Defense Civil Support: DOD, HHS, and DHS Should Use Existing Coordination Mechanisms to Improve Their Pandemic Preparedness
Published: 2017-02-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The U.S. Army estimates that if a severe infectious disease pandemic were to occur today, the number of U.S. fatalities could be almost twice the total number of battlefield fatalities in all of America's wars since the American Revolution in 1776. A pandemic occurs when an infectious agent emerges that can be efficiently transmitted between humans and has crossed international borders. DOD's day-to-day functioning and the military's readiness and operations abroad could be impaired if a large percentage of its personnel are sick or absent, and DOD's assistance to civil authorities might be limited.
House Report 114-102 included a provision for GAO to assess DOD's planning and coordination to support civil authorities during a pandemic. This report assesses the extent to which (1) DOD has guidance and plans for supporting civil authorities in the event of a domestic outbreak of a pandemic disease and (2) HHS and DHS have plans to respond to a pandemic if DOD support capabilities are limited, and they have mechanisms to coordinate their pandemic preparedness and response. GAO reviewed agency pandemic guidance and plans, interagency coordination mechanisms, and pandemic-related exercises and after-action reports.
section_title: What GAO Found
paragraphs: Strategy for Homeland Defense and Support to Civil Authorities states that DOD often is expected to play a prominent supporting role to primary federal agencies. DOD also assists those agencies in the preparedness, detection, and response to other non-pandemic viruses, such as the recent outbreak of the Zika virus.
HHS and DHS have plans to guide their response to a pandemic, but their plans do not explain how they would respond in a resource-constrained environment in which capabilities like those provided by DOD are limited. DOD coordinates with the agencies, but existing coordination mechanisms among HHS, DHS, and DOD could be used to improve preparedness. HHS's Pandemic Influenza Plan is the departmental blueprint for its preparedness and response to an influenza pandemic. DHS's National Response Framework is a national guide on how federal, state, and local governments are to respond to such incidents. DOD, HHS, and DHS have mechanisms—such as interagency working groups, liaison officers, and training exercises—to coordinate their response to a pandemic. For example, training exercises are critical in preparing these agencies to respond to an incident by providing opportunities to test plans, improve proficiency, and assess capabilities and readiness. These existing mechanisms provide the agencies opportunities to improve their preparedness and response to a pandemic. HHS and DHS plans do not specifically identify what resources would be needed to support a response to a pandemic in which demands exceeded federal resources. These officials stated that there would be no way of knowing in advance what resources would be required. HHS and DHS are in the process of updating their plans and thus have an opportunity to coordinate with each other and with DOD to determine the appropriate actions to take should DOD's support be limited.
section_title: What GAO Recommends
paragraphs: GAO recommends that DOD, HHS, and DHS use existing coordination mechanisms to explore opportunities to improve preparedness and response to a pandemic if DOD's capabilities are limited. DOD, HHS, and DHS concurred with GAO's recommendations.

section_title: Letter
paragraphs: The U.S. Army estimates that if a severe infectious disease pandemic  were to occur today, the number of U.S. fatalities could be almost twice  as great as the total number of battlefield fatalities—over 1 million as of  September 2016—from all of America’s wars since the American  Revolution in 1776. In comparison, the number of U.S. fatalities  (approximately 650,000) from the 1918-1919 “Spanish flu” pandemic is  equivalent to about 64 percent of those battlefield fatalities. Extrapolating  from data on influenza fatalities from 1918 to 2011—the most recent  analysis available—the U.S. Army projects that fatalities in the United  States alone from a severe infectious disease pandemic would be over   2 million. Moreover, influenza viruses—especially highly pathogenic  influenza strains like H5N1—remain an urgent global infectious disease  threat. As of January 2017, the World Health Organization had confirmed  856 human cases of H5N1 infection worldwide between 2003 and 2017,  and almost 53 percent of those infections were fatal.
A severe infectious disease pandemic is a unique type of disaster and  differs from other disasters because of the transmissibility of influenza  viruses, the universal susceptibility of the world’s population to viruses  that have not previously circulated, and the mobility of human  populations. A pandemic occurs when an infectious agent emerges— such as a novel influenza virus—that can be efficiently transmitted  between humans and has spread across international borders. It could be  natural, accidental, or deliberate in origin, occurring over a wide  geographic area. A pandemic has the potential to affect the Department  of Defense’s (DOD) ability to accomplish its mission and may result in  significant increases in requests for DOD assistance from civil authorities  if they become overwhelmed in responding to it. A pandemic could  significantly impair the military’s readiness, jeopardize ongoing military  operations abroad, and threaten the day-to-day functioning of the  department if a large percentage of its personnel are sick or absent. A  pandemic outbreak would be not only a medical problem, but also a  personnel and national security problem. Federal officials anticipate that a  pandemic would occur in multiple waves over a period of time, rather than  as a discrete event. In 2006, the then Homeland Security Council, which  was subsequently merged with the National Security Council, estimated  that during the peak weeks of a severe influenza pandemic, 40 percent of  the U.S. workforce might not be at work because of illness, the need to  care for family members who are ill, or fear of becoming infected. DOD  personnel would not be immune, and if the department were to face a  similar absentee rate, then DOD’s ability to support requests for  assistance from civil authorities responding to a pandemic might be  limited. In fact, DOD itself might require support from another federal  agency, such as the Department of Health and Human Services (HHS),  for vaccine procurement and distribution and delivery of antiviral drugs.
The federal government’s response to major domestic disasters and  emergencies is guided by the National Response Framework, a national- level guide on how local, state, and federal governments are to respond  to such incidents. The framework describes specific authorities, key roles and responsibilities, and best practices for managing incidents that range  from the serious but purely local to large-scale terrorist attacks or natural  disasters. According to the National Response Framework, HHS serves  as the federal government’s primary agency responsible for public health  and medical preparation and planning for and response to a biological  terrorism attack or a naturally occurring outbreak that results from either a  known or a novel pathogen, including an emerging infectious disease.  The Department of Homeland Security (DHS) is the federal agency  responsible for domestic incident management. DOD may be asked to  serve in a supporting role to HHS and provide support functions to  supplement civil authorities’ resources in response to public health and  medical disasters. According to Joint Publication 3-28, Defense Support  of Civil Authorities, civil authorities include the government of the United  States and the governments of the 50 states, the District of Columbia, the  Commonwealth of Puerto Rico, and the U.S. territories.
According to DOD Directive 3025.18, Defense Support of Civil Authorities  (DSCA), and officials in the Office of the Deputy Assistant Secretary of  Defense for Homeland Defense Integration and Defense Support of Civil  Authorities, the department must evaluate requests for assistance from  civil authorities according to their legality, lethality, risk, cost,  appropriateness, and effect on readiness.
In 2006 and 2007, we issued several reports that identified management  challenges in DOD’s influenza pandemic planning and preparedness  efforts, such as defining roles, responsibilities, and authorities, among  other challenges, and made recommendations to address these  challenges. DOD agreed with and took actions on the recommendations  we made in these reports. For example, DOD clarified roles and  responsibilities and provided guidance on how DOD combatant  commands were to plan for pandemics. In June 2015, we testified on  DOD’s efforts from March 2010 through December 2014 to address our  recommendations to strengthen its strategy, plans, and guidance for  support of civil authorities.
