhs.gov), which is a national  network of lessons learned and best practices for emergency responders  and homeland security officials;    sponsoring state pandemic summits with all 50 states and additional    disseminating pandemic preparedness checklists for workplaces,  individuals and families, schools, health care, community organizations,  and state and local governments; and    providing additional guidance for the public, such as on pandemic vaccine  targeting and allocation and pre-pandemic community planning.
There are established coordination networks that are being used to  provide information to state and local governments and to the private  sector about pandemic planning and preparedness. For example, the FEBs  are charged with providing timely and relevant information to support  emergency preparedness and response coordination, and OPM expects the  boards to establish notification networks and communications plans to be  used in emergency and nonemergency situations. The boards are also  expected to disseminate relevant information received from OPM and  other agencies regarding emergency preparedness information and to  relay local emergency situation information to parties such as OPM, FEB  members, media, and state and local government authorities. FEB  representatives generally viewed the boards as an important  communications link between Washington and the field and among field  agencies. Each of the selected boards we reviewed reported conducting  communications activities as a key part of its emergency support service.  In addition, critical infrastructure coordinating councils have been also  primarily used as a means to share information and develop pandemic- specific guidance across the industry sectors, such as banking and finance  and telecommunications, and across levels of government.
However, as noted earlier, state and local officials from all of the states  and localities we interviewed wanted additional federal influenza  pandemic guidance from the federal government on specific topics, such  as implementing community interventions, fatality management, and  facilitating medical surge. Although the federal government has issued  some guidance, it may not have reached state and local officials or may  not have addressed the particular concerns or circumstances of the state  and local officials we interviewed. In addition, private sector officials have  told us that they would like clarification about the respective roles and  responsibilities of the federal and state governments during an influenza  pandemic emergency, such as in state border closures and influenza  pandemic vaccine distribution.
section_title: Performance Monitoring and Accountability for Pandemic Preparedness Needs Strengthening
paragraphs: As indicated earlier, in August 2007 we reported that although the National  Pandemic Strategy and Implementation Plan identified the overarching  goals and objectives for pandemic planning, the documents had some  gaps. Most of the implementation plan’s performance measures consist of  actions to be completed, such as disseminating guidance, but the measures  are not always clearly linked with intended results. This lack of clear  linkages makes it difficult to ascertain whether progress has in fact been  made toward achieving the national goals and objectives described in the  National Pandemic Strategy and Implementation Plan. Without a clear  linkage to anticipated results, these measures of activities do not give an  indication of whether the purpose of the activity is achieved. For example,  most of the action items’ performance measures consist of actions to be  completed, such as guidance developed and disseminated. Further, 18 of  the action items have no measure of performance associated with them. In  addition, the National Pandemic Implementation Plan does not establish  priorities among its 324 action items, which becomes especially important  as agencies and other parties strive to effectively manage scarce resources  and ensure that the most important steps are accomplished. This is further  complicated by the lack of a description of the financial resources needed  to implement the action items, which is one of six characteristics of an  effective national strategy.
We also found that some action items, particularly those that are to be  completed by state, local, and tribal governments or the private sector, do  not identify an entity responsible for carrying out the action. Although the  plan specifies actions to be carried out by states, local jurisdictions, and  other entities, including the private sector, it gives no indication of how  these actions will be monitored, how their completion will be ensured, or  who will be responsible for making sure that these actions are completed.  Also, it appears that HSC’s determination of completeness has not been  accurately applied for all of the action items. Several of the action items  that were reported by the HSC as being completed were still in progress.  For example, our June 2007 report on U.S. agencies’ international efforts  to forestall an influenza pandemic found that eight of the plan’s  international-related action items included in the HSC’s progress report as  completed either did not directly address the associated performance  measure or did not indicate that the completion deadline had been met.  As stated earlier, we are currently assessing the implementation of the  plan.
