Influenza Pandemic: Agencies Report Progress in Plans to Protect Federal Workers but Oversight Could Be Improved
Published: 2012-07-25T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Federal agencies must plan to protect federal workers essential to ensuring the continuity of the countrys critical operations in the event of a pandemic. GAO reported in 2009 that agencies had made uneven progress in developing operational influenza pandemic plans and some agencies were not close to having plans. In addition, there was no real mechanism to monitor agencies progress.
GAO was asked to (1) determine what progress federal agencies report they have made since GAOs 2009 report and identify challenges federal agencies report they face in protecting their workforce during an influenza pandemic, and (2) determine the extent to which oversight of agencies progress is being conducted and how the oversight information is being used.
GAO surveyed the 24 agencies covered by the Chief Financial Officers Act of 1990, conducted a follow-up case study review, and interviewed agency officials responsible for providing guidance to other federal agencies in planning for an influenza pandemic.
section_title: What GAO Found
paragraphs: In 2012, federal agencies reported they had made progress in planning to protect their federal employees during an influenza pandemic. For example:
Twenty-three of 24 federal agencies reported they had completed influenza pandemic plans that address the operational approach they would use to protect their employees in the event of an influenza pandemic. In 2009, 20 agencies reported completing such plans.
All 24 agencies reported that, to reduce employees risk of exposure to influenza, they developed policies or procedures such as telework and avoiding all unnecessary travel. In the 2009 survey, 22 agencies reported developing the former policy and 18 the latter.
All of the agencies reported that they planned for the distribution of hygiene supplies to protect employees whose duties require them to work onsite during an influenza pandemic. In 2009, 18 agencies reported taking this planning step.
However, the agencies reported uneven status in some key areas suggesting some additional oversight is needed. For example, only nine agencies reported they have classified all or most jobs for onsite mission essential functions by exposure risk level. Additional oversight could help in ensuring that, by classifying jobs by exposure risk level, agencies have appropriate measures in place to protect those employees who must carry out mission essential functions that cannot be performed remotely during an influenza pandemic.
There is limited oversight of agencies progress to protect their employees during a pandemic. In 2008, the Homeland Security Council required agencies to certify their pandemic planning status, but according to agencies officials, has not done so since then. As in 2009, GAO interviewed four agenciesDepartment of Health and Human Services, Department of Homeland Security (DHS), Department of Labor, and Office of Personnel Management. Each of these agencies is responsible for providing influenza pandemic continuity of operations guidance, which includes elements such as planning, personnel protection, or workplace options to federal departments and agencies. DHS and the Federal Emergency Management Agency (FEMA) reported they conduct biennial assessments of department and agency continuity capabilities and report the results to the President through the National Continuity Coordinator. However, this assessment does not include planning elements specific to influenza pandemic planning, such as whether federal workers influenza pandemic risk assessments are regularly updated and whether agencies have planned to provide protective measures to mitigate exposure risks. Including such information in the biennial assessment process could provide monitoring, evaluation, and reporting of progress and help focus attention on those areas in which reported progress is uneven.
section_title: What GAO Recommends
paragraphs: GAO recommends that DHS provide additional oversight of agencies pandemic preparedness and help focus attention on areas of uneven progress reported in GAOs survey by directing FEMA to include in its biennial assessments of agencies continuity capabilities consideration of agencies progress in assessing exposure risk levels of occupational exposure, identifying appropriate protective measures, and establishing operational plans to provide such protections for federal workers during an influenza pandemic. DHS concurred with the recommendation.

section_title: Letter
paragraphs: During an influenza pandemic many federal employees will be able to  perform their agencies’ mission essential functions remotely through  telework arrangements, but other federal employees, such as air traffic  controllers, will have to work at assigned locations where there will be an  increased chance of infection due to proximity to others. Anxiety and  concern over working during an influenza pandemic could reduce the  number of critical federal employees available to work. For example,  researchers who studied the attitudes of emergency pre-hospital medical  care providers concluded that absenteeism could significantly impair the  community’s frontline medical response.learned from the 2003 outbreak of Severe Acute Respiratory Syndrome  (SARS) in Toronto was that although health care workers have a duty to   Among the reported lessons  provide care, institutions have a reciprocal duty to support health care  workers so they can do their jobs as effectively and safely as possible.
The HSC was established pursuant to Executive Order 13228, on October 8, 2001, for  purposes of advising and assisting the President with respect to all aspects of homeland  security and serving as a mechanism for ensuring (1) coordination of homeland security- related activities of executive departments and agencies and (2) effective development  and implementation of homeland security policies. Congress subsequently established the  HSC for the purpose of more effectively coordinating the policies and functions of the  federal government relating to homeland security. See Homeland Security Act of 2002,  Pub. L. No. 107-296 (Nov. 25, 2002), 6 U.S.C. § 491 and § 494.
Aviation Administration (FAA) faced unique challenges protecting air  traffic controllers who must perform essential onsite functions during an  influenza pandemic.
In June 2009, we reported that there was no mechanism in place to  monitor and report on agencies’ progress in developing influenza  pandemic plans to protect their workforce and recommended that the  HSC request that the Department of Homeland Security (DHS) monitor  and report to the Executive Office of the President on the readiness of  agencies to continue their operations while protecting their employees in  the event of a pandemic. The HSC noted that it would give serious  consideration to our report findings and recommendations, and DHS said  the report findings and recommendations would contribute to its efforts to  ensure that government entities are well prepared for what may come  next. Given the importance of agencies’ ability to continue operations  while protecting their employees in the event of an influenza pandemic,  you asked us to (1) determine what progress federal agencies report they  have made since our 2009 report and identify challenges federal  agencies report they face in protecting their workforce during an influenza  pandemic; and (2) determine the extent to which oversight of agencies’  progress was being conducted and how the oversight information is being  used.