House Report 114-102, accompanying a bill for the National Defense  Authorization Act for Fiscal Year 2016, included a provision for us to  assess the extent of DOD’s planning and coordination to support civil  authorities in the event of a domestic outbreak of a pandemic disease.  This report assesses the extent to which (1) DOD has guidance and plans  for supporting civil authorities in the event of a domestic outbreak of a  pandemic disease and (2) HHS and DHS have plans to respond to a  pandemic if DOD’s support capabilities are limited, and they have  mechanisms to coordinate their pandemic preparedness and response  with DOD. While this report focuses on DOD’s domestic pandemic  response, DOD also is involved in pandemic responses outside of the  United States and its territories. We also are including information on  DOD’s preparedness, detection, and response to the Zika virus in  appendix I of this report. While the Zika virus is not a pandemic condition  at this time, we are highlighting this issue because of the recent outbreak  of the Zika virus and concerns about its effects on military service  members, DOD civilians, and their dependents.
To determine the extent to which DOD has guidance and plans for  supporting civil authorities in the event of a domestic outbreak of a  pandemic, we obtained and analyzed federal guidance primarily from  three documents: (1) the National Strategy for Pandemic Influenza,  which provides an overview of the approach that the federal government  will take to prepare for and respond to an influenza pandemic; (2) the  National Strategy for Pandemic Influenza Implementation Plan, which  lays out implementation requirements, distributes responsibilities among  the appropriate federal agencies, lists planning assumptions to facilitate  planning efforts, and defines expectations for nonfederal entities; and  (3) DOD Directive 3025.18, Defense Support of Civil Authorities, which  establishes policies and assigns responsibilities within the department for  defense support of civil authorities. We also obtained guidance from the  Department of Defense Global Campaign Plan for Pandemic Influenza  and Infectious Diseases, combatant commands’ pandemic plans, and  other directives—among other guidance—to determine how DOD plans  for and responds to influenza pandemics and infectious diseases. We  compared DOD’s Global Campaign Plan pandemic planning guidance  with the National Response Framework to determine how DOD provides  support to primary federal agencies in their response to incidents such as  pandemics.
To determine the extent to which HHS and DHS have plans to respond to  a pandemic if DOD’s support capabilities are limited, and they have  mechanisms to coordinate their pandemic preparedness and response  with DOD, we obtained and analyzed pandemic planning guidance, such  as HHS’s Pandemic Influenza Plan, DHS’s National Response  Framework, and Federal Interagency Operational Plans, to identify these  primary agencies’ roles and responsibilities in the event of a pandemic.  We reviewed guidance documents and plans to determine the  mechanisms HHS and DHS use to coordinate with DOD; other federal,  state, local, tribal, and territorial authorities; and the private sector to  prepare for a domestic outbreak of a pandemic disease. We compared  HHS’s and DHS’s pandemic planning guidance with DOD’s pandemic  planning guidance to determine whether there was unity of effort among  DOD and primary federal agencies. We also obtained and analyzed  policy and guidance from DOD, HHS, and DHS to identify their roles and  responsibilities for coordinating with governmental and private sector  entities. To determine how DOD, HHS, and DHS coordinate and  participate in training exercises in preparation for a domestic outbreak of  a pandemic disease, we obtained and analyzed DOD’s and DHS’s  training exercise guidance to identify joint training exercises,  documentation, and sharing requirements in preparation for a pandemic  disease response. We conducted interviews with DOD, HHS, and DHS  officials to identify the pandemic-related training exercises they conducted  from fiscal year 2011 through 2015. We selected this time period because  these were the most recent fiscal years for which there is complete  information available. From DOD and the Federal Emergency  Management Agency (FEMA), we also obtained after-action reports and  lessons learned to identify the participants and the type of training  exercises conducted. We determined that the interviews, after-action  reports, and lessons-learned documentation were sufficiently reliable for  the purposes of determining the extent to which DOD and FEMA  conducted or participated in pandemic-related training exercises during  these fiscal years.
To address each of our objectives, we collected and analyzed documents  and interviewed cognizant officials at various DOD offices, including the  Offices of the Under Secretary of Defense for Policy, Office of the  Assistant Secretary of Defense for Homeland Defense and Global  Security, Office of the Assistant Secretary of Defense for Health Affairs,  Office of the Deputy Assistant Secretary of Defense for Homeland  Defense Integration and Defense Support of Civil Authorities, the Joint  Staff, U.S. Northern Command, U.S. Pacific Command, U.S. Southern  Command, the National Guard Bureau, the Defense Intelligence Agency,  U.S. Army Medical Command, U.S. Army Medical Research and Materiel  Command, and the Armed Forces Health Surveillance Branch. We also  collected and analyzed documents and conducted interviews with  cognizant officials at HHS (including the Office of the Assistant Secretary  for Preparedness and Response, the Centers for Disease Control and  Prevention, the Food and Drug Administration, and the National Institutes  of Health), and from DHS (including FEMA). More detailed information on  our scope and methodology can be found in appendix II of this report.
We conducted this performance audit from September 2015 to February  2017 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
subsections: section_title: Roles and Responsibilities
paragraphs: The National Response Framework consists of a base document and two  types of annexes—the Emergency Support Function Annex and the  Support Annex. The 2014 Quadrennial Defense Review notes the  importance of DOD’s role in protecting the homeland and supporting civil  authorities in mitigating the effects of natural disasters such as  pandemics. DOD works closely with other federal agencies to  coordinate the federal response to address the threat of pandemics and  other types of incidents. Under the National Response Framework,  Emergency Support Function (ESF) #8, Public Health and Medical  Services Annex, HHS, DHS, and DOD have specific roles and  responsibilities to support civil authorities and coordinate response efforts  with other federal agencies to address public health and medical  disasters.
Department of Health and Human Services. HHS, through its Assistant  Secretary for Preparedness and Response, leads all federal public  health and medical responses to public health emergencies and other  incidents covered by the National Response Framework and coordinates  with other departments and supporting agencies to accomplish this  mission. Several of its key functions under ESF #8 include activating the National Disaster Medical System as necessary to ensuring the proper disposal of contaminated products and the  decontamination of affected food facilities in order to protect the public  health;  coordinating public health and medical support, patient evacuation,  and movement requirements with other primary and supporting  departments, agencies, and government authorities throughout the  incident; and  coordinating with support agencies—such as DOD—when an incident  requires federal assistance above and beyond its interagency  mechanisms.
Department of Homeland Security. DHS serves as the lead for  interagency coordination and planning for emergency response. Several  of its key functions under ESF #8 include assisting in providing information and liaison with emergency arranging transportation to evacuate patients who are too seriously ill  or otherwise incapable of being evacuated in general evacuation  conveyances; and arranging for the use of U.S. Coast Guard aircraft and other assets in  providing urgent airlift and other transportation support.
