Influenza Pandemic: Monitoring and Assessing the Status of the National Pandemic Implementation Plan Needs Improvement
Published: 2009-11-24T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The current H1N1 pandemic highlights the threat posed to our nation by an influenza pandemic. The previous administration's Homeland Security Council (HSC) issued the Implementation Plan for the National Strategy for Pandemic Influenza (Plan) in May 2006 to help address a pandemic. The Government Accountability Office (GAO) was asked to (1) determine how the HSC and responsible federal agencies monitor the progress and completion of the Plan's action items; and (2) assess the extent to which selected action items have been completed. To do this, GAO interviewed officials from the HSC and the six federal agencies responsible for implementing most of the Plan, and analyzed a random sample of 60 action items. While this report does not assess the response efforts for the H1N1 pandemic, GAO continues to monitor the outbreak and the federal response.
section_title: What GAO Found
paragraphs: To oversee agencies' progress in implementing the Plan's action items, the HSC, which is supported by the White House National Security Staff in this administration, convenes regular interagency meetings, asks agencies for summaries of progress; and leads the interagency process that monitors the progress of the Plan. Officials from the six agencies stated that they monitor action items tasked to more than one agency by selecting one or two agencies to report a consolidated summary of progress, approved by each responsible agency, to the HSC. However, neither the HSC nor the agencies monitor or report on the 17 action items intended for nonfederal entities, including, for example, action items asking state, local, and tribal entities to ensure their preparedness plans address mass immunization, even though the information may have been available from other sources, such as the interagency review of state pandemic plans led by the Department of Health and Human Services. In addition, the Plan does not describe the types of information needed to carry out the Plan's response-related action items, although agencies may have operational plans or other existing guidance that would provide this information. The HSC reported in October 2008 that the majority of the 324 action items were designated as complete. However, GAO's review of 60 action items found that it was difficult to determine the actual status of some of the 49 designated as complete. All of the action items reviewed have both a description of activities to be carried out and a measure of performance, which the HSC stated that it used to assess completion. However, for more than half of the action items considered complete, the measures of performance do not fully address all of the activities contained in their descriptions. While the HSC's progress summaries sometimes corrected for this by either referring to activities in the action item's description or some other information not reflected in either the measure of performance or description, future progress reports would benefit from using measures of performance that are more consistent with the action items' descriptions. The Plan is predicated on a type of pandemic different in severity and origin than the current H1N1 pandemic, but it is serving as the foundation for the response to the outbreak, supplemented by an additional plan tailored specifically to the characteristics of the H1N1 pandemic. Nevertheless, the National Strategy for Pandemic Influenza and Plan will still be needed for future events as most of the action items in the Plan were to be completed by May 2009. As recommended in earlier GAO work, but not yet implemented, the Plan should be updated to take into account certain missing elements and lessons learned from the H1N1 pandemic; the update should also address the monitoring and assessment improvements GAO identified in this report.

section_title: Letter
paragraphs: An influenza pandemic remains a real threat to our nation and to the  world, as we are witnessing during the current H1N1 pandemic, which  began in spring 2009 and continues today. The previous administration’s  Homeland Security Council (HSC) took an active approach to the potential  disaster of an influenza pandemic by, among other things, issuing the  National Strategy for Pandemic Influenza (Strategy) in November 2005,  and the Implementation Plan for the National Strategy for Pandemic  Influenza (Plan) in May 2006. The Strategy lays out high-level goals to  prepare for and respond to an influenza pandemic, while the Plan is  intended to support the broad framework and goals articulated in the  Strategy by outlining specific steps that federal departments and agencies  should take to achieve the goals. The Plan includes 324 action items, a  majority of which have measures of performance and associated time  frames. Both the Strategy and Plan are based on a scenario that assumes a  severe pandemic originating outside the United States, spreading first  among animal populations and then transmitted to humans. While the  current pandemic does not share these characteristics, according to the  Director of Medical Preparedness Policy for the White House National  Security Staff (NSS), which supports the HSC in the current  administration, the Strategy and Plan provide the foundation for an  additional planning document, the National Framework for 2009-H1N1  Influenza Preparedness and Response, that was developed this year to  respond to the H1N1 pandemic. The framework for the 2009 H1N1  pandemic has not yet been made publicly available.