To address these objectives, we surveyed the 24 agencies covered by  the Chief Financial Officers Act of 1990 (CFO Act) to determine whether  they made progress in their preparedness to protect their workforce since  our 2009 survey and to identify challenges they faced in planning for  protection of their workers. All 24 CFO Act agencies completed the  survey for a response rate of 100 percent. In addition, to better  understand the extent to which influenza pandemic planning had filtered  down to the component and facility levels, we also gathered data from  these levels in our 2012 survey. In our 2009 survey, 15 of 24 agencies  provided examples of key component-level mission essential functions  that could not be performed remotely during an influenza pandemic.  Using those examples, we selected a component from each of these 15  agencies for our 2012 survey and surveyed the agencies to determine  whether they had made plans at lower organizational levels to protect  their employees whose onsite presence was necessary in order to carry  out mission essential functions. In addition to these surveys, we  conducted follow-up work to assess FAA’s progress in addressing the  unique challenges we highlighted in our 2009 report regarding protection  for air traffic controllers who must perform onsite mission essential  functions during an influenza pandemic. Further, we analyzed  documentation of oversight activities and interviewed officials from the  Department of Health and Human Services (HHS), DHS, Federal  Emergency Management Agency (FEMA), Department of Labor’s (Labor)  Occupational Safety and Health Administration (OSHA), and the Office of  Personnel Management (OPM), who were tasked with providing  guidance, policy, or influenza pandemic related expertise to other federal  agencies in planning for an influenza pandemic. Lastly, we reviewed the  Implementation Plan, National Response Framework (NRF), our prior  work assessing influenza, and other relevant literature to help inform our  analyses.
We conducted this performance audit from July 2011 through July 2012 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives. Detailed information on our  scope and methodology appears in appendix III.
subsections: section_title: Background
paragraphs: The federal government employed over 4.3 million federal employees  throughout the United States and abroad in 2010.perform functions across a multitude of sectors, from those vital to the  long-term well-being of the country—such as environmental protection,  intelligence, social work, and financial services—to those directly charged  with aspects of public safety—including corrections, airport and aviation  safety, medical services, border protection, and agricultural safety.
In the event of any emergency, federal employees responsible for their  agencies’ mission essential functions will be expected to continue them in  order to sustain agency operations. 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, as we have witnessed  with the 2009 H1N1 influenza pandemic. 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 because of illness, the need to care for  family members who are sick, or fear of becoming infected.
In response to concerns that the emergence of H5N1 avian influenza (or  bird flu) in Asia in 2003 would mutate and result in a human influenza  pandemic, the President and his HSC issued two planning documents.  Issued in November 2005, the National Strategy for Pandemic Influenzaprovides a high-level overview of the approach that the federal  government will take to prepare for and respond to an influenza  pandemic. The Implementation Plan issued in May 2006 lays out the  broad implementation requirements and responsibilities among the  appropriate federal agencies, including that agencies have operational  influenza pandemic plans that address the protection of federal  employees, and clearly defines expectations of nonfederal entities.
To help federal agencies plan for and respond to an influenza pandemic,  the HSC issued the Key Elements of Departmental Pandemic Influenza  Operational Plans (Key Elements), a checklist for federal agencies to  use in planning their influenza pandemic preparedness. The checklist  includes elements covering plans and procedures, essential functions and  services, safety and health for their employees, communications, human  capital, and information technology (IT) capabilities. The Key Elements  also reference Federal Continuity Directives 1 and 2, which guide the   and instructs agencies to  identification of mission essential functions,include functions that cannot be deferred for 12 weeks or more without  impact to an agency’s mission and nonessential functions that can be  suspended temporarily during an influenza pandemic.
We reported in June 2009 that the HSC requested that federal agencies  certify to the council that they were addressing applicable elements of the   Because  Key Elements checklist in December 2006 and October 2008.the certification process, as implemented, did not provide for monitoring  and reporting as envisioned in the Implementation Plan, we  recommended in our June 2009 report that the HSC request that the  Secretary of Homeland Security monitor and report to the Executive  Office of the President on the readiness of agencies to continue their  operations while protecting their employees in the event of an influenza  pandemic. In commenting on our report, the Acting Executive Secretary  of the HSC noted that the report made useful points regarding  opportunities for enhanced monitoring and reporting within the executive  branch concerning agencies’ progress in developing plans to protect their  workforce. The official also noted that the council would give serious and  careful consideration to the report findings and recommendations. We will  discuss HSC and DHS’s efforts in more detail later in the report.
section_title: Agencies Reported Progress in Planning to Protect Employees during an Influenza Pandemic
subsections: section_title: Additional Agencies Reported Completing Influenza Pandemic Plans to Protect Their Federal Workers
paragraphs: As shown in figure 1, almost all of the agencies we surveyed—or an  increase of three agencies since 2009—reported in 2012 that they have  completed influenza pandemic plans that address the operational  approach for how they would protect their federal employees in the event  of an influenza pandemic. HHS reported that while they will continue to  work towards a final document, they recognize the need for continuous  improvement and incorporation of lessons learned. They describe the  draft influenza pandemic plan as a “living document” that allows for  continuous updates. Because of that, they do not have a target date for  when a final plan will be completed. Additionally, HHS is supporting a  series of research studies on the effectiveness of respirators or surgical  masks to prevent influenza infection and to better understand their role in  workforce protection. HHS reports that pandemic planning is an ongoing  process that is shaped by lessons learned in the field as well as  improvements in the medical and scientific research base.
In addition, 20 agencies reported that their influenza pandemic plans  addressed how they would protect federal employees who maintained  mission essential functions that could not be performed remotely during  an influenza pandemic. Of the four remaining agencies, three of them— including the Department of Education (Education), General Services  Administration (GSA), and Small Business Administration (SBA)— reported all of their mission essential functions could be performed  remotely, and the U.S. Agency for International Development (USAID)  reported that its plan was being updated to include this information.
section_title: Agencies Reported Progress Incorporating Protective Strategies into Their Influenza Pandemic Plans
paragraphs: According to OSHA guidance on protecting workers, the best strategy to  reduce the risk of becoming infected with influenza during an influenza  pandemic is to avoid crowded settings and other situations that increase  the risk of exposure to someone who may be infected. If it is absolutely  necessary to be in a crowded setting, the time spent in a crowd should be  as short as possible. Some basic hygiene and social distancing  precautions, such as encouraging employees to wash their hands or use  a hand sanitizer after they cough, sneeze, or blow their noses, can be   Figure 2 shows progress agencies  implemented in every workplace.reported to have made incorporating various protective strategies since  2009. Specifically, all of the agencies reported that they developed  policies or procedures consistent with this strategy such as telework and  avoiding all unnecessary travel. They have also planned for the  distribution of hygiene supplies to protect employees whose duties  require their presence at an assigned workplace during an influenza  pandemic.