Department of Defense. DOD is responsible—subject to the availability  of resources and the direction of the President or by approval of the  Secretary of Defense—for providing support functions and supplementing  civil authorities’ resources in response to public health and medical  disasters. Several of its key functions under ESF #8 include providing military personnel for casualty clearing or staging and other providing support for the evacuation of patients to locations where  hospital care or outpatient services are available; and providing military personnel to assist in the protection of public health  by providing, for example, food, water, wastewater removal, solid  waste disposal, hygiene, and vector control.  (See appendix III for a more complete discussion of these federal  agencies’ roles and responsibilities in support of the National Response  Framework through ESF #8.)
section_title: Process for Requesting DOD Support
paragraphs: DOD typically provides support in response to a formal request for  assistance (RFA) from other federal departments or agencies and—in  cases where response is needed immediately—from state, local, or tribal and territorial governments. Support provided in response to such RFAs  may help these civil authorities to prepare for, prevent, protect against,  respond to, and recover from domestic incidents, including terrorist  attacks and major disasters. DOD assets are usually requested if other  federal, state, local, and tribal assets are not available. However, DOD  resources are not typically required to respond every domestic incident.  DOD resources can be made available to support disaster response  through a presidential declaration. For example, according to the Robert  T. Stafford Disaster Relief and Emergency Assistance Act (commonly  referred to as the Stafford Act), when a state’s capabilities and resources  are overwhelmed and the President declares an emergency or disaster,  the state Governor can request assistance from the federal government.  The Stafford Act gives the President the authority to establish a program  of disaster preparedness and response support. Homeland Security  Presidential Directive-5 designates the Secretary of Homeland Security  as the principal federal official for domestic incident management.  Defense resources are committed only after the primary agency submits  a request for assistance, through proper channels, and the President or  Secretary of Defense authorizes DOD to provide support. Such support  may help civil authorities prepare for, prevent, protect against, respond to,  or recover from domestic incidents—including pandemics and major  disasters. Figure 1 illustrates how DOD’s support is obtained through the  current RFA process following a presidential declaration of a major  disaster or emergency.
FEMA currently is developing guidance that will include a standardized  mission assignment process, which will replace the current mission  assignment process. According to FEMA officials, they have not yet  determined when a final version of the guidance will be issued.
section_title: Providing Immediate Response Authority without a Presidential Declaration
paragraphs: Defense support of civil authorities also can be requested and provided  when there has been no presidential declaration. DOD Directive 3025.18,  Defense Support of Civil Authorities, authorizes immediate response  authority for providing support. This can be invoked when DOD is  requested to respond to an incident under imminently serious conditions  when time does not permit approval from a higher authority. Upon request  from a civil authority, DOD officials may employ resources under their  control for up to 72 hours, subject to any supplemental direction provided  by higher headquarters, to save lives, prevent human suffering, or  mitigate great property damage within the United States. Immediate  response authority does not permit actions that would subject civilians to  the use of military power that is regulatory, prescriptive, proscriptive, or  compulsory. In addition, the Economy Act permits one federal agency to  request the support of another federal agency, provided that the  requested services cannot be obtained more cheaply or conveniently by  contract. Under this Act, a federal agency with lead (primary)  responsibility may request the support of DOD without the presidential  declaration of emergency required by the Stafford Act. Finally, DOD may  provide health services—as a supporting agency to HHS—in accordance  with the National Disaster Medical System, following HHS’s declaration of  a public health emergency. According to DOD guidance, for the purpose  of activating the National Disaster Medical System, a public health  emergency may include a public health emergency declaration by the  Secretary of Health and Human Services or a declaration of a disaster or  emergency pursuant to the Stafford Act.
section_title: DOD Has Guidance and Plans to Support Civil Authorities during a Pandemic
paragraphs: DOD has developed guidance and plans at various levels to direct its  efforts to provide assistance in support of civil authorities in the event of a  domestic outbreak of a pandemic disease. The Department of Defense  Global Campaign Plan for Pandemic Influenza and Infectious Diseases  3551-13, issued in 2013, provides overarching guidance to DOD and  the military services on how to plan and prepare for a pandemic outbreak.  According to a DOD official, other DOD guidance—such as the Guidance  for the Employment of the Force—directs U.S. Northern Command and  U.S. Pacific Command to be prepared to provide defense support of civil  authorities and the Joint Strategic Capabilities Plan specifies how this  should be accomplished.
According to the Global Campaign Plan, U.S. Northern Command is  designated by DOD as the global synchronizer for influenza pandemic  and infectious disease plans. In this role, U.S. Northern Command is  responsible for providing strategic planning guidance for the department’s  efforts to prepare for and respond to pandemic diseases. This guidance  directs the geographic combatant commands and the military services to  develop influenza pandemic and infectious disease plans and to  coordinate and synchronize those plans with the Global Campaign Plan.  As the lead synchronizer, U.S. Northern Command is responsible for  ensuring that plans developed by the combatant commands and military  services are aligned with the Global Campaign Plan in areas such as  biosurveillance and disease monitoring and sharing best practices;  among other responsibilities. U.S. Northern Command’s CONPLAN   3591-09 Response to Pandemic Influenza provides guidance to U.S.  Northern Command decision makers on identifying the capabilities and  forces needed to maintain the defense of the homeland while limiting the  long-term effect of a pandemic on the security, health, and safety of the  nation. This plan explains how U.S. Northern Command would respond to  a pandemic outbreak by identifying capabilities—such as personal protective equipment and medical countermeasures—to prevent human- to-human transmission. The plan also includes key assumptions about  how a pandemic could affect DOD’s ability to provide homeland defense.  For example, the plan states that an absentee rate of 40 percent among  DOD personnel, occurring at the height of a severe pandemic wave,  could affect U.S. Northern Command’s ability to protect the homeland and  result in fewer resources being available to support requests for support  from civil authorities. The Homeland Defense mission can be performed  only by DOD and thus is its first priority. The pandemic response  ultimately is the responsibility of state, local, and tribal and territorial  authorities, and with the support of other federal agencies. The plan  states that an influenza pandemic would cause unprecedented illness,  death, and disruption to normal patterns of life, resulting in emotional,  psychological, spiritual, and physical pressures on U.S. Northern  Command’s forces. The plan states that the combatant command will  mitigate the risk of a pandemic by synchronizing planning within the  department and with other elements of national power (i.e., diplomatic,  informational, military, and economic) to support U.S. government  strategies and objectives embodied in the National Strategy for Pandemic  Influenza. In addition, the plan states that the combatant command will  coordinate resources with federal departments and agencies to ensure  that preparedness and response efforts are prioritized and resourced to  respond to a pandemic.
Other combatant commands also have developed plans for providing  support in the event of a pandemic. According to an official from U.S.  Northern Command, currently all six of the geographical combatant  commands have pandemic influenza and infectious disease plans for  their assigned areas of responsibility. The remaining three ‘functional”  combatant commands, which include the U.S. Special Operations  Command, have not developed pandemic influenza and infectious  disease plans because they operate in support of and within the  supported geographical combatant command’s area of responsibility.
For example, U.S. Pacific Command’s CONPLAN 5003-13, Commander  United States Pacific Command Concept Plan for Pandemic and  Emerging Infectious Diseases, fulfils strategic guidance to prepare for and  maintain response plans for pandemic and emerging infectious diseases  for regional execution in support of U.S. Northern Command’s Global  Campaign Plan. According to U.S. Pacific Command officials, CONPLAN  5003-13 serves as an operational framework for interagency and  international collaboration, DOD coordination, and synchronization of a  whole-of-government response to pandemics and infectious diseases.  Specifically, U.S. Pacific Command’s CONPLAN 5003-13 states that the  combatant command will adopt an active, layered defense with respect to  a disease of operational significance. The plan for such a defense  consists of the following six phases:
Phase 0 (Prepare): security cooperation and partner activities aimed  at building the capacity of partner nations and partner nation militaries  in coordination with the host nation, the international health  community, and federal agencies.