In August 2007, we reported that while the development of the Strategy  and Plan were an important first step in guiding national preparedness, the  Plan lacked a prescribed process for monitoring and reporting on  progress, which is one element of the six desirable characteristics of a  national strategy. To address this and other areas that we had identified,  we recommended that the HSC establish a specific process and time frame  for updating the Plan, including lessons learned from exercises and other  events, such as the 2009 H1N1 pandemic. For this report, you asked us to  focus on the progress in implementing the action items in the Plan,  specifically (1) determining how the HSC and the responsible federal  agencies are monitoring the progress and completion of the Plan’s action  items; and (2) assessing the extent to which selected action items have  been completed, whether activity has continued on the selected action  items reported as complete, and the nature of that work. We did not assess  the response to the 2009 H1N1 pandemic in this report, but we are  continuing to monitor the outbreak and the federal government’s  response.
To address these objectives, we conducted an in-depth analysis of a  random sample of 60 action items in the Plan. These 60 action items are  listed in appendix II. We drew a random sample from the 286 action items  involving six federal agencies with primary responsibility for ensuring  completion of the large majority (88 percent) of the 324 action items.  These six agencies include the Department of Defense (DOD), Department  of Health and Human Services (HHS), Department of Homeland Security  (DHS), Department of State (DOS), Department of Transportation (DOT),  and the Department of Agriculture (USDA). We do not generalize the  results of our analysis because the particular analytical steps we took  across the selected action items varied, and as a result there was no  common underlying measure on which to generalize the results to all of  the action items in the Plan. In addition, we did not review all of the action  items in the Plan in depth because our analyses involved multiple  assessments for each action item, including the review of large volumes of  agency documentation in determining the level of evidence for completion  of the action item. See appendix I for a more detailed discussion of our  scope and methodology.
For both objectives, we interviewed officials and obtained documentation  from the six agencies. We also reviewed the HSC’s 6-month, 1-year, and 2- year progress reports, and the HSC’s 1-year summary report on the  implementation of the action items in the Plan. In addition, we interviewed  a senior HSC official in the previous administration and the Director of  Medical Preparedness Policy for the NSS in the current administration,  who is responsible for overseeing the implementation of the Plan. We also  relied on our prior pandemic work, including a review of whether the  Strategy and Plan contained all the characteristics of an effective national  strategy, to inform our analysis. To address the first objective, we  assessed information from interviews and documentation on how the HSC  and the selected agencies monitored the progress and completion of all  action items. We also interviewed representatives from nonfederal entities  that agency officials had identified as working on specific action items,  such as the World Organisation for Animal Health (OIE) and the Denver  Health Medical Center, to determine whether they had been consulted on  the status of those action items. To address the second objective, we  analyzed the 49 action items designated as complete in the HSC’s 2-year  progress report from the random sample of 60 action items, along with  collected documentation and interviews with selected agency officials and  a senior HSC official from the prior administration. To describe the extent  to which action items had been completed, we analyzed information on  the 49 selected action items in the Plan, the HSC progress reports, and  documentation on each of the 49 action items. To evaluate the extent of  work that has continued on the 49 action items in our sample designated  as complete and the nature of that work, we asked all selected agencies  with primary responsibility if they had performed additional work and, if  so, to provide a brief description of the nature of that work. In addition,  for the 34 selected action items designated as complete in the HSC’s 1-year  progress report, we analyzed each action item’s summary in the HSC’s 1-  and 2-year progress reports for any new information on work conducted in  that period.
We conducted this performance audit from July 2008 to November 2009 in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives. Detailed information on our scope and  methodology appears in appendix I. A list of related GAO products is also  included at the end of this report.
subsections: section_title: Background
paragraphs: An influenza pandemic is caused by a novel strain of influenza virus for  which there is little resistance and which therefore is highly transmissible  among humans. Unlike incidents that are discretely bounded in space or  time (e.g., most natural or man-made disasters), an influenza pandemic is  not a singular event, but is likely to come in waves, each lasting weeks or  months, and pass through communities of all sizes across the nation and  the world simultaneously. While a pandemic will not directly damage  physical infrastructure such as power lines or computer systems, it  threatens the operation of critical systems by potentially removing the  essential personnel needed to operate them from the workplace for weeks  or months.