Moreover, as shown in figure 3, agencies reported an increase over 2009  in a variety of other actions that could reduce the risk of exposure for  federal workers, including the use of flexible schedules to reduce the  number of employees who must be at work at one time or in one specific  location and implementing pandemic influenza-specific office protocols  such as no-handshake policies. However, not all of these actions may be  applicable to all workplace settings.
According to Federal Continuity Directive 1, agencies must implement a  process to communicate human capital guidance for emergencies, such  as pay, leave, staffing, and other human resources flexibilities, to  employees to ensure continuity of mission essential functions during an  emergency. Given the potential severity of an influenza pandemic, it is  important that employees understand the policies and requirements of  their agencies and the alternatives, such as telework, that may be  available to them.
While a majority of agencies surveyed in 2009 reported they had made  information available to employees on how human capital policies and  flexibilities would change in the event of an influenza pandemic, figure 4  shows that all surveyed agencies reported in 2012 that they have made  such information available to their employees.
As noted earlier, all of the agencies reported that they developed policies  or procedures for using telework in the event of an influenza pandemic. In  our 2012 survey, we asked agencies if they had tested the various modes  of IT and telecommunications capabilities to ensure that they would be  capable of handling employees working remotely during an influenza  pandemic. As shown in figure 5, almost all of the agencies reported to  have tested e-mail, teleconferencing, intranet access, and access to vital  records or files. Desktop videoconferencing was the least tested mode  because a majority of federal agencies reported that they did not have  such capabilities.
We previously reported that it is important to recognize that agency  influenza pandemic plans will continue to be revised and improved with  additional time and information regarding influenza pandemic  preparedness. One recent event that prompted agencies to consider  such revisions to their plans was the 2009 H1N1 influenza pandemic,  which was the first human influenza pandemic in more than 4 decades.  Seventeen agencies reported in 2012 that they updated their influenza  pandemic plan to include lessons learned from the pandemic. The  Department of Energy (DOE), for example, reported that it had revised its  plan to recommend that precautions and safeguards be based on the  local prevalence of influenza at a specific DOE site rather than applying  assumptions used for its headquarters location. HHS reported that  following the first wave in the spring of 2009 and in anticipation of the  second wave in the fall of 2009, HHS’s Assistant Secretary for  Administration convened a human capital task force to provide real-time  solutions for key workforce related issues, including identification of  departmental preparedness requirements and institutionalization of  process and procedures. HHS also reported that after the 2009 H1N1  influenza pandemic, it had incorporated lessons learned that the task  force identified as areas for improvement related to human capital into its  draft influenza pandemic plan’s human capital management and  workforce protection annex. The areas where HHS has emphasized  process improvement include the identification of mission critical  employees that could work remotely and prompt communication of HHS’s  recommended actions for workforce protection and human capital plans  to supervisors and employees.
Three agencies—the Department of Defense (DOD), Department of  Veterans Affairs (VA), and National Science Foundation (NSF)—reported  that they were planning to update their plans to include lessons learned  from the 2009 H1N1 influenza pandemic during 2012 and 2013. In  contrast, the Department of Agriculture (USDA), Department of  Commerce (Commerce), SBA, and USAID, concluded that they did not  have lessons learned from the 2009 H1N1 influenza pandemic  specifically related to workforce protection that warranted an update to  their influenza pandemic plans.
section_title: Majority of Agencies Reported Various Influenza Pandemic Planning Activities at Component and Facility Levels
paragraphs: We reported in June 2009 that because the primary threat to continuity of  operations during an influenza pandemic is the threat to employee health,  agencies’ plans to protect their workforce need to be operational at the  facility level. In addition, we reported that filtering influenza pandemic  plans down to individual facilities and making them operational presented  challenges for the agencies.
A majority of agencies continued to report that they require pandemic  plans at the component level, as shown in figure 6. Four agencies  reported they did not require component level plans. The Department of  Housing and Urban Development (HUD), OPM, and NSF reported in both  2009 and 2012 that they did not require their components to complete  influenza pandemic plans. Although USAID reported in 2009 that it  required its components to complete plans, the agency reported in 2012  that it uses a consolidated plan.
To better understand the extent to which influenza pandemic planning  had filtered down to the component and facility levels, we included  questions about these levels in our 2012 survey. For our 2012 survey, we  selected one component from each of the 15 agencies who had provided  examples of their key component-level mission essential functions that  could not be performed remotely during an influenza pandemic in our  2009 survey, as shown in table 1.
Figure 7 shows a high number of these agencies reported a broad level of  activity in influenza pandemic planning for their selected components.  Fourteen agencies reported that they have completed influenza pandemic  plans that address how federal workers would be protected in the event of  an influenza pandemic for their selected component and VA reported that  its selected component, National Cemetery Administration, is covered  under its departmental influenza pandemic plan and consequently does  not need a separate component plan.
Of the 14 agencies with selected components that have plans, all but one  reported they have addressed how employees who have onsite mission  essential functions would be protected in the event of an influenza  pandemic. The remaining agency, the Nuclear Regulatory Commission  (NRC), reported that this was not applicable for its selected component,  the Office of Nuclear Reactor Regulation (NRR), because NRR plans to  perform all its mission essential functions remotely.
Further, 12 agencies with selected components reported they had  incorporated lessons learned from the 2009 H1N1 influenza pandemic in  their pandemic plans. Of the remaining two agencies with selected  components that have plans, the Department of Transportation (DOT)  reported that it has not yet incorporated lessons learned for its selected  component, FAA, but is planning to incorporate them by the fall of 2012.  In addition, Commerce reported that it does not plan on updating the  National Oceanic and Atmospheric Administration’s (NOAA) influenza  pandemic plan to include lessons learned from the 2009 H1N1 influenza  pandemic because there were no lessons specifically related to workforce  protection that warranted a change. However, Commerce reported that  NOAA will be reviewing its pandemic plan in late 2012.