We have also reported that, although DOD instituted reporting  requirements for its components responsible for implementing 31 action  items tasked to DOD in the National Pandemic Implementation Plan, there  were not similar oversight mechanisms in place for pandemic-related tasks  that were not specifically part of the National Plan. For example, DOD  did not require DOD components to report on their development or  revision of their continuity of operations plans in preparation for an  influenza pandemic. Over time, a lack of clear lines of authority, oversight  mechanisms, and goals and performance measures could hamper the  leadership’s abilities to ensure that planning efforts across the department  are progressing as intended as DOD continues its influenza pandemic  planning and preparedness efforts. Additionally, without clear  departmentwide goals, it would be difficult for all DOD components to  develop effective plans and guidance. In response to our recommendation,  DOD designated an official to lead DOD’s pandemic efforts, established a  Pandemic Influenza Task Force, and communicated this information  throughout the department. DOD also assigned responsibility to the U.S.  Northern Command for directing, planning, and synchronizing DOD’s  global response to an influenza pandemic and disseminated this  information throughout the department.
There have been some other instances where performance and  accountability has been strengthened. The FEBs have recently established  performance measures for their emergency support role. In our May 2007  report, we recommended that OPM continue its efforts to establish  performance measures and accountability for the emergency support  responsibilities of the FEBs before, during, and after an emergency event  that affects the federal workforce outside Washington, D.C. In response  to our recommendation, the FEB strategic plan for fiscal years 2008  through 2012 includes operational goals with associated measures for its  emergency preparedness, security, and employee safety line of business.  The data intended to support these measures include methods such as  stakeholder and participant surveys, participant lists, and emergency  preparedness test results.
In providing funding to states and certain localities to help them to  prepare for a pandemic, HHS has instituted a number of accountability  requirements. As described above, HHS received $5.62 billion in  supplemental appropriations specifically available for pandemic influenza- related purposes in fiscal year 2006. As shown in figure 4, a total of $770  million, or about 14 percent of the supplemental appropriations, went to  states and localities for preparedness activities. Of the $770 million, $600  million was specifically provided by Congress for state and local planning  and exercising. The HHS pandemic funding was administered by CDC and  required all 50 states and 3 localities to, among other things, develop  influenza pandemic plans and conduct influenza pandemic exercises.  According to CDC officials, all 50 states and the localities that received  direct funding have met these requirements.
section_title: Concluding Observations
paragraphs: Strengthening preparedness for large-scale public health emergencies,  including the possibility of an influenza pandemic, is one of the issues that  we identified as among those needing the urgent attention of the new  administration and Congress during this transition period. Although much  has been done, many challenges remain, as is evidenced by the fact that  almost half of the recommendations that we have made over the past 3  years have still not been fully implemented. Given the change in  administration and the associated transition of senior federal officials, it  will be essential for this administration to continue to exercise and test the  shared leadership roles that have been established between HHS and DHS,  as well as the relative roles, responsibilities, and authorities for a  pandemic among the federal government, state and local governments and  the private sector. In the area of critical infrastructure protection, DHS  should continue to work with other federal agencies and private sector  members of the critical infrastructure coordinating councils to help  address the challenges required to coordinate between the federal and  private sectors before and during a pandemic. These challenges include  clarifying roles and responsibilities of federal and state governments. DHS  and HHS should also, in coordination with other federal agencies,  continue to work with states and local governments to help them address  identified gaps in their pandemic planning. To help improve international  disease surveillance and detection efforts, the United States should  continue to work with international organizations and other countries to  help address gaps in available information, which limit the capacity for  comprehensive, well-informed comparisons of risk levels by countries.
Continued leadership focus on pandemic preparedness is particularly  crucial now as the attention on influenza pandemic may be waning as  attention shifts to other more immediate national priorities. In addition, as  leadership changes across the executive branch, the new administration  should recognize that the threat of an influenza pandemic remains  unchanged and should therefore continue to maintain momentum in  preparing the nation for a possible influenza pandemic.