On June 11, 2009, the World Health Organization (WHO) declared a  pandemic based on the novel influenza A (H1N1) virus currently in wide  circulation by raising the worldwide pandemic alert level to Phase 6—the  highest level. Figure 1 shows the WHO phases of a pandemic,  characterizing Phase 6 as community-level outbreaks in at least one  country in a different WHO region in addition to the criteria defined in  Phase 5. This action was a reflection of the spread of the new H1N1 virus,  not the severity of illness caused by the virus. At that time, more than 70  countries had reported cases of 2009 H1N1 and there were ongoing  community-level outbreaks in multiple parts of the world. As of November  8, 2009, WHO reported over 503,536 confirmed cases and at least 6,260  deaths, acknowledging, however, that the number of cases was actually  understated since it is no longer requiring affected countries to count  individual cases and confirm them through laboratory testing.
Similar to the seasonal influenza, the 2009 H1N1 influenza can vary from  mild to severe. Given ongoing H1N1 activity to date, the Centers for  Disease Control and Prevention (CDC) stated that it anticipates that there  will be more cases, more hospitalizations, and more deaths associated  with this pandemic in the United States in the fall and winter. The novel  H1N1 virus, in conjunction with regular seasonal influenza viruses, poses  the potential to cause significant illness with associated hospitalizations  and deaths during the U.S. influenza season. The United States continues  to report the largest number of 2009 H1N1 cases of any country  worldwide, although most people who have become ill have recovered  without requiring medical treatment. The 2009 H1N1 influenza has been  reported in all 50 states, the District of Columbia, Guam, American Samoa,  the Commonwealth of the Northern Mariana Islands, Puerto Rico, and the  U.S. Virgin Islands.
subsections: section_title: National Planning Efforts for an Influenza Pandemic
paragraphs: As shown in figure 2, the Strategy lays out three high-level goals to prepare  for and respond to an influenza: (1) stop, slow, or otherwise limit the  spread of a pandemic to the United States; (2) limit the domestic spread of  a pandemic and mitigate disease, suffering, and death; and (3) sustain  infrastructure and mitigate impact on the economy and the functioning of  society. These goals are underpinned by three pillars that are intended to  guide the federal government’s approach to a pandemic threat, including:  (1) preparedness and communication, (2) surveillance and detection, and  (3) response and containment. Each pillar describes domestic and  international efforts, animal and human health efforts, and efforts that  would need to be undertaken at all levels of government and in  communities. The Plan outlines steps for federal entities and also provides  expectations for nonfederal entities—including state, local, and tribal  governments; the private sector; international partners; and individuals— to prepare themselves and their communities.
Of the 324 action items in the Plan, 144 are related to pillar 1 on  preparedness and communication; 86 are related to pillar 2 on surveillance  and detection; and the remaining 94 are related to pillar 3 on response and  containment. Nearly all of the action items (307 of 324) have a measure of  performance, and most (287 of 324) of the action items have a time frame  identified either in the action item’s description, measure of performance,  or both. Most of the action items in the Plan—those that were not tied to  response—were expected to have been completed in 3 years, by May 2009.  Since the issuance of the Plan in May 2006, the HSC publicly reported on  the status of the action items at 6 months, 1 year, and 2 years in December  2006, July 2007, and October 2008, respectively. Although this  administration has not yet publicly reported on the 3-year status of  implementing the Plan’s action items, an NSS official stated that the 3-year  progress report had been in development prior to the 2009 H1N1  pandemic, and may be released shortly.