The 14 agencies with selected components that have plans reported that  all of the components included five of eight social distancing strategies to  help reduce the risk of exposure for their employees, as shown in figure  8. As we mentioned earlier, avoiding crowded settings is one of the best  ways to prevent infection during an influenza pandemic. However, not all  of these actions may be applicable to all workplace settings.
Figure 9 shows agency responses to our 2012 survey regarding influenza  pandemic plans at the facility level.selected components have also required their facilities to complete  influenza pandemic plans. The remaining seven agencies—Department  of the Treasury (Treasury), HHS, Labor, National Aeronautics and Space  Administration (NASA), NRC, Social Security Administration (SSA), and  USDA—reported that they have not required facility-level plans for the  components we had selected for a variety of reasons. For example, HHS,  Labor, and Treasury reported they did not require their selected  component’s facilities to complete separate influenza pandemic plans   Eight of the 15 agencies that have  because they are covered under the component’s plan, while NASA and  NRC reported that it was not applicable because they have no facilities  for the components we had selected. For example, NRC reported that  NRR does not have facilities because it is located inside the main NRC  headquarters complex.
All of the eight agencies requiring components’ facilities plans reported  that these plans addressed how employees with onsite mission essential  functions would be protected during an influenza pandemic. In addition,  five of these eight agencies—DOE, Department of Justice, DOT,  Environmental Protection Agency (EPA), and Department of State  (State)—reported that all of their selected components’ facilities plans  addressed how employees would be protected in the event of an  influenza pandemic. Of the remaining three, DHS reported that half or  more of Customs and Border Protection’s facilities addressed worker  protection in their plans and Commerce and VA reported that some, but  less than half, of their selected components’ facilities have done so.
The use of various social distancing strategies reported in facilities’  pandemic plans is highlighted in figure 10. As the figure shows, all eight  of the agencies whose components’ facilities were required to complete  influenza pandemic plans also reported that their facility-level plans  included social distancing strategies, such as implementing pandemic  influenza-specific office protocols, restricting meetings and gatherings,  and avoiding all unnecessary travel.
Employees who must work onsite during an influenza pandemic will face  varying levels of exposure risk. The level of risk depends, in part, on  whether or not they will be in close proximity to people potentially infected  with the influenza pandemic virus. OSHA has given guidance on steps  employers can take to reduce the risk of exposure to influenza pandemic   For example, an agency could make changes to the  in their workplace.work environment to reduce workplace hazards, such as installing sneeze  guards between customers and employees to provide a barrier to  transmission of the influenza virus. Additionally, an agency could provide  personal protective equipment, such as surgical masks and N-95  respirators, to employees which, if used correctly, can help prevent some  exposures. The steps that agencies could take to plan for appropriate  employee protections include determining the number of employees they  may need to protect, notifying those employees that may be expected to  work, and classifying jobs by exposure risk level.
However, as figure 11 shows, although many of the agencies have  identified mission essential functions that cannot be performed remotely,  less than half have determined the number of employees that are tasked  with performing onsite mission essential functions and notified the  employees that they would be expected to work onsite during an  influenza pandemic. Labor reported using a methodology of determining  occupational risk exposure and telework designations by position rather  than by function and is not represented in figure11. Through this  methodology, Labor does not identify mission essential functions that  cannot be continued through telework in the event of an influenza  pandemic but does determine the number of its employees who perform  mission essential functions that cannot be continued through telework.  Labor reports that the notification of employees is a responsibility of its  component agencies and the extent to which this has been completed is  not known at the department level.
Seventeen agencies reported that they have identified which mission  essential functions could not be performed remotely while EPA, HUD, and  USAID reported that they were still in the process of determining them.
Ten of 17 agencies have determined the number of employees that would  perform mission essential functions in the event of an influenza  pandemic. The remaining seven agencies that have identified onsite  mission essential functions reported that they have not yet determined the  number of employees that must perform such functions in the event of an  influenza pandemic. For example, SSA reported that it has not  determined which jobs could be performed remotely because the  agency’s telework policy has not been ratified in its labor contract.
Of the 10 agencies that have determined the number of employees that  cannot work remotely, all of them reported that they had also notified all  or most of their employees who may be expected to continue operations  during an influenza pandemic, an increase of 1 agency over 2009.
As we reported in June 2009, agencies should prepare employees for the  risks of performing onsite mission essential functions. A key step in  making these determinations is to classify jobs by exposure risk level for  mission essential functions that cannot be performed remotely. As figure  12 shows, of the 21 agencies reporting jobs associated with mission  essential functions that cannot be performed remotely, although 9  agencies reported that they have classified all or most of their jobs by  exposure risk level, 8 agencies reported having classified few or none. As  noted earlier, Education, GSA, and SBA reported that all of their mission  essential functions could be performed remotely.
Figure 13 shows that many agencies reported to have classified jobs that  have onsite mission essential functions by exposure risk level for their  selected component. Nine of the 14 agencies that have a selected  component with onsite mission essential functions reported that they have  classified all or most of their jobs by exposure risk level and only two  agencies have classified a few or none. However, when compared to  figure 12, agencies reported classifying jobs at the component level with  onsite mission essential functions by exposure risk level to a greater  degree than at the agency level.
Twelve agencies and 11 selected components that completed or nearly  completed the exposure risk classification also reported that they have  specified the appropriate protection measures and could implement them,  if instructed, to either a great extent or to some extent for those  employees that cannot work remotely during an influenza pandemic.
section_title: Agencies Highlighted Various Challenges in Planning for an Influenza Pandemic
paragraphs: With the exception of DOD and Labor, 22 agencies identified various  challenges in our 2012 survey that they faced in planning how to protect  their workforce during an influenza pandemic. The top three challenges  agencies most frequently cited, as shown in figure 14, were related to (1)  medical countermeasures, such as antivirals and vaccines; (2)  information sharing; and (3) implementing various social distancing  strategies.