As agreed with your office, we plan no further distribution of this report  until 30 days from its date, unless you publicly announce its contents  earlier. At that time, we will send copies to other interested parties. In  addition, this report is available at no charge on GAO’s Web site at  http://www.gao.gov.
If you or your staff have any further questions about this report, please  contact me at (202) 512-6543 or steinhardtb@gao.gov, or Sarah Veale,  Assistant Director, at (202) 512-6890 or veales@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. Major contributors to this report are listed in  appendix III.
section_title: Appendix I: Open Recommendations from GAO’s Work on an Influenza Pandemic as of February 2009
subsections: section_title: Influenza Pandemic: HHS Needs to Continue Its Actions and Finalize Guidance for Pharmaceutical Interventions, GAO-08-671, September 30, 2008
paragraphs: The Secretary of Health and  Human Services should  expeditiously finalize guidance to  assist state and local jurisdictions  to determine how to effectively  use limited supplies of antivirals  and pre-pandemic vaccine in a  pandemic, including prioritizing  target groups for pre-pandemic  vaccine.
In December 2008, HHS released final guidance  on antiviral drug use during an influenza pandemic.   HHS officials informed us that they are drafting the  guidance on pre-pandemic influenza vaccination.
The Secretaries of Health and  Human Services and Homeland  Security should, in coordination  with other federal agencies,  convene additional meetings of  the states in the five federal  influenza pandemic regions to  help them address identified gaps  in their planning.
HHS and DHS officials indicated that while no  additional meetings are planned at this time, states  will have to continuously update their pandemic  plans and submit them for review.
The Secretary of Homeland  Security should work with sector- specific agencies and lead efforts  to encourage the government and  private sector members of the  councils to consider and help  address the challenges that will  require coordination between the  federal and private sectors  involved with critical infrastructure  and within the various sectors, in  advance of, as well as during, a  pandemic.
DHS officials informed us that the department is  working on initiatives, such as developing  pandemic contingency plan guidance tailored to  each of the critical infrastructure sectors, and  holding a series of “webinars” with a number of the  sectors.
Influenza Pandemic: Further Efforts Are  Needed to Ensure Clearer Federal  Leadership Roles and an Effective National  Strategy,   GAO-07-781, August 14, 2007  (1) HHS and DHS officials stated that several  influenza pandemic exercises had been conducted  since November 2007 that involved both agencies  and other federal officials, but it is unclear whether  these exercises rigorously tested federal  leadership roles in a pandemic.
Influenza Pandemic: Opportunities Exist to  Clarify Federal Leadership Roles and  Improve Pandemic Planning,  GAO-07-1257T, September 26, 2007  (1) The Secretaries of Homeland  Security and Health and Human  Services should work together to  develop and conduct rigorous  testing, training, and exercises for  an influenza pandemic to ensure  that the federal leadership roles  are clearly defined and  understood and that leaders are  able to effectively execute shared  responsibilities to address  emerging challenges.  Once the  leadership roles have been  clarified through testing, training,  and exercising, the Secretaries of  Homeland Security and Health  and Human Services should  ensure that these roles are clearly  understood by state, local, and  tribal governments; the private  and nonprofit sectors; and the  international community.  (2) The Homeland Security  Council should establish a specific  process and time frame for  updating the National Pandemic  Implementation Plan. The process  should involve key nonfederal  stakeholders and incorporate  lessons learned from exercises  and other sources. The National  Pandemic Implementation Plan  should also be improved by  including the following information  in the next update: (A) resources  and investments needed to  complete the action items and  where they should be targeted, (B)  a process and schedule for  monitoring and publicly reporting  on progress made on completing  the action items, (C) clearer  linkages with other strategies and  plans, and (D) clearer descriptions  of relationships or priorities among  action items and greater use of  outcome-focused performance  measures. (2) HSC did not comment on the recommendation  and has not indicated if it plans to implement it.