Phase 1 (Protect): identification and characterization of a disease of  operational significance.
Phase 2 (Mitigate): more significant DOD actions to further protect  the force and maintain mission assurance.
Phase 3 (Respond): requests for defense support of civil authorities  related to pandemics or emerging infectious diseases, or for foreign  humanitarian assistance, have been received and authorized through  the request for assistance process.
Phase 4 (Stabilize): maintaining appropriate force protection and  force health protection measures and finalizing defense support of  civil authorities and force health protection requests related to  pandemic emerging and infectious diseases.
Phase 5 (Transition and Recovery): redeploying forces while  maintaining vigilance for a potential second wave outbreak of a  pandemic or emerging infectious disease.
In addition, the plan assumes that certain challenges could affect military  personnel’s ability to support civil authorities in responding to a pandemic.  For example, the plan states that a disease of operational significance  could, among other things, create a global pandemic with the potential of  incapacitating upwards of 40 percent of the workforce worldwide. Beyond  its primary negative effects, a disease of operational significance could  have secondary and tertiary effects, which could significantly threaten the  economic, political, and social stability of nations and regions.
The military services have developed plans to contain and mitigate the  effects of pandemic influenza and infectious diseases. For example, the  Army’s Pandemic Influenza and Infectious Disease Plan states that the  Army will support geographic combatant commands to contain or mitigate  the effects of an influenza pandemic or infectious disease of operational  significance. The plan also states that the Army will conduct theater and  functional planning to protect the personnel and resources necessary to  maintain readiness to sustain mission assurance and support, as  directed, other U.S. government efforts to protect the nation’s welfare, to  include assisting partner countries. According to an official in the Office of  the Assistant Secretary of Defense for Homeland Defense Integration and  Defense Support of Civil Authorities, the Army, the Navy, and the Air  Force have provided installations with guidance necessary to develop  installation-level disease containment plans to ensure force health  protection and continuity of operations in response to pandemics, and  direct coordination with state and local authorities.
According to the Strategy for Homeland Defense and Support to Civil  Authorities, DOD often is expected to play a prominent supporting role to  primary federal agencies in their response efforts. According to officials in  the Office of the Deputy Assistant Secretary of Defense for Homeland  Defense Integration and Defense Support of Civil Authorities, in the event  of a pandemic, DOD’s support would be most useful in providing unique  military capabilities, such as logistics and transportation, to distribute  medical supplies and other assets to an affected site. Moreover, in  anticipation of requests for this type of assistance, these officials said that  because DOD has this role, it is critical that those primary agencies be  aware of DOD’s capabilities in a given scenario. Furthermore, the  strategy states that DOD historically has supported civil authorities in a  wide variety of domestic contingencies, often in response to natural  disasters. However, the 21st century security environment, the  concentration of population in major urban areas, and the interconnected  nature of critical infrastructures have all combined to fundamentally alter  the scope and scale of “worst case” incidents for which DOD might be  called upon to provide support. This environment creates the potential for  complex catastrophes, with effects that would qualitatively and  quantitatively exceed those experienced to date. In such events, the  demand for defense support of civil authorities would be unprecedented.
Meeting this demand would be especially challenging if, for example, a  cyber attack, or other electrical power grid disruption creating cascading  failures of critical infrastructure, or DOD’s capabilities being limited if a  pandemic were to threaten lives and greatly complicate DOD response  operations. According to Joint Publication 5-0, Joint Operation Planning,  an important consideration in effective planning is to anticipate certain  events. This publication also states that the body of knowledge and  understanding created during DOD’s planning allows commanders to  monitor, assess, and adapt to uncertain and changing environments and  to anticipate and act proactively in crisis situations.
According to officials in the Office of the Deputy Assistant Secretary of  Defense for Homeland Defense Integration and Defense Support of Civil  Authorities, there may be expectation gaps between DOD and primary  agencies regarding DOD’s capabilities to provide support. Primary  agencies coordinate with support agencies—such as DOD—when an  incident requires more capabilities than those primary agencies can  provide, such as materiel movement during a pandemic. These officials  said that while HHS and FEMA can usually rely on DOD during natural  disasters, including a pandemic, should support capabilities from primary  sources (e.g., other local, regional, state, and federal agencies, non- governmental organizations, and the private sector) become  overwhelmed, DOD might not always be in a position to provide  requested assistance because its capabilities may be limited.
section_title: HHS and DHS Have Plans to Respond to a Pandemic, but Their Plans Do Not Explain How They Would Respond If DOD’s Capabilities Are Limited, and Coordination Mechanisms Among the Three Agencies Exist That Could Enhance Their Preparedness
paragraphs: HHS and DHS have plans to guide their responses to a pandemic, but  their plans do not explain how they would respond in a resource- constrained environment where state and local capabilities are  overwhelmed or unavailable, and other federal capabilities, like DOD’s,  are limited. In addition, DOD, as well as HHS and DHS, through FEMA,  use existing mechanisms to coordinate their pandemic preparedness and  response. These three departments also have conducted joint training  exercises to test plans, improve proficiency, and assess capabilities and  readiness to plan, prepare for, and respond to pandemic outbreaks.
subsections: section_title: HHS and DHS Have Plans for Coordinating Pandemic Preparedness and Response But They Do Not Include Guidance on How They Would Respond If DOD Were Unable to Assist
paragraphs: HHS’s Pandemic Influenza Plan is its blueprint for influenza pandemic  preparedness and response. The plan assigns lead roles and  responsibilities for response actions to specific HHS agencies and offices.  HHS’s plan also outlines planning assumptions for its influenza pandemic  response, but it is not intended to address what actions other agencies  are to take during a pandemic. For example, it outlines assumptions that  must be considered in strategic planning, including the ability of an  influenza virus to spread rapidly worldwide. In addition, the plan  assumes that there would be large demands on the health care system  and potential national and community disruption as a result of the  widespread illness.
The Secretary of Health and Human Services serves as the lead for all  federal public health and medical response to public health emergencies,  as previously noted, under ESF #8 and incidents covered by the National  Response Plan or its update. In addition, the National Response  Framework, which is DHS’s guidance for coordinating national support to  respond to an emergency—such as a pandemic—recognizes HHS as the  primary federal agency to respond to public health emergencies and  incidents. The National Response Framework also designates primary  agencies—such as HHS—to oversee preparedness activities through  ESF #8, monitor progress in meeting core capabilities, and coordinate  with both primary and support agencies through training exercises and  other activities. Under ESF #8, DOD may be expected to provide support capabilities, such as logistical support, to public health and  medical response operations, evacuation of patients to locations where  hospital care is available, medical supplies for distribution to mass care  centers, and assistance in managing human remains—including victim  identification and mortuary affairs. (Appendix III lists DOD’s roles and  responsibilities to support the National Response Framework.) ESF #8  serves as a key mechanism to assist HHS in its pandemic preparedness  and response because, according to the National Response Framework,  emergency support functions bring together the capabilities of federal  departments and agencies and other national-level assets.