section_title: The HSC Monitors Agencies’ Progress on Most Action Items
paragraphs: The HSC monitors the status of action items in the Plan tasked to federal  agencies by convening regular interagency meetings and requesting  summaries of progress from agencies. According to a former HSC official  who was involved with monitoring the Plan in the prior administration and  officials from all of the six agencies, following the development of the  Plan, the HSC officials convened interagency meetings at the Sub-Policy  Coordination Committee level (deputy assistant secretary or his or her  representative) that included discussions on the implementation of action  items. The former HSC official stated that these meetings are a forum for  monitoring the status of the Plan’s action items. These meetings were held  weekly after the release of the Plan and biweekly after the spring of 2008,  according to the former HSC official. Officials from several of the selected  agencies stated that the interagency meetings facilitate interagency  cooperation and coordination on the action items in the Plan. Officials  also said that these meetings provide a venue to raise and address  concerns relating to how to implement particular action items, and enable  them to build relationships with their colleagues in other agencies. In  addition, the HSC requested that agencies provide the Council with  periodic summaries of their progress on the action items in preparation for  the HSC’s progress reports, according to officials from all of the selected  agencies.
Officials from the six selected agencies informed us that, in this  administration, the NSS continues to lead the interagency process used to  monitor progress of the Plan. Officials from several of the selected  agencies stated that the NSS continues to hold meetings at the Sub- Interagency Policy Committee level to monitor efforts related to influenza  pandemic, with a primary focus on the 2009 H1N1 response. According to  an NSS official, the NSS has also requested periodic summaries of  progress from agencies on the action items.
For action items that involve multiple federal agencies, the six agencies  monitor the action items assigned to them by designating one or two  agencies to report one consolidated summary of progress for each action  item to the HSC, according to agency officials. Some action items task  additional federal agencies with a support role as well. According to  agency officials, all agencies tasked with responsibility for an action item  have to approve its summary of progress before it is provided to the HSC.  The HSC’s 6-month, 1-year, and 2-year progress reports state that the  action items’ summaries in the reports were prepared by relevant agencies  and departments. Officials from all six agencies said that the HSC does not  always require them to submit supporting documentation along with their  summary of progress to determine if an action item is complete. For  instance, officials at three of the agencies said that the HSC does not  require them to submit supporting documentation, while officials from  two other agencies said that additional information is required by the HSC  if it is not convinced about the completeness of an action item, or if it is  unclear that the respective measure of performance was met based on the  summary of progress.
For the 112 action items in the Plan that include both federal agencies and  nonfederal entities, the responsible federal agencies determined how they  would work with and monitor the nonfederal entities. According to the  former HSC official, the responsible agencies determined how these action  items would be implemented, including deciding which nonfederal entities  they would work with and in what manner they would work with them.  Among the six agencies we reviewed, five said that they worked with  nonfederal entities to implement some of the action items in the Plan. For  example, DOT officials stated that they worked with professional  associations to develop guidelines and recommendations for Emergency  Medical Services (EMS) and 9-1-1 call centers, and HHS officials told us  that they worked with medical experts to develop guidance on mass  casualty care. We interviewed representatives of nine of these nonfederal  entities and all of them confirmed that the status of the action items with  which they were associated had been accurately reported. However, they  also told us that they had not been asked for input into the summaries of  progress for the action items with which they were associated and had  therefore been unable to check the accuracy of the summaries before they  were reported.
subsections: section_title: The HSC Uses Information Provided by Agencies to Determine Action Item Status
paragraphs: The HSC makes the final determination as to whether the Plan’s action  items are completed, according to the former HSC official and officials  from the selected agencies. The HSC bases its determination on  information from federal agencies, and uses the measure of performance  associated with the action items as criteria for completion, as stated in the  HSC’s 6-month, 1-year, and 2-year progress reports. Officials from three of  the selected agencies stated that their agencies advise the HSC as to  whether they believe an action item is complete when they provide  summaries of progress to the HSC, while officials from two selected  agencies stated that they provide summaries of progress to the HSC, and  the HSC ultimately determines if an action item is complete. An  interagency group led by the HSC reviews the agencies’ summaries of  progress to help determine if action items are complete. The former HSC  official told us that the HSC’s method of assessing whether an action item  was complete depends on the specific action item. For some action items,  the former HSC official stated that the summary of progress is reviewed by  both an interagency group and a technical working group consisting of  subject-matter experts.
section_title: Neither the HSC nor Agencies Monitor Action Items Intended for Nonfederal Entities
paragraphs: As we reported in August 2007, state and local jurisdictions that will play  crucial roles in preparing for and responding to a pandemic were not  directly involved in developing the Plan, even though it relies on these  stakeholders’ efforts. Stakeholder involvement during the planning  process is important to ensure that the federal government’s and  nonfederal entities’ responsibilities are clearly understood and agreed  upon. Moreover, the Plan states that in the event of an influenza pandemic,  the distributed nature and sheer burden of disease across the nation would  mean that the federal government’s support to any particular community is  likely to be limited, with the primary response to a pandemic coming from  state governments and local communities. In our June 2008 report on  states’ influenza pandemic planning and exercising, officials from selected  states and localities confirmed that they were not directly involved in  developing the Plan. Further, HHS officials confirmed that the Plan was  developed by the federal government without any state input.