Avian Influenza: USDA Has Taken Important  Steps to Prepare for Outbreaks, but Better  Planning Could Improve Response,  GAO-07-652, June 11, 2007  (1) The Secretaries of Agriculture  and Homeland Security should  develop a memorandum of  understanding that describes how  USDA and DHS will work together  in the event of a declared  presidential emergency or major  disaster, or an Incident of National  Significance, and test the  effectiveness of this coordination  during exercises. (1) Both USDA and DHS officials told us that they  have taken preliminary steps to develop additional  clarity and better define their coordination roles.  For example the two agencies meet on a regular  basis to discuss such coordination. (2) The Secretary of Agriculture  should, in consultation with other  federal agencies, states, and the  poultry industry identify the  capabilities necessary to respond  to a probable scenario or  scenarios for an outbreak of highly  pathogenic avian influenza. The  Secretary of Agriculture should  also use this information to  develop a response plan that  identifies the critical tasks for  responding to the selected  outbreak scenario and, for each  task, identifies the responsible  entities, the location of resources  needed, time frames, and  completion status. Finally, the  Secretary of Agriculture should  test these capabilities in ongoing  exercises to identify gaps and  ways to overcome those gaps. (2) USDA officials told us that it has created a draft  preparedness and response plan that identifies  federal, state, and local actions, timelines, and  responsibilities for responding to highly pathogenic  avian influenza, but the plan has not been issued  yet. (3) The Secretary of Agriculture  should develop standard criteria  for the components of state  response plans for highly  pathogenic avian influenza,  enabling states to develop more  complete plans and enabling  USDA officials to more effectively  review them. (3) USDA told us that it has drafted large volumes  of guidance documents that are available on a  secure Web site. However, the guidance is still  under review and it is not clear what standard  criteria from these documents USDA officials and  states should apply when developing and  reviewing plans. (4) The Secretary of Agriculture  should focus additional work with  states on how to overcome  potential problems associated with  unresolved issues, such as the  difficulty in locating backyard birds  and disposing of carcasses and  materials. (4) USDA officials have told us that the agency has  developed online tools to help states make  effective decisions about carcass disposal. In  addition, USDA has created a secure Internet site  that contains draft guidance for disease response,  including highly pathogenic avian influenza, and it  includes a discussion about many of the  unresolved issues. (5) The Secretary of Agriculture  should determine the amount of  antiviral medication that USDA  would need in order to protect  animal health responders, given  various highly pathogenic avian  influenza scenarios. The  Secretary of Agriculture should  also determine how to obtain and  provide supplies within 24 hours of  an outbreak. (5) USDA officials told us that the National  Veterinary Stockpile now contains enough antiviral  medication to protect 3,000 animal health  responders for 40 days.  However, USDA has yet  to determine the number of individuals that would  need medicine based on a calculation of those  exposed to the virus under a specific scenario.   Further, USDA officials told us that a contract for  additional medication for the stockpile has not yet  been secured, which would better ensure that  medications are available in the event of an  outbreak of highly pathogenic avian influenza.