Almost half of the agencies, or 11, reported that understanding what  actions they should take to procure, prioritize, and distribute vaccines and  antivirals for their employees was a challenge. Specifically, some of these  challenges included the lack of guidance related to policies and  procedures for allocating and distributing vaccines and antivirals for their  employees and how they should plan for nonfederal employees. For  example, State reported that it had faced challenges because vaccines  were not readily available during the 2009 H1N1 influenza pandemic for  the approximately 50,000 employees and accompanying family members  who work in embassies and consulates overseas. During the 2009 H1N1  influenza pandemic, State received a rationed shipment of vaccines for 2  percent of its workforce, which encompassed both domestic-based and  international-based employees. The initial shipments were sent to State  offices in Baghdad and Kabul; other diplomatic posts had to wait for later  shipments. As we had reported in June 2011 on lessons learned from the  2009 H1N1 influenza pandemic, the H1N1 vaccine was not widely  available when expected or when demand was highest in October 2009.  By the time the H1N1 vaccine was widely available in late December  2009, the peak of H1N1 influenza activity had passed and many  individuals were no longer as interested in getting vaccinated.DOT reported that there is a need for governmentwide guidance or   Further,  authority clarifying what federal agencies can legally do to protect onsite  contractors who work closely with federal employees.
Unlike the allocation and distribution of seasonal influenza vaccines, the  allocation and distribution of influenza pandemic vaccines are managed  by the federal government. For example, during the 2009 H1N1  pandemic, the federal government determined that HHS would manage  the allotment of the H1N1 vaccine. However, the federal agencies each  make a decision whether or not to procure antivirals for their employees.  Nevertheless, agencies still reported challenges. HHS reported that it  issues nationwide guidance on the use of antivirals which informs the  plans of employers who have chosen to stockpile these drugs, including  federal agencies. However, HHS noted that it is an agency decision  whether to purchase and distribute antivirals. HHS officials also  acknowledged the lack of an approved process for internal HHS  distribution of antivirals for its employees as a challenge, but noted they  are evaluating lessons learned from the 2009 H1N1 influenza pandemic  regarding this issue and will incorporate them into future influenza  pandemic planning. Further, DOT reported that it had not planned for  procuring antiviral medications for prophylaxis because there is no  requirement or reimbursement for federal agencies to do so; and SBA  reported that stockpiling antivirals and prioritizing distribution of antivirals  for its workforce, including who and when, were challenges.
Tied with medical countermeasures, 11 agencies cited challenges related  to information sharing among federal agencies and also with their  employees. For example, DOT and USDA reported they had not obtained  post-H1N1 information regarding governmentwide lessons learned or  best practices related to workforce protection issues that could be  incorporated into their pandemic plans to help plan for future influenza  pandemics. According to DHS’s NRF, federal agencies should  incorporate lessons learned from real-life incidents, such as an influenza  pandemic, to make improvements in further strengthening their capability  to respond to future emergencies. The NRF specifies that evaluation and continual process improvement are cornerstones of effective  preparedness. We had previously recommended in June 2011 that the  HSC should work with HHS, DHS, and other federal agencies to  incorporate lessons learned from the 2009 H1N1 pandemic in addition to  the lessons we identified, which included sharing relevant findings of  agencies’ after-action reports with key stakeholders, in planning for future  pandemics.
As noted earlier, agencies reported that there were challenges with  communicating pandemic-related information to their employees. USDA,  for example, reported that it was challenging to provide recurring  pandemic-related information to ensure new employees were cognizant  of its pandemic plans and guidance. In addition, HUD reported that  providing real-time information to its employees could be a challenge,  based on its experience with the 2009 H1N1 influenza pandemic. Further,  HHS reported that it recognized that during the 2009 H1N1 influenza  pandemic, its internal communication plans for workplace protection and  human capital planning were delayed or inadequate. To address this  shortfall, HHS’s Centers for Disease Control and Prevention (CDC) and  OPM published a communications toolkit during the 2009 H1N1 influenza  pandemic in October 2009 for the federal workforce that included  communications resources and guidance for federal employees and  supervisors to use. government establish the need for relevant, reliable, and timely  communications. According to these standards, effective communications  should occur with information flowing down, across, and up the  organization as well as with external stakeholders that may have a  significant impact in meeting agency objectives. Information sharing  prior to and during an emergency, such as an influenza pandemic, is  important to ensure the continuity of agencies’ operations and mission  essential functions.
HHS, CDC, and OPM, Preparing for the Flu: A Communications Toolkit for the Federal  Workforce (Oct. 1, 2009). was a challenge. Although we pointed out earlier that all 24 agencies  reported that they planned to use telework as a means to protect their  employees in the event of an influenza pandemic, several agencies  reported that it may be a challenge to implement the measure. NASA, for  instance, reported that because of the high level of commitment of its  employees to assure mission success, educating and encouraging its  workforce to use various social distancing recommendations, such as  teleworking from home, canceling meetings, and not reporting to work  when sick, was a challenge. In addition, NSF reported that it did not know  whether all of its employees had internet capabilities in their homes to  carry out work tasks remotely, while SBA reported that it was challenging  to encourage all staff to become telework-enabled—such as having the  appropriate capabilities at home to be able to work remotely. With respect  to workspace configuration, DHS reported the difficulty of reconfiguring  workspace to protect employees who must perform classified work in a  sensitive compartmented information facility. Such facilities present  similar social distancing challenges for air traffic controllers who work in  close capacity in air route traffic control centers, which we will discuss  next.
section_title: Pandemic Plans to Protect Air Traffic Controllers Have Progressed, but Social Distancing Remains an Intractable Challenge
paragraphs: We reported in 2009 that FAA pandemic plans to protect air traffic  controllers were not ready for implementation and also highlighted various  challenges in protecting air traffic controllers who had to perform onsite  mission essential functions during an influenza pandemic. We followed up  with FAA officials on the extent of their progress on four specific issues.
First, since our 2009 report, FAA has ensured that its facilities developed  plans to protect air traffic controllers during an influenza pandemic. In  2009, we reported that the Air Traffic Organization (ATO), FAA’s line of  business responsible for air traffic controllers’ services, had not directed  facilities, such as its air route traffic control centers, to develop pandemic- specific plans. ATO directed its facilities 3 months after our report was  issued to develop contingency staffing plans to mitigate the probable  impact of an influenza pandemic and also instructed its facilities on  immediate preparedness steps at the facility level. For example, ATO  facility managers were instructed to identify employees who were eligible  and willing to telework, ensure that the appropriate employees complete  the FAA telework program, and identify the minimum cadre of employees,  by position, who would need to telework during an influenza pandemic  outbreak to sustain mission essential services.