Although the Plan calls for actions to be carried out by states, local  jurisdictions, and other entities, including the private sector, it gives no  indication of how these actions will be monitored and how their  completion will be ensured. While the HSC reported on progress on all of  the action items involving both federal and nonfederal entities that are  included in the 2-year progress report, the 17 action items that are  intended for nonfederal entities are not monitored or reported on by the  HSC or the six federal agencies we reviewed. According to the former HSC  official in the prior administration and an NSS official in the current  administration, the HSC is not in a position to assess progress on these  action items because the federal government cannot direct nonfederal  entities to complete them. Therefore, these 17 action items do not contain  measures of performance against which to measure progress. Although the  HSC’s 1- and 2-year progress reports stated that the HSC intended to  continue and intensify its work with nonfederal entities, the 2-year  progress report does not have any information on work conducted on  these 17 action items nor is their status reported. Examples of the 17  action items intended for nonfederal entities include the following:    State, local, and tribal pandemic preparedness plans should address  the implementation and enforcement of isolation and quarantine, the  conduct of mass immunization programs, and provisions for release or  exception.
States should ensure that pandemic response plans adequately address  law enforcement and public safety preparedness across the range of  response actions that may be implemented, and that these plans are  integrated with authorities that may be exercised by federal agencies  and other state, local, and tribal governments.
Although there is no information on these two action items in the HSC’s 2- year progress report, we reported in June 2008 that HHS had led a  multidepartment effort to review pertinent parts of states’ influenza  pandemic plans in 22 priority areas, and had provided feedback to states  in November 2007. These priority areas included mass vaccination, law  enforcement, and community containment, which includes community- level interventions designed to limit the transmission of a pandemic virus  with emphasis on isolation and quarantine, closing schools, and  discouragement of large public gatherings, at a minimum. This HHS-led  review found major gaps in these three areas, which are activities cited in  the two action items noted above. Since our 2008 report, HHS led a second  interagency assessment of state influenza pandemic plans, which found  that although states have made important progress toward preparing for  combating an influenza pandemic, most states still have major gaps in  their pandemic plans. So, for these two action items, HHS had gathered  information on their status for other purposes and made it publicly  available on www.flu.gov, but this information was not reported in the  HSC’s progress reports.
section_title: The Plan Lacks a Description of the Information Needed to Carry Out Response- Related Action Items
paragraphs: The Plan includes response-related action items that have a measure of  performance or time frame associated with a pandemic or animal  outbreak. In a response-related section in the HSC’s 2-year progress  report, the report states that although neither a pandemic nor animal  outbreak had occurred in the United States as of October 2008, the federal  government had exercised many of the capabilities called for in these  action items.
We found that the Plan does not describe the specific circumstances, such  as the type or severity of an outbreak or pandemic, under which the  response-related action items would be undertaken. In addition, for  response-related action items in which the trigger is not an outbreak or  pandemic, the Plan does not describe the types of information that would  be needed in order to make a decision to implement the action items. For  example, one of the action items, shown in table 1 below, calls for DOS  and DHS to impose restrictions on travel into the United States as  appropriate. However, a senior DOS official told us that the agency does  not have triggers for when these travel restrictions would be implemented.  As we have previously reported, in preparing for, responding to, and  recovering from any catastrophic disaster, roles and responsibilities must  be clearly defined, effectively communicated, and well understood in  order to facilitate rapid and effective decision making. In an August 2009  report on U.S. preparations for the 2009 H1N1 pandemic, the President’s  Council of Advisors on Science and Technology highlighted the need for  quantitative triggers and recommended that federal agencies adopt  structured frameworks for key decision making by incorporating  scenarios and specific trigger points for action.