section_title: Appendix II: Implemented Recommendations from GAO’s Work on an Influenza Pandemic as of February 2009
paragraphs: Appendix II: Implemented Recommendations  from GAO’s Work on an Influenza Pandemic  as of February 2009 (1) The Secretary of Defense should  instruct the Assistant Secretary of Defense  for Homeland Defense and Americas’  Security Affairs to issue guidance that  specifies which of the tasks assigned to  DOD in the plan and other pandemic  planning tasks apply to the individual  combatant commands, military services,  and other organizations within DOD, as  well as what constitutes fulfillment of these  actions. (1) The 14 national implementation plan tasks  assigned to the Joint Staff as the lead  organization within DOD, which includes tasks to  be performed by the combatant commands, have  been completed. According to DOD, the  department’s Global Pandemic Influenza Planning  Team developed recommendations for the  division of responsibilities, which were included in  U.S. Northern Command’s global synchronization  plan for pandemic influenza. Additionally, DOD  assigned pandemic influenza-related tasks to the  combatant commands in its 2008 Joint Strategic  Capabilities Plan. (2) The Secretary of Defense should  instruct the Assistant Secretary of Defense  for Homeland Defense and Americas’  Security Affairs to issue guidance that  specifies U.S. Northern Command’s roles  and responsibilities as global synchronizer  relative to the roles and responsibilities of  the various organizations leading and  supporting the department’s influenza  pandemic planning. (2) Revisions to DOD’s 2008 Joint Strategic  Capabilities Plan, as well as guidance from the  Secretary of Defense during a periodic review of  U.S. Northern Command’s pandemic influenza  global synchronization plan, clarified and better  defined U.S. Northern Command’s role as global  synchronizer. (3) The Secretary of Defense should  instruct the Assistant Secretary of Defense  for Homeland Defense and Americas’  Security Affairs to work with the Under  Secretary of Defense (Comptroller) to  identify the sources and types of resources  combatant commands need to accomplish  their influenza pandemic planning and  preparedness activities. (3) DOD, through U.S. Northern Command as the  global synchronizer for pandemic influenza  planning, collected information from the  combatant commands on funding requirements  related to pandemic influenza preparedness and  submitted this information through DOD’s formal  budget and funding process. Through this  process, five of the combatant commands (U.S.  Northern Command, U.S. European Command,  U.S. Pacific Command, U.S. Central Command,  and U.S. Transportation Command) obtained  about $25 million for fiscal years 2009 through  2013 for pandemic influenza planning and  exercises. Future pandemic influenza-related  funding requirements will be addressed through  DOD’s established budget process. (4) The Secretary of Defense should  instruct the Joint Staff to work with the  combatant commands to develop options  to mitigate the effects of factors that are  beyond the combatant commands’ control. (4) The combatant commands are increasingly  inviting representatives from the United Nations,  including the World Health Organization and the  Food and Agriculture Organization; host and  neighboring nations; and other federal  government agencies to exercises and  conferences to share information and fill  information gaps. Additionally, U.S. Northern  Command and U.S. Pacific Command, along with  the military services and installations, are  increasingly working and planning with state,  local, and tribal representatives. DOD views  updating and reviewing plans to ensure that they  are current as a continuous process driven by  changes in policy, science, and environmental  factors.
The Chairman, Federal Reserve, the  Comptroller of the Currency, and the  Chairman, Securities and Exchange  Commission, should consider taking  additional actions to ensure that market  participants adequately prepare for an  outbreak, including issuing formal  expectations that business continuity plans  for a pandemic should include measures  likely to be effective even during severe  outbreaks, and setting a date by which  market participants should have such  plans.
In December 2007, the Federal Reserve, in  conjunction with the Federal Financial Institutions  Examination Council, issued an Interagency  Statement on Pandemic Planning to each Federal  Reserve Bank and to all banking organizations  supervised by the Federal Reserve. The  statement directed those banks to ensure the  pandemic plans they have in place are adequate  to maintain critical operations during a severe  outbreak. In December 2007, the Office of the  Comptroller of the Currency, in conjunction with  the Federal Financial Institutions Examination  Council, also issued an Interagency Statement on  Pandemic Planning to the national banks,  outlining the same requirements for pandemic  plans as the guidance issued by the Federal  Reserve. In July and August of 2007, the  Securities and Exchange Commission’s Market  Regulation Division issued letters to the major  clearing organizations and exchanges—those  covered by the Commission’s 2003 Policy  Statement on Business Continuity Planning for  Trading Markets—that directed these  organizations to confirm by year-end 2007 that  their pandemic plans are adequate to maintain  critical operations during a severe outbreak. (1) OPM should initiate discussion with the  Department of Homeland Security and  