In addition, according to the National Response Framework, the  Secretary of Homeland Security is responsible for coordinating  preparedness activities within the United States to respond to and recover  from major disasters and emergencies. The Secretary’s responsibilities  also include managing FEMA’s emergency management and response  authorities. According to DHS’s Response Federal Interagency  Operational Plan, primary and support agencies involved in implementing  federal emergency support functions conduct contingency and  operational planning in conjunction with federal, state, local, tribal, and  territorial authorities and the private sector.
According to officials with HHS’s Office of the Assistant Secretary for  Preparedness and Response, mechanisms such as interagency dialogue  and coordination among federal, state, and local entities are often used to  determine what resources would be needed during a pandemic. For  example, HHS officials said that surge capabilities, such as capabilities  developed through the local Hospital Preparedness Program, could be  used to support the local response effort prior to requesting state or  federal assistance. HHS officials stated that there are other existing  mechanisms, such as the Public Health Emergency Medical  Countermeasures Enterprise and Enterprise Executive Committee, which  consists of senior program managers across the partner agencies who  address issues such as influenza pandemic preparedness and response  capabilities, among other issues. Influenza Risk Management Meetings  are another existing mechanism that provides partner agencies with a  venue to discuss their influenza pandemic response.
HHS and DHS plans also do not specifically address what resources  would be needed to support a response to a pandemic in an environment  where federal resources, including DOD, are exceeded by demands.  HHS officials stated that there would be no way of knowing in advance  what unique facts, circumstances, or conditions might occur to determine  what resources would be needed. The National Response Framework  notes the importance of planning as a core capability to manage the life  cycle of a potential crisis, determine capability requirements, and help  stakeholders learn their roles. Planning includes the analysis and  dissemination of risk assessment data, and the development of plans,  procedures, mutual aid and assistance agreements, strategies, and other  arrangements to perform specific missions and tasks to improve incident  preparedness and response. When planning for an incident, such as a  pandemic, governments at all levels have a responsibility to develop  continuity plans that identify essential functions, succession and  delegation of authority, continuity facilities, communication capabilities,  and human resource issues. HHS and DHS are in the process of  updating their pandemic plans, which presents an opportunity for them to  coordinate with each other and with DOD to determine the appropriate  actions to take—training exercises, pre-scripted mission assignments, or  other coordination activities—should DOD’s support be limited during a  pandemic.
Finally, according to the Global Campaign Plan, large-scale, sustained  military conflicts in multiple theaters of operation could severely degrade  DOD’s capabilities and capacities to support civil authorities in responding  to a pandemic. Although DOD may have personnel and equipment  available to some degree to support civil authorities, it may not have the  appropriate number or type of personnel, equipment, or training available  to provide adequate support. According to an official in the Office of the  Deputy Assistant Secretary of Defense for Homeland Defense Integration  and Defense Support of Civil Authorities, DOD is not funded for defense  support of civil authority missions and must adapt funded military  capabilities to conduct such missions.
section_title: DOD Coordinates Internally, with HHS, and with DHS through FEMA to Prepare Its Pandemic Response
paragraphs: DOD uses various mechanisms, including planning activities, interagency  work groups, liaison officers, and training exercises both to coordinate  within the department and its support with HHS and with DHS through  FEMA. For example, according to DOD officials, DOD coordinates among  its own organizations, such as the combatant commands and military  services, to develop pandemic response plans. Specifically, Joint Staff  officials stated they collaborate with the Office of the Secretary of  Defense, the combatant commands, and the military services to establish  guidance for providing support to civil authorities. We previously reported  that U.S. Northern Command faced challenges involving coordination with  interagency partners and the states in planning, conducting, and  assessing exercises. We recommended that DOD coordinate with DHS  and FEMA to develop guidance and consistently involve state officials in  planning, executing, and assessing exercises that incorporate relevant  state-specific information. In response, DOD stated that it continues to  expand its efforts to ensure that states are able to benefit from  participation in DOD-sponsored exercises.
According to officials from the Office of the Assistant Secretary of  Defense for Homeland Defense Integration and Defense Support of Civil  Authorities, the Joint Staff and the U.S. Pacific Command, DOD  coordinates formally and informally with HHS and DHS to identify  capability requirements for supporting civil authorities in the event of a  pandemic outbreak. For example, officials from the Office of the Assistant  Secretary of Defense for Homeland Defense Integration and Defense  Support of Civil Authorities and FEMA stated DOD actively is participating  in interagency planning efforts to develop FEMA’s Biological Incident  Annex. FEMA currently is updating the Biological Incident Annex that,  according to FEMA officials, will include for the first time information on  influenza pandemic and infectious disease guidance. As a member of the  Public Health Emergency Medical Countermeasures Enterprise, DOD  coordinates with HHS through formal working groups and interagency  agreements to develop medical countermeasures for pandemic  outbreaks. According to HHS officials, this interagency collaboration  helped to develop and distribute diagnostics and vaccines for the 2009  H1N1 influenza pandemic and the antibody therapeutics for the 2014-15  Ebola epidemic (see figure 2). In addition, officials in the Office of the  Assistant Secretary of Defense for Health Affairs stated the DOD officials  sit on the National Security Council’s Sub-Integrated Policy Committee on  Pandemic Preparedness, which oversaw interagency implementation of  the National Strategy for Pandemic Influenza.
According to DOD, HHS, and DHS officials, the three agencies each have  liaison officers located in the others to collaborate on federal response  plans and facilitate and coordinate requests for DOD assistance. FEMA  officials stated that DOD’s primary mechanism for coordination with state  and local entities is through the Defense Coordinating Officer and FEMA  staff. According to officials with U.S. Northern Command, Defense  Coordinating Officers assist in regional integrated disaster planning and  coordination activities and help identify specific capabilities that DOD is  likely to be asked to provide in support of specific civil authorities’ disaster  responses. During an incident response, the Defense Coordinating  Officer would integrate with the federal coordinating officer and, upon  receiving a request for DOD assistance, would help tailor the request to  leverage key DOD capabilities and then submit the request to U.S.  Northern Command to begin the Secretary of Defense approval process.  FEMA officials stated that Defense Coordinating Officers are integrated  with their assigned FEMA regions, and therefore they know what  capabilities are being requested and what capabilities DOD has available  to respond to these requests. Further, officials from DOD, HHS, and  FEMA stated that DOD has conducted or participated in training  exercises with HHS and DHS to assess its capabilities for responding to a  pandemic outbreak.
section_title: DOD, HHS, and FEMA Have Conducted Joint Pandemic-Related Training Exercises and Disseminated After-Action Reports and Lessons Learned
paragraphs: To prepare for a pandemic outbreak, DOD, HHS, and FEMA conducted  joint training exercises from 2011 through 2015, the most recent fiscal  years for which there is complete information available on training  exercises. Exercises play an instrumental role in preparing these  agencies to respond to an incident by providing opportunities to test  plans, improve proficiency, and assess capabilities and readiness. Short  of performance in actual operations, exercises provide the best means to  assess the effectiveness of organizations in achieving mission  preparedness. Exercises also provide an ideal opportunity to enhance  preparedness by collecting, developing, implementing, and disseminating  lessons learned and verifying that corrective action has been taken to  resolve previously identified issues.