Second, FAA augmented its agencywide pandemic plan with a workplace  protection policy. In 2010, FAA updated ATO’s draft pandemic plan with  detailed protective measures for its workforce, including air traffic  controllers. For example, FAA added information to the plan about  sanitizers that are safe to use on air traffic control equipment. At the time  of our report in 2009, FAA had not yet certified a sanitizer to be used to  sanitize the equipment. It was important for FAA to certify a sanitizer  because many sanitizers are caustic and could corrode sensitive  equipment necessary for flight safety. ATO’s plan now states employees  should regularly cleanse shared equipment using certified disinfectant or  cleaning agents. Additional measures call for employees to take a  pandemic awareness course, cover coughs, and wash their hands  frequently, which are consistent with CDC’s guidance. FAA reported the  plan has been distributed as guidance to managers and supervisors and  remains in draft status as it is a “living document.”
Third, FAA has addressed issues related to medication. At the time of our  report in 2009, the Office of Aerospace Medicine had not finalized its  policy on the preventative use of the flu medication Tamiflu by on-duty  controllers. FAA regulations on medication for air traffic controllers are  strict because certain medications may impair air traffic controllers’  performance. The Office of Aerospace Medicine revised and finalized its  policy in 2009 regarding the use of Tamiflu for preventative use by on- duty controllers. they have been prescribed antiviral medications by either a public health  authority or their personal physicians, if no side effects from the  medications are evident, and if they are operating normally on the job.
FAA, Use of Anti-Influenza Medication by FAA Employees Performing Safety-Related  Duties (Oct. 8, 2009).
Finally, FAA was not able to resolve social distancing challenges. CDC  recommends maintaining 6 feet of separation during an influenza  pandemic, but this is not possible for air traffic controllers because they  work in close quarters. According to FAA officials, they considered having  air traffic controllers use personal protective equipment, but concluded  that N-95 respirators or surgical masks impede the clear verbal  communications necessary to maintain aviation safety. At the time of our  report in 2009, FAA had just received the results of a feasibility study for  the use of a powered air purifying respirator. The study findings  suggested that if FAA used the technology, it would need to address  many potential problems including noise, visibility, and comfort. At this  time, FAA officials state they have not identified a technical solution to  equip controllers with a practical protective piece of equipment that will  mitigate the risk of working in close quarters while supporting adequate  communications necessary for safety. The FAA official responsible for  ATO’s pandemic planning stated social distancing challenges appear  intractable with the current technology, although FAA will continue to seek  opportunities to mitigate potential exposure to influenza. For the present,  this includes being vigilant in implementing hygiene measures in their  workspaces and exploring other mitigation controls such as technological  advances that reduce transmissibility.
section_title: Agencies’ Plans and Progress to Protect Federal Workers during an Influenza Pandemic Receive Limited Oversight
paragraphs: Federal Continuity Directive 1 requires federal executive agency heads to  evaluate program readiness to ensure the adequacy and capability of  continuity plans and programs. In addition, the agency head must submit  an annual report to the National Continuity Coordinator (NCC) to certify  the agency has this capability. As previously discussed, all agencies  reported having completed influenza pandemic agency plans.
Under the HSC’s Implementation Plan, DHS was charged with, among  other things, monitoring and reporting to the President on the readiness of  departments and agencies to continue their operations while protecting  their workers during an influenza pandemic. However, DHS officials said  the HSC informed them in late 2006 or early 2007 that they were not  required to report on these responsibilities. Rather, the HSC requested  that agencies certify to the council that their plans addressed the  applicable elements of a pandemic checklist in 2006 and again in 2008.  However, according to two agencies’ officials, the HSC has not asked  agencies to certify their plans since then. As we reported in 2011, the  National Security Staff (NSS), who supports the HSC, is coordinating a  larger effort to transition national preparedness from a dependence on  fixed plans for specific threats to an approach based on a variety of  hazards, or an all-hazards approach in accordance with Presidential  Policy Directive 8.We submitted a request for information and  asked to meet with the relevant NSS subject matter experts regarding  oversight of agencies’ preparedness to protect workers during a  pandemic. An NSS official advised that the NSS would not be able to  provide responsive information because these issues are currently being   Officials  addressed through the Presidential Policy Directive 1 process.at two agencies we spoke with informed us that the NSS has reconvened  the Pandemic Preparedness Sub-Interagency Policy Coordination  Committee to primarily address domestic pandemic preparedness efforts,  with a focus on coordination between departments and agencies. In the  absence of any information from the HSC, it is not possible to determine  what, if anything, it is doing to oversee federal agency pandemic  planning. Regarding the 2009 recommendation we made to the HSC,  DHS officials told us that the HSC has not requested the Secretary of  Homeland Security to monitor and report to the President on the  readiness of agencies to continue their operations while protecting their  employees in the event of a pandemic.
As we did in 2009, we interviewed four agencies to which the  Implementation Plan assigns responsibilities related to pandemic  preparedness. The four agencies we selected are responsible for  providing guidance, policy, or influenza pandemic-related expertise to  other agencies. Each of these agencies is responsible for providing  influenza pandemic continuity of operations (COOP) guidance, which  includes elements such as COOP planning, personnel protection, or  workplace options for federal departments and agencies.
Labor’s OSHA is responsible for promoting the safety and health of  workers, including communication of information related to an  influenza pandemic to workers and employers.
HHS is responsible for the overall coordination of the public health  and medical emergency response during an influenza pandemic. HHS  communicates information related to an influenza pandemic, ensures  provision of essential human services, implements measures to limit  the spread of influenza, provides recommendations related to the use,  distribution, and allocation of influenza countermeasures, and to the  provision of care in mass casualty settings.
OPM, in coordination with DHS, HHS, DOD, and Labor, provides  guidance to federal departments and agencies on human capital  management and COOP planning criteria related to an influenza  pandemic.