other responsible stakeholders to consider  the feasibility of integrating the federal  executive board’s (FEB) emergency  support responsibilities into the established  emergency response framework, such as  the National Response Plan. (1) In January 2008, the FEBs were included in  the National Response Framework section on  regional support structures that have the potential  to contribute to development of situational  awareness during an emergency. In addition, in  August 2007, the FEBs were integrated into the  National Continuity Policy Implementation Plan  issued by the White House Homeland Security  Council. (2) OPM should continue its efforts to  establish performance measures and  accountability for the emergency support  responsibilities of the FEBs before, during,  and after an emergency event that affects  the federal workforce outside Washington,  D.C. (2) The FEB strategic plan for fiscal years 2008  through 2012 includes operational goals with  associated measures for its emergency  preparedness, security, and employee safety line  of business. The data intended to support these  measures includes methods such as stakeholder  and participant surveys, participant lists, and  emergency preparedness test results. (3) OPM, as part of its strategic planning  process for the FEBs, should develop a  proposal for an alternative to the current  voluntary contribution mechanism that  would address the uncertainty of funding  sources for the boards. (3) In November 2008, OPM submitted a  legislative proposal to provide for interagency  funding of FEB operations nationwide. (4) OPM should work with FEMA to  develop a memorandum of understanding,  or some similar mechanism that formally  defines the FEB role in emergency  planning and response. (4) In addition to integrating the FEBs into  national emergency plans, FEMA and OPM  signed a memorandum of agreement on August  1, 2008. Among other things, the memorandum  states that the federal executive boards and  FEMA will work together in carrying out their  respective roles in the promotion of the National  Incident Management System and the National  Response Framework. (1) The Secretary of Defense should  instruct the Assistant Secretary of Defense  for Homeland Defense, as the individual  accountable for DOD’s influenza pandemic  planning and preparedness efforts, to  clearly and fully define and communicate  departmentwide the roles and  responsibilities of the organizations that  will be involved in DOD’s efforts, with clear  lines of authority; the oversight  mechanisms, including reporting  requirements, for all aspects of DOD’s  influenza pandemic planning efforts, to  include those tasks that are outside of the  national implementation plan; and the  goals and performance measures for  DOD’s planning and preparedness efforts. (1) The Deputy Secretary of Defense verbally  designated the Assistant Secretary of Defense for  Homeland Defense, working with the Assistant  Secretary of Defense for Health Affairs, to lead  DOD’s pandemic influenza efforts and established  a Pandemic Influenza Task Force. This  information was communicated throughout the  department when the Principal Deputy to the  Assistant Secretary of Defense for Homeland  Defense and Americas’ Security Affairs issued  DOD’s Implementation Plan for Pandemic  Influenza within the department in a July 2006  memo. Additionally, U.S. Northern Command was  designated as the lead combatant command for  directing, planning, and synchronizing DOD’s  global response to an influenza pandemic; this  information was disseminated throughout the  department in November 2006. (2) The Secretary of Defense should  instruct the Assistant Secretary of Defense  for Homeland Defense to work with the  Under Secretary of Defense (Comptroller)  to establish a framework for requesting  funding for the department’s preparedness  efforts. The framework should include the  appropriate funding mechanism and  controls to ensure that needed funding for  DOD’s influenza pandemic preparedness  efforts is tied to the department’s goals. (2) The Office of the Under Secretary of Defense  (Comptroller) is utilizing established protocols for  programming funds related to pandemic influenza  preparedness for DOD. Funding requests for  preparedness efforts were submitted as part of  the department’s fiscal year 2009 integrated  program and budget review, and long-term  funding requests will be included in future budget  requests. (3) The Secretary of Defense should  instruct the Assistant Secretary of Defense  for Health Affairs to clarify DOD’s guidance  to explicitly define whether or how all types  of personnel—including DOD’s military and  civilian personnel, contractors,  dependents, and beneficiaries—would be  included in DOD’s distribution of vaccines  and antivirals, and communicate this  information departmentwide. (3) In August 2007, DOD issued additional  guidance related to the distribution of its vaccine  and antiviral stockpiles in the event of an  influenza pandemic. (4) The Secretary of Defense should  instruct the Assistant Secretary of Defense  for Public Affairs to implement a  comprehensive and effective  communications strategy departmentwide  that is transparent as to what actions each  group of personnel should take and the  limitations of the efficacy, risks, and  potential side effects of vaccines and  antivirals. (4) DOD has updated its publicly available  pandemic influenza Web site, to include links to  the Military Vaccine Agency, which provides  information on the risks and side effects of  vaccines.