These exercises have included state and local agencies and private  sector organizations. For example, according to documentation obtained  from U.S. Northern Command, in July 2015, U.S. Northern Command  conducted Vista Express, an infectious disease training exercise that  included a weaponized anthrax scenario. Over 80 individuals from 29  organizations participated, including individuals from DHS, FEMA, other  federal agencies, and private organizations. According to HHS officials, in  2011 HHS hosted exercises to test public health plans, processes, and  procedures to respond to an anthrax outbreak. Participants included  representatives from state, local, tribal, territorial and federal agencies. In  September 2013, the National Security Staff sponsored an exercise for  senior-level federal government executives to discuss interagency plans  for response to pandemics, including agency roles and responsibilities.  While HHS and DHS have conducted joint training exercises with DOD,  they have not exercised a pandemic outbreak scenario in which DOD  capabilities are limited. In addition, DOD has not exercised a pandemic  outbreak scenario with HHS and DHS. DOD officials believe that an  exercise in which DOD participates—but for which it provides limited  capabilities or none at all—would be useful in preparing for a pandemic  response. However, U.S. Northern Command has not participated in such  an exercise.
DOD, HHS, and DHS have issued after-action reports and have  documented lessons learned information from the training exercises they  have conducted, and they have shared these documents with each other.  Specifically, U.S. Northern Command provides external partners with  access to its website to provide lessons-learned information. In addition,  our analysis of U.S. Northern Command and U.S. Pacific Command after- action reports and other exercise information related to pandemic  response for fiscal years 2011 through 2015 indicated that lessons  resulting from training exercises, or from a real-world event such as the  Ebola outbreak, are summarized in after-action reports or other  documentation. According to U.S. Pacific Command officials, federal,  state, and local entities can access DOD’s Joint Lessons Learned  Information System, through a registered account, to retrieve after-action  reports and other information, consistent with DOD’s security  requirements. Otherwise, these entities would need to request after- action reports and other information either from the organization that  conducted the training exercise or from the Joint Staff.
According to HHS officials, HHS prepares an after-action report or a  summary of conclusions for each pandemic-related training exercise.  They stated that after-action reports or other documentation are  disseminated through electronic mail to all participants in a training  exercise. Agencies that do not participate in the training exercises but are  involved in pandemic response efforts also are provided this  documentation. While this documentation is not shared with a broad  audience, HHS officials said that it is available to DOD stakeholders upon  request, and as soon as it is approved for broad release, it is shared with  all participants. Further, HHS has access to DOD’s Joint Lessons  Learned Information System, and thus can access the reports posted   on it.
Similarly, our analysis of FEMA documentation from fiscal years 2013  through 2015 indicated that FEMA also documented lessons learned  resulting from pandemic-related training exercises. FEMA managed its  Lessons Learned Information System as an independent system through  2015; however, FEMA has since consolidated this system with the Naval  Postgraduate School’s Homeland Security Digital Library. According to  FEMA officials, federal agencies can access FEMA’s published lessons- learned information through DOD’s Joint Lessons Learned Information  System or by requesting such information from FEMA. Federal agencies  without access to DOD’s Joint Lessons Learned Information System can  obtain historical lessons-learned information through the Homeland  Security Digital Library or directly from FEMA. According to a FEMA  official, FEMA also encourages exercise sponsors to publish their reports  on the Homeland Security Information Network. In addition, FEMA,  DOD, and several other federal agencies coordinate and share lessons- learned information through monthly interagency planners’  teleconferences, exercise planning workshops, and an annual DOD  conference.
section_title: Conclusions
paragraphs: DOD has developed plans for how it could, if requested, provide support  to civil authorities in the event of a pandemic. HHS and FEMA plans  contain guidance to respond to a pandemic, but they do not address a  scenario in which DOD’s capabilities are limited. DOD, HHS, and DHS  also have coordination mechanisms to respond to a pandemic, but they  may have an expectation gap regarding the capabilities DOD can provide.  Unless DOD, HHS, and DHS explore opportunities to enhance their  existing coordination mechanisms—such as working groups, Defense  Coordinating Officers, and training exercises—to identify approaches for  responding to a pandemic in the event that DOD’s capabilities are limited,  HHS and FEMA risk being unprepared to respond. Given that a severe  pandemic is a unique type of disaster and could affect a significant  portion of the U.S. population, including both civilian and military  personnel, further planning would help HHS and DHS, as well as DOD, to  improve their planning and preparation in response to a pandemic. HHS  and DHS are in the process of updating their plans, which presents an  opportunity for them to coordinate with each other and with DOD to  determine the appropriate actions to take should DOD’s support be  limited during a pandemic. Doing so could further position the federal  government to be better prepared to respond to a severe pandemic  outbreak should one occur.
section_title: Recommendations for Executive Action
paragraphs: We are making three recommendations, one each to DOD, HHS, and  FEMA, to use existing coordination mechanisms to improve their  preparedness and response to a pandemic if DOD’s capabilities are  limited.
As DOD plans to respond to a pandemic, we recommend that the  Secretary of Defense direct the Under Secretary of Defense for Policy  and other DOD officials, as appropriate, to use DOD’s existing  coordination mechanisms with HHS and FEMA to explore opportunities to  improve their preparedness and response to a pandemic if DOD’s  capabilities are limited.
As HHS plans to respond to a pandemic, we recommend that the  Secretary of Health and Human Services direct the Assistant Secretary  for Preparedness and Response to use HHS’s existing coordination  mechanisms with DOD and FEMA to explore opportunities to improve  their preparedness and response to a pandemic if DOD’s capabilities are  limited.
As DHS, through FEMA, plans to respond to a pandemic, we recommend  that the Secretary of Homeland Security direct the Administrator of FEMA  to use FEMA’s existing coordination mechanisms with DOD and HHS to  explore opportunities to improve their preparedness and response to a  pandemic if DOD’s capabilities are limited.
section_title: Agency Comments and Our Evaluation
paragraphs: In written comments on a draft of this report, DOD, HHS, and DHS  agreed with all three of our recommendations and discussed steps they  plan to take to address these recommendations. The full text of DOD’s,  HHS’s, and DHS’s written comments are reprinted in their entirety in  appendixes IV, V, and VI, respectively. DOD and HHS also provided us  with technical comments, which we incorporated in the report as  appropriate.
DOD concurred with our recommendation to use its existing coordinating  mechanisms with HHS and FEMA to explore opportunities to improve  their preparedness and response to a pandemic if DOD’s capabilities are  limited. DOD stated that it would work with HHS—the primary agency for  public health and medical services and the lead for pandemic planning— and DHS to explore opportunities that leverage existing coordination  mechanisms in identifying the full spectrum of resources from federal,  state, local, and private sector entities for pandemic preparedness and  response. We believe these actions, if fully implemented, will address our  recommendation.
HHS concurred with our recommendation with comments explaining how  it will use its existing coordination mechanisms with DOD and FEMA to  explore opportunities to improve their preparedness and response to a  pandemic if DOD’s capabilities are limited. HHS stated that it would  ensure that the issue of limited support from DOD during a pandemic is  included in its analysis and rewrite during its next review of its Pandemic  Annex to the All-Hazards plan. We believe these actions, if fully  implemented, will address our recommendation.