DHS coordinates the overall domestic federal response during an  influenza pandemic, including implementing policies that facilitate  compliance with recommended social distancing measures,  developing a common operating picture for all federal agencies, and  ensuring the integrity of the nation’s infrastructure.
DHS does not conduct oversight of agencies’ plans as originally  envisioned in the Implementation Plan, and DHS officials responsible for  coordinating organizational roles and responsibilities related to these  responsibilities confirmed that DHS does not specifically provide oversight  of agencies’ influenza pandemic plans. But these officials told us that  DHS is the federal lead agency for coordinating overall continuity  operations. In this capacity, DHS coordinates the assessment of  agencies’ continuity activities and programs. The DHS Secretary provides  biennial assessments of department and agency continuity capabilities  and reports the results to the President, through the NCC, and to agency  heads as required by Federal Continuity Directive 1.
FEMA officials responsible for the national continuity program noted that  while agencies are responsible for their preparedness, and FEMA does  not assess the efficacy of overall agency pandemic preparedness,  FEMA’s biennial assessment process does assess whether agencies’  continuity plans address some of the unique considerations of an  influenza pandemic. FEMA collects agency information for the  assessment through continuity exercises and the Continuity Evaluation  Tool (evaluation tool), a comprehensive survey covering 14 elements of  continuity programs, plans, and procedures for all-hazards, including a  pandemic threat. In addition to reporting to the NCC, FEMA also  compares the results of multiple biennial continuity assessments to  identify government trends in overall continuity preparedness. The  evaluation tool asks whether agencies’ communications capabilities will  allow them to continue operations for all types of emergencies, including  influenza pandemics. The evaluation tool also asks if agencies have  given full consideration to social distancing strategies, such as telework.  Because the evaluation tool which FEMA uses to evaluate agencies’  continuity plans is based on an all-hazards approach, it does not include  the planning elements identified in the Key Elements checklist that  agencies specifically use for pandemic planning. Consequently, the  evaluation tool, for example, does not include pandemic preparedness- related questions such as whether federal workers’ influenza pandemic  risk assessments are regularly updated and whether agencies have  planned to provide protective measures to mitigate exposure risks.
section_title: Conclusions
paragraphs: Our follow-up survey of the 24 CFO Act agencies showed that significant  progress has been made in many areas since we last reported on this  issue in 2009. In particular, almost all or most of the agencies, selected  components, and their facilities have completed pandemic plans that  address how they would protect employees that were associated with  mission essential functions that could not be performed remotely. In  addition, almost half of the agencies reported to have determined the  number of employees that would have to perform mission essential  functions and also notified the employees that they were expected to  continue these operations during an influenza pandemic. However, the  agencies also reported uneven status in some key areas suggesting  some oversight targeted to bring attention to these areas is needed. For  example, only nine agencies reported that they have classified all or most  jobs for onsite mission essential functions by exposure risk level. Given  the continued threat of an influenza pandemic, it is important that  agencies have operational pandemic plans that identify appropriate  workforce strategies to protect employees while ensuring mission  essential functions continue. Adequate oversight could help in ensuring  that, by classifying jobs by exposure risk level, agencies have appropriate  measures in place to protect those employees who must carry out  mission essential functions that cannot be performed remotely during an  influenza pandemic.
Agencies reported several challenges in planning for federal worker  protection in the event of an influenza pandemic. Sharing of information  among agencies is related to some of these challenges. The Pandemic  Preparedness Sub-Interagency Policy Coordination Committee meetings  led by the NSS may provide a venue and opportunity to identify agencies’  needs and improve coordination to address gaps the agencies perceive in  guidance and pandemic-related information needs.
FAA has made progress in three of the four areas related to protecting air  traffic controllers we highlighted as challenges in 2009. However, FAA  has not yet found a viable way to address how onsite air traffic  controllers, who work in close proximity to each other, could be separated  during an influenza pandemic. Further, FAA has not yet identified  personal protective equipment alternatives for use by air traffic controllers  who must report to work during an influenza pandemic. These issues will  continue to be challenges for which FAA may not be able to find viable  solutions.
FEMA’s biennial assessment of agencies’ continuity capabilities does not  consider agency responses to significant influenza pandemic-related  questions regarding protection of federal workers. Such questions may  include whether jobs have been classified by exposure risk level and  whether appropriate protective measures have been identified and will be  available as needed for their employees. While agencies have reported in  2012 they have made significant progress in planning for protecting  workers during an influenza pandemic, additional oversight targeted to  those areas in which reported progress is uneven could help focus  attention on those areas. The existing biennial assessment process  provides an opportunity to provide monitoring, evaluation and reporting on  protecting federal workers during an influenza pandemic.
section_title: Recommendation For Executive Action
paragraphs: To provide additional oversight of agencies’ progress in their  preparedness to protect workers, help focus attention on areas of uneven  progress reported in our survey, and build upon the efforts FEMA has  underway, we recommend that the Secretary of Homeland Security direct  the Administrator of FEMA to include in its biennial assessments of  agencies’ continuity capabilities consideration of agencies’ progress in  assessing exposure risk levels, identifying appropriate protective  measures, and establishing operational plans to provide such protections.
section_title: Agency Comments
paragraphs: We provided the Secretary of Homeland Security with a draft of this report  for review and comment. In written comments, the Director of the  Departmental GAO-Office of the Inspector General Liaison Office  concurred with the recommendation and stated that DHS is committed to  ensuring COOP programs continue to focus on all-hazards, including  pandemic planning, in an evolving environment. As part of this  commitment, FEMA reviews its Continuity Evaluation Tool on a regular  basis and will update it to provide specific attention to pandemic planning  within the context of all-hazard planning, including assessing the risk of  pandemic impacts to specific functions, identifying protective measures  for employees performing those functions, and planning for providing  protection, as appropriate. Technical comments were also provided,  which we incorporated. DHS’s comments are reprinted in appendix IV.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. We are sending copies of this report to the Department of  Homeland Security; relevant congressional committees; and other  interested parties. The report also is available at no charge on the GAO  website at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-9110 or czerwinskis@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found  on the last page of this report. GAO staff who made major contributions to  this report are listed in appendix V.
section_title: Appendix I: Chief Financial Officers Act Agencies
section_title: Appendix II: List of Agencies and Selected Components
section_title: Appendix III: Objectives, Scope, and Methodology
paragraphs: The objectives of this report were to (1) determine what progress federal  agencies report they have made since our 2009 report and identify  challenges federal agencies report they face in protecting their workforce  during an influenza pandemic, and (2) determine the extent to which  oversight of agencies’ progress was being conducted and how the  oversight information is being used.