As of late May 2009, an official from only one of the four selected agencies  responsible for the 10 response-related action items in our sample, the  Deputy Associate Director for Security Policy at DOT, stated that the 2009  H1N1 outbreak had triggered an action item from this group (5.3.5.3) for  which the agency was responsible. For the remaining nine action items,  officials from all four agencies noted that none of the action items for  which their agency had responsibility were relevant to the H1N1 outbreak  at that time.
The Plan states that the operational details on how to carry out actions in  support of the Strategy will be included in departmental pandemic plans.  Federal agencies may have operational plans or other existing guidance  that would specify the information needed to determine whether to  undertake the response-related action items during a pandemic. However,  the Plan itself gives no indication of whether these plans or guidance  actually contain such information, or whether the information that would  be needed has been determined in advance.
section_title: Status of Some Selected Action Items Considered Complete Was Difficult to Determine
paragraphs: The HSC reported in October 2008 that about 75 percent of the 324 action  items in the Plan were designated as complete based on its criteria of  whether the measures of performance were achieved. Among the 60  action items in our sample, 49 had been designated as complete, 3  designated as in-progress, and 8 had no reported status. For a number of  reasons, as stated in the following sections, it was difficult to determine  the actual status of some of the 49 selected action items that were  designated complete.
subsections: section_title: Measures of Performance Used to Determine Status Do Not Always Fully Reflect the Descriptions of the Action Items
paragraphs: As discussed earlier, according to the HSC’s progress reports, a  determination that an action item is complete is based on whether the  action item’s measure of performance is achieved. Our review found,  however, that for more than half of the action items considered complete,  the measures of performance did not fully address all the activities  contained in their descriptions. In some instances, the HSC used  information other than the measures of performance to report progress.
All of the 49 action items designated as complete that we reviewed have  both a description of activities to be carried out, and a measure of  performance, which generally is used as an indicator to measure progress  of completion by responsible parties in carrying out what is specified in its  respective description. We found that the types of performance measures  for selected action items varied widely. For instance, measures of  performance may call for processes to be developed and implemented,  changes to be effected in foreign countries, or products such as guidance  or a vaccine to be developed.
As we reported in 2007, most of the Plan’s measures of performance for  action items are focused on activities, such as disseminating guidance, and  are not always clearly linked to the goals and objectives described in the  Strategy and Plan. In these cases, it is difficult to determine whether the  goals and objectives have been achieved. We found that the selected  action items’ measures of performance addressed the descriptions of their  respective action items to varying degrees. Examples can be seen in   table 2.
All of the 49 selected action items’ measures of performance either fully or  partially addressed their respective descriptions. In 23 of the 49 selected  action items that were designated as complete in the HSC’s 2-year  progress report, we found that the measures of performance fully  addressed the respective descriptions for the action items. For the  remaining 26 action items, the measures of performance partially  addressed their respective descriptions. For example, as noted in table 2,  the description for one of the action items calls for DOD to conduct an  assessment of military support related to transportation and borders that  could be requested during a pandemic. While the measure of performance  did not include this activity, the HSC nevertheless designated the action  item as complete.
Our review also found that for 22 of the 49 selected action items  designated as complete in the HSC’s 2-year progress report, the progress  summaries fully addressed how the measures of performance were  achieved, thereby supporting the HSC’s designation of complete for these  action items. However, for the other 27 selected action items designated as  complete, the progress summaries did not fully address how the measures  of performance were achieved. Specifically, in 18 of the 27 selected  action items, the HSC’s summaries addressed some but not all of the  activities specified in the respective measures of performance, and for the  remaining 9 action items, the summaries did not address at all how the  measures of performance were achieved. In these instances, we found  that the HSC either used the action item’s description, or used information  that was not reflected in either the description or measure of performance,  to assess completion. Table 3 below includes two examples where the  HSC summaries partially addressed or did not address the action item’s  measure of performance.