DHS concurred with our recommendation to use FEMA’s existing  coordination mechanisms with DOD and HHS to explore opportunities to  improve their preparedness and response to a pandemic if DOD’s  capabilities are limited. In its written response, FEMA agreed that  strengthening established relationships with its DOD and HHS partners,  including conducting planning events and live exercises, are cornerstones  to increased preparedness for all interagency partners tasked with  emergency response. FEMA stated that its Office of Response and  Recovery planners will continue to explore opportunities to improve and  update pandemic preparedness plans by incorporating key planning  assumptions, restraints, constraints, post-exercise lessons learned, and  other relevant factors related to scenarios in which DOD support is  limited. FEMA noted that its planning efforts would be completed by  March 13, 2017. We believe these efforts will enhance FEMA’s ability to  improve its preparedness and response to a pandemic should DOD  support be limited and, if fully implemented, will address our  recommendation.
We are sending copies of this report to the appropriate congressional  committees; Secretaries of Defense, Health and Human Services, and  Homeland Security; the Under Secretary of Defense for Policy; the  Assistant Secretary of Defense for Homeland Defense and Global  Security; the Assistant Secretary of Defense for Health Affairs; the Deputy  Assistant Secretary of Defense for Homeland Defense Integration and  Defense Support of Civil Authorities; the Chairman of the Joint Chiefs of  Staff; the Department of Defense Inspector General, the Commanders,  U.S. Northern Command, U.S. Pacific Command, and U.S. Southern  Command; the Secretaries of the Army, the Navy, and the Air Force; the  Commandant of the Marine Corps; the Chief, National Guard Bureau; the  Director of the Defense Intelligence Agency; the Commanders, U.S. Army  Medical Command and U.S. Army Medical Research and Materiel  Command; the Chief of the Armed Forces Health Surveillance Branch;  and the Directors, Centers for Disease Control and Prevention, Food and  Drug Administration, National Institutes of Health, Federal Emergency  Management Agency, and Office of Management and Budget.
If you or your staff have any questions concerning this report, please  contact Joseph Kirschbaum at (202) 512-9971 or KirschbaumJ@gao.gov.  Contact points for our Offices of Congressional Relations and Public  Affairs may be found on the last page of this report. GAO staff who made  key contributions to this report are listed in appendix VII.
section_title: Appendix I: DOD’s Preparedness, Detection of, and Response to Zika Virus
paragraphs: The Department of Defense (DOD) also assists federal agencies in  combating other non-pandemic viruses that have occurred, such as the  recent Zika virus. DOD has taken steps to establish preparedness,  detection, and response measures to deal with the Zika virus. In February  and March 2016, DOD issued guidance on surveillance, control, and  testing to DOD medical and force health protection personnel, military  services, and installations, and the combatant commands regarding,  among other things, prevention, diagnosis, and treatment of the virus.  DOD has no dedicated budget for Zika virus preparedness, detection, and  response, but it recently provided about $2 million to military laboratories  to expand Zika virus surveillance worldwide and assess the virus’s effect  on deployed service members’ health and readiness. In addition, funds  from DOD’s Humanitarian Assistance Program have been used to  purchase equipment and supplies in support of U.S. Southern  Command’s Zika prevention projects in several Latin American countries.  Further, National Guard units have received funding from the National  Guard Bureau’s State Partnership Program to provide vector (i.e.,  mosquito) control and provide personal protective training to partner  nations.
The Zika virus is transmitted to humans predominantly through the bite of  an infected Aedes aegypti or Aedes albopictus mosquito. Infected  individuals may experience fever, rash, and muscle and joint pain for a  short period. Human-to-human transmission is also possible through  sexual contact, blood transfusions, and from mother to child. Recently,  the Centers for Disease Control and Prevention concluded that Zika virus  infection during pregnancy is a cause of microcephaly and other severe  fetal brain defects;  thus, pregnant women are at particular risk. In  addition, the Zika virus is possibly associated with the Guillain-Barré  syndrome, a rare disorder in which the body’s immune system attacks  part of the nervous system in infected adults; however, this association  has not been firmly established.
There currently is no vaccine available to prevent infection by the Zika  virus. Because of the risk to pregnant women, DOD has issued guidance  to the military departments and combatant commands to determine if they  should allow relocation and temporary assignment for pregnant service  members, DOD employees, and their dependents in areas outside the  United States where the Zika virus is being actively transmitted. U.S.  Northern Command, U.S. Pacific Command, and U.S. Southern  Command each have issued guidance on health protection measures to  control the spread of the virus and guidance to pregnant service  members, DOD personnel, and dependents to consult their health care  providers on the risk of the Zika virus before they travel. The guidance  also states service members, DOD personnel, and dependents who  suspect they have been infected with the virus should consult their health  care provider.
Figure 3 shows a close-up photograph of the Aedes aegypti mosquito, the  species primarily responsible for the spread of the Zika virus.
According to Armed Forces Health Surveillance Branch (AFHSB) officials,  the AFHSB tracks the Zika virus among military service members, DOD  civilians, and their dependents and provides weekly surveillance reports  to DOD on how the virus is spreading. AFHSB also has issued guidance  giving direction to military treatment facilities and laboratories. DOD  medical facilities have been notified of the concerns surrounding Zika  virus infections and are prepared to test patients who may have been  infected. As of August 3, 2016, DOD had reported that 41 active duty,  reserve, and National Guard members had been diagnosed with Zika,  including one service member who is pregnant. An additional seven  family members have been diagnosed with Zika. According to DOD  officials, at least 13 DOD laboratories currently are equipped to test  human specimen samples for the Zika virus. DOD officials stated that  researchers at the Uniformed Services University of the Health Sciences,  Walter Reed Army Institute of Research, and Naval Medical Research are  developing vaccines, diagnostic tests, and treatments for Zika and related  viruses. Recently, DOD researchers indicated that the results of vaccine  tests in non-human primates have proven effective and DOD has  advanced efforts to proceed with conducting human trials. DOD officials  stated that the department also is collaborating with the Department of  Health and Human Services, Assistant Secretary for Preparedness and  Response/Biomedical Advanced Research and Development Authority,  and National Institutes of Health/National Institute of Allergy and  Infectious Diseases, and the Centers for Disease Control and Prevention  to develop, manufacture, and test a Zika vaccine.
According to U.S. Pacific Command officials, the first documented  outbreaks of the Zika virus occurred in 2007 in the South Pacific, on Yap  Island, in the Federated States of Micronesia. Between 2013 and 2015,  outbreaks occurred on a number of Pacific islands, including French  Polynesia and the Cook Islands. U.S. Pacific Command recently issued  guidance to service members and DOD civilians to take precautions when  traveling to areas affected by the Zika virus.