To address the first objective, we developed and administered a web- based survey of the 24 agencies covered by the Chief Financial Officers  Act of 1990 (CFO Act) to determine to what extent they had made  progress in their preparedness to protect their workforce for an influenza  pandemic since our 2009 survey and to identify challenges they faced in  planning for protection of their workers. We developed the survey  questions based on guidelines for worker protection from the Homeland  Security Council (HSC), Department of Health and Human Services  (HHS), Federal Emergency Management Agency (FEMA), Occupational  Safety and Health Administration (OSHA), and Office of Personnel  Management (OPM), and we also used some of the survey questions we  asked in 2009. The survey included questions related to (1) pandemic  plans, (2) mission essential functions that could not be continued through  telework during an influenza pandemic, (3) assessment of levels of  exposure risk, (4) measures planned to protect workers who would not be  able to work remotely, (5) social distancing strategies, (6) testing of  information technology and telecommunications capabilities, (7)  communication of human capital pandemic policies, (8) oversight of  pandemic planning, and (9) challenges in planning for worker protection.
To better understand the extent to which influenza pandemic planning  had filtered down to the component and facility levels, we also gathered  data from these levels in our 2012 survey. In our 2009 survey, 15 of 24  agencies provided examples of some of the key component-level mission  essential functions that could not be performed remotely during an  influenza pandemic. Using those examples, we selected a component  from each of these 15 agencies for our 2012 survey and surveyed the  agencies to determine whether they had made plans at lower  organizational levels to protect their employees whose onsite presence  was necessary in order to carry out mission essential functions.
Prior to disseminating our web-based survey, we conducted a series of  pretests from November 16 through November 21, 2011, with three  agencies to further refine our questions, clarify any ambiguous portions of  the survey, and identify potentially biased questions. Upon completion of  the pretests and development of the final survey questions and format,  we sent an announcement of the upcoming survey to the 24 CFO Act  agencies on December 12, 2011. These agencies were notified that the  survey was available online on December 14, 2011. We sent reminder e- mail messages to nonrespondents on January 3, 2012, and January 9,  2012. The survey was available online until January 13, 2012, and the  results were confirmed or updated through June 2012. All 24 CFO Act  agencies completed the survey for a response rate of 100 percent.
Furthermore, we reviewed the National Strategy for Pandemic Influenza  Implementation Plan, National Response Framework, our prior work  assessing influenza, and other relevant literature. We defined mission  essential functions based on the Department of Homeland Security’s  (DHS) Federal Continuity Directive 1 as those functions that enable an  organization to provide vital services, exercise civil authority, maintain the  safety of the general public, and sustain the industrial and economic base  during disruption of normal operations. The scope of our work did not  include an independent evaluation of the effectiveness of the workforce  protection measures recommended by federal lead pandemic agencies.
In addition to the survey, we conducted follow-up work to determine  whether the Federal Aviation Administration had made progress in  addressing the unique challenges we highlighted in our 2009 report  regarding protection for air traffic controllers who must perform onsite  mission essential functions during an influenza pandemic. We reviewed  agency and component pandemic plans and conducted interviews with  agency officials.
To address the second objective, we analyzed documentation of  oversight activities and our prior work, and conducted interviews with  officials from DHS, HHS, FEMA, OPM, and OSHA, who were tasked with  providing guidance, policy, or influenza pandemic related expertise to  other federal agencies in planning for an influenza pandemic.
We conducted this performance audit from July 2011 through July 2012 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 IV: Comments from the Department of Homeland Security
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, William J. Doherty, Assistant  Director; Maya Chakko; David Dornisch; Karin Fangman; Robert Gebhart;  Stuart Kaufman; Ruben Montes de Oca; Patricia Norris; Susan Sato; and  Andrew Stavisky made major contributions to this report. Ellen Grady and  Judith Kordahl verified the information in the report.
section_title: Related GAO Products
paragraphs: Influenza Pandemic: Lessons from the H1N1 Pandemic Should Be  Incorporated into Future Planning. GAO-11-632. Washington, D.C.: June  27, 2011.
Influenza Vaccine: Federal Investments in Alternative Technologies and  Challenges to Development and Licensure. GAO-11-435. Washington,  D.C.: June 27, 2011.
Disaster Response: Criteria for Developing and Validating Effective  Response Plans. GAO-10-969T. Washington, D.C.: September 22, 2010.
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: Gaps in Pandemic Planning and Preparedness  Need to Be Addressed. GAO-09-909T. Washington, D.C.: July 29, 2009.
Influenza Pandemic: Increased Agency Accountability Could Help Protect  Federal Employees Serving the Public in the Event of a Pandemic.  GAO-09-404. Washington, D.C.: June 12, 2009.
Influenza Pandemic: Continued Focus on the Nation’s Planning and  Preparedness Efforts Remains Essential. GAO-09-760T. Washington,  D.C.: June 3, 2009.
Influenza Pandemic: Sustaining Focus on the Nation’s Planning and  Preparedness Efforts. GAO-09-334. Washington, D.C.: February 26,  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: 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 Vaccine: Issues Related to Production, Distribution, and Public  Health Messages. GAO-08-27. Washington, D.C.: October 31, 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.
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.
Influenza Pandemic: Applying Lessons Learned from the 2004–05  Influenza Vaccine Shortage. GAO-06-221T. Washington, D.C.: November  4, 2005.
Influenza Vaccine: Shortages in 2004–05 Season Underscore Need for  Better Preparation. GAO-05-984. Washington, D.C.: September 30, 2005.
Influenza Pandemic: Challenges in Preparedness and Response.  GAO-05-863T. Washington, D.C.: June 30, 2005.
Influenza Pandemic: Challenges Remain in Preparedness.  GAO-05-760T. Washington, D.C.: May 26, 2005.