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, major contributors to this report  include Sarah Veale, Assistant Director; Maya Chakko; Susan Sato; Mark  Ryan; Kara Marshall; and members of GAO’s Pandemic Working Group.
section_title: Related GAO Products
paragraphs: Veterinarian Workforce: Actions Are Needed to Ensure Sufficient  Capacity for Protecting Public and Animal Health. GAO-09-178.  Washington, D.C.: February 4, 2009.
Influenza Pandemic: HHS Needs to Continue Its Actions and Finalize  Guidance for Pharmaceutical Interventions. GAO-08-671. Washington,  D.C.: September 30, 2008.
Influenza Pandemic: Federal Agencies Should Continue to Assist States  to Address Gaps in Pandemic Planning. GAO-08-539. Washington, D.C.:  June 19, 2008.
Emergency Preparedness: States Are Planning for Medical Surge, but  Could Benefit from Shared Guidance for Allocating Scarce Medical  Resources. GAO-08-668. Washington, D.C.: June 13, 2008.
Influenza Pandemic: Efforts Under Way to Address Constraints on  Using Antivirals and Vaccines to Forestall a Pandemic. GAO-08-92.  Washington, D.C.: December 21, 2007.
Influenza Pandemic: Opportunities Exist to Address Critical  Infrastructure Protection Challenges That Require Federal and Private  Sector Coordination. GAO-08-36. Washington, D.C.: October 31, 2007.
Influenza Pandemic: Federal Executive Boards’ Ability to Contribute to  Pandemic Preparedness. GAO-07-1259T. Washington, D.C.: September 28,  2007.
Influenza Pandemic: Opportunities Exist to Clarify Federal Leadership  Roles and Improve Pandemic Planning. GAO-07-1257T. Washington, D.C.:  September 26, 2007.
Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer  Federal Leadership Roles and an Effective National Strategy.  GAO-07-781. Washington, D.C.: August 14, 2007.
Emergency Management Assistance Compact: Enhancing EMAC’s  Collaborative and Administrative Capacity Should Improve National  Disaster Response. GAO-07-854. Washington, D.C.: June 29, 2007.
Influenza Pandemic: DOD Combatant Commands’ Preparedness Efforts  Could Benefit from More Clearly Defined Roles, Resources, and Risk  Mitigation. GAO-07-696. Washington, D.C.: June 20, 2007.
Influenza Pandemic: Efforts to Forestall Onset Are Under Way;  Identifying Countries at Greatest Risk Entails Challenges. GAO-07-604.  Washington, D.C.: June 20, 2007.
Avian Influenza: USDA Has Taken Important Steps to Prepare for  Outbreaks, but Better Planning Could Improve Response. GAO-07-652.  Washington, D.C.: June 11, 2007.
The Federal Workforce: Additional Steps Needed to Take Advantage of  Federal Executive Boards’ Ability to Contribute to Emergency  Operations. GAO-07-515. Washington, D.C.: May 4, 2007.
Financial Market Preparedness: Significant Progress Has Been Made,  but Pandemic Planning and Other Challenges Remain. GAO-07-399.  Washington, D.C.: March 29, 2007.
Influenza Pandemic: DOD Has Taken Important Actions to Prepare, but  Accountability, Funding, and Communications Need to be Clearer and  Focused Departmentwide. GAO-06-1042. Washington, D.C.: September 21,  2006.
Catastrophic Disasters: Enhanced Leadership, Capabilities, and  Accountability Controls Will Improve the Effectiveness of the Nation’s  Preparedness, Response, and Recovery System.  GAO-06-618. Washington,  D.C.: September 6, 2006.