According to U.S. Southern Command officials, two Army National Guard  units were dispatched earlier this year to Guyana and Suriname to  provide subject matter expertise in combatting the spread of the Zika  virus. In addition, officials said that the command is testing for the Zika  virus at the Navy Research Medical Unit in Peru. Further, U.S. Pacific  Command officials stated the command is collaborating closely with the  Pan American Health Organization and other U.S. federal agencies, such  as the U.S. Agency for International Development, to conduct needs  assessments for regional ministries to mitigate the effects of the mosquito  that carries the Zika virus.
section_title: Appendix II: Objectives, Scope, and Methodology
paragraphs: House Report 114-102, accompanying a bill for the National Defense  Authorization Act for Fiscal Year 2016, included a provision that we  assess the extent of the Department of Defense (DOD) planning to  support civil authorities in the event of a domestic outbreak of a pandemic  disease. This report assesses the extent to which (1) DOD has guidance  and plans for supporting civil authorities in the event of a domestic  outbreak of a pandemic disease, and (2) HHS and DHS have plans to  respond to a pandemic if DOD’s support capabilities are limited, and they  have mechanisms to coordinate their pandemic preparedness and  response with DOD.
To determine the extent to which DOD has guidance and plans for  supporting civil authorities in the event of a domestic outbreak of a  pandemic disease, we obtained and analyzed DOD guidance (e.g., DOD  Directive 3025.18, Defense Support of Civil Authorities), policies (e.g.,  Department of Defense Global Campaign Plan for Pandemic Influenza  and Infectious Disease), and directives, among other guidance, to  determine DOD’s roles and responsibilities. We also obtained federal  guidance such as DHS’s National Response Framework to determine  which primary agencies would rely on DOD’s efforts to support civil  authorities in the event of a domestic outbreak of a pandemic disease,  and DHS’s Response Federal Interagency Operational Plan, which  provides guidance to federal agencies on planning and coordinating  federal response efforts. We compared DOD pandemic planning  guidance with the National Response Framework to identify DOD’s role in  support of primary federal agencies in their response to incidents such as  pandemics. We also reviewed GAO’s prior work on influenza pandemic  planning within DOD and other federal agencies. A list of related GAO  products on influenza pandemics is included at the end of this report.
To determine the extent to which HHS and DHS have plans to respond to  a pandemic if DOD’s support capabilities are limited, and they have  mechanisms to coordinate their pandemic preparedness and response  with DOD, we obtained and analyzed pandemic planning guidance, such  as HHS’s Pandemic Influenza Plan, DHS’s National Response  Framework, and Federal Interagency Operational Plans to identify these  primary agencies’ roles and responsibilities in support of civil authorities  and in the event of a severe disease pandemic. We also identified— through interviews with agency officials and a review of guidance  documents and plans—the mechanisms HHS and DHS use to coordinate  with DOD and other federal, state, local, tribal, and territorial authorities  and the private sector to prepare for a domestic outbreak of a pandemic  disease and determined how coordination occurs among these entities.  We compared HHS and DHS pandemic and response planning guidance  with DOD pandemic planning guidance to determine the unity of effort  among DOD and primary federal agencies to provide capabilities in  support of civil authorities. In addition, we obtained and analyzed policy  and guidance from DOD, HHS, and DHS to identify their roles and  responsibilities for coordinating with governmental and private sector  entities. To determine the extent to which DOD conducts or participates in  training exercises with civil authorities in preparation for a domestic  outbreak of a pandemic disease, we obtained and analyzed DOD and  primary federal agency training exercise guidance to identify joint training  exercises, documentation, and sharing requirements in preparation for a  pandemic disease response. We conducted interviews with DOD, HHS,  DHS, and FEMA to identify the pandemic-related training exercises they  conducted during fiscal years 2011 through 2015. From DOD and FEMA,  we also obtained after-action reports and lessons learned to identify the  training exercise participants and the type of training exercises  conducted. We determined that the interviews, after-action reports, and  lessons-learned documentation were sufficiently reliable for the purposes  of determining the extent to which DOD and FEMA conducted or  participated in pandemic-related training exercises from fiscal years 2011  through 2015, the most current, complete fiscal years available.
To address our objectives, we interviewed cognizant officials at various  DOD offices, including the Office of the Under Secretary of Defense for  Policy, Office of the Assistant Secretary of Defense for Homeland  Defense and Global Security, Office of the Assistant Secretary of Defense  for Health Affairs, Office of the Deputy Assistant Secretary of Defense for  Homeland Defense Integration and Defense Support of Civil Authorities,  the Joint Staff, U.S. Northern Command, U.S. Pacific Command, U.S.  Southern Command, the National Guard Bureau, the Defense Intelligence  Agency, U.S. Army Medical Command, U.S. Army Medical Research and  Materiel Command, and the Armed Forces Health Surveillance Branch.  We also conducted interviews with cognizant officials at HHS (including  the Assistant Secretary for Preparedness and Response, Centers for  Disease Control and Prevention, Food and Drug Administration, and  National Institutes of Health) and DHS, including the Federal Emergency  Management Agency. We interviewed these officials to determine their  agency roles and responsibilities in support of civil authorities during a  pandemic response; the mechanisms DOD and primary federal agencies,  which have the lead in managing the federal response to a domestic  incident, use to coordinate planning and response efforts for a pandemic;  and the joint training exercises to identify potential capability gaps in their  pandemic response plans.
We conducted this performance audit from September 2015 to February  2017 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.
section_title: Appendix III: Summary of Agencies’ Roles and Responsibilities to Support the National Response Framework
paragraphs: Under the National Response Framework, Emergency Support Function  (ESF) #8, Public Health and Medical Services provides the mechanism  for coordinated federal government assistance to supplement state, tribal,  and local resources in response to a public health and medical disaster,  potential or actual incidents requiring a coordinated federal response, or  during a developing potential health and medical emergency. Table 1  below summarizes the roles and responsibilities of the Department of  Health and Human Services, as the primary federal agency, and the  Departments of Defense and Homeland Security and Federal Emergency  Management Agency, as supporting agencies, in response to the  National Response Framework.
section_title: Appendix IV: Comments from the Department of Defense
section_title: Appendix V: Comments from the Department of Health and Human Services
section_title: Appendix VI: Comments from the Department of Homeland Security
section_title: Appendix VII: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contacts named above, GAO staff who made key  contributions on this report include Elizabeth Curda, Acting Director;   Mark A. Pross, Assistant Director; Tracy Barnes, Steve Boyles;   Margaret Holihan; Joanne Landesman; Latrealle Lee; Amie Lesser; and  Amber Sinclair.
section_title: Related GAO Products
paragraphs: Emerging Infectious Diseases: Preliminary Observations on the Zika  Virus Outbreak, GAO-16-470T. Washington, D.C.: March 2, 2016.
Influenza Pandemic: Lessons from the H1N1 Pandemic Should Be  Incorporated into Future Planning, GAO-11-632. Washington, D.C.:   June 27, 2011.
Influenza Pandemic: Monitoring and Assessing the Status of the National  Pandemic Implementation Plan Needs Improvement, GAO-10-73.  Washington, D.C.: November 24, 2009.
Influenza Pandemic: Sustaining Focus on the Nation’s Planning and  Preparedness Efforts, GAO-09-334. Washington, D.C.: February 26,  2009.
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.
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: DOD Has Taken Important Actions to Prepare, but  Accountability, Funding, and Communications Needed to be Clearer and  Focused Departmentwide, GAO-06-1042. Washington, D.C.: September  21, 2006.