section_title: Some Selected Action Items Were Designated as Complete Despite Requiring Actions outside the Authority of the Responsible Entities
paragraphs: Of the 49 selected action items designated as complete, 11 have measures  of performance that cannot be accomplished solely by responsible entities  tasked to work on these action items. Five of these require other  countries’ assistance while the remaining six require nondesignated  entities’ participation in order for the action items to be completed. For  these 11 action items, the responsible federal agencies are not able to  achieve the measures of performance for these action items on their own,  but can provide assistance, such as funding and guidance, to encourage  completion of these action items by others. For example, one of the action  items below calls for DOS to promote, among other things, rapid reporting  of influenza cases by other nations; the measure of performance is that all  high-risk countries improve their capacity for rapid reporting. Even  though this outcome is beyond DOS’s ability to achieve on its own, the  action item was considered complete, and no explanation was provided.
Some examples of the measures of performance that cannot be entirely  fulfilled by the agencies and organizations in the United States include the  following:    DOS, in coordination with other agencies, shall work on a continuing  basis through the Partnership and through bilateral and multilateral  diplomatic contacts to promote transparency, scientific cooperation,  and rapid reporting of avian and human influenza cases by other  nations within 12 months. Measure of performance: All high-risk  countries actively cooperating in improving capacity for transparent,  rapid reporting of outbreaks.
USDA shall provide technical assistance to priority countries to  increase safety of animal products by identifying potentially  contaminated animal products, developing screening protocols,  regulations, and enforcement capacities that conform to the World  Organisation for Animal Health (OIE) avian influenza standards for  transboundary movement of animal products, within 36 months.  Measure of performance: All priority countries have protocols and  regulations in place or in process.
We previously reported in June 2007 that DOS officials confirmed that the  following action item, which was designated as complete in the HSC’s 2- year progress report, had a measure of performance that was difficult to  address because the agency did not have the means to accurately estimate  the effective reach or impact of their efforts on target audiences. As a  result, this action item could only be achieved with the participation from  nondesignated entities.
DOS, in coordination with HHS, the United States Agency for  International Development (USAID), USDA, DOD, and DHS, shall lead  an interagency public diplomacy group to develop a coordinated,  integrated, and prioritized plan to communicate U.S. foreign policy  objectives relating to our international engagement on avian and  pandemic influenza to key stakeholders (e.g., the American people, the  foreign public, nongovernmental organizations, international  businesses), within 3 months. Measure of performance: Number and  range of target audiences reached with core public affairs and public  diplomacy messages, and impact of these messages on public  responses to avian and pandemic influenza.
section_title: Additional Work Was Conducted on Some Selected Action Items Designated as Complete
paragraphs: We found that work has continued on some of the selected action items  the HSC designated as complete, including providing additional guidance,  training and exercises. In some instances, continued efforts may be  warranted—for example, when new information or circumstances might  require an update of guidance. In addition, according to the HSC’s  progress reports, a determination of “complete” indicates that the measure  of performance has been achieved but does not necessarily mean that  work on the action items has ended; the work is ongoing in many cases.
Our analysis of the 1-year and 2-year progress reports confirmed that there  was additional work conducted for 20 of the 34 selected action items  initially designated complete as of the 1-year report. For example, one of  the action items called for national spokespersons to coordinate and  communicate messages to the public. The HSC’s 1-year report stated that  for this action item, which was designated as complete, the federal  government had engaged various spokespersons by providing training for  risk communications and supporting community and individual actions to  reduce illness and death. In the HSC’s 2-year report, the HSC provided new  information on an influenza pandemic communications plan, which  included messaging and spokesperson development components and  numerous regional and local crisis and emergency risk communications  trainings. In another example, an action item required all hospitals and  health facilities funded by HHS, DOD, and the Department of Veterans  Affairs (VA) to develop and publicly disseminate guidance materials on  infection control. In its 1-year report, the HSC provided information on  guidance documents issued by HHS on hospital infection control and VA’s  national infection prevention campaign, whereas in its 2-year report, the  HSC reported on new information related to two DOD guidance  documents on preparation and response health policy and clinical and  public health guidelines for the military health system.
Action items 6.1.1.3., 7.3.2.1., and 9.1.2.2. implementation of a national animal vaccination program. An official  from the Food and Agriculture Organization (FAO) also confirmed that  additional work had continued for this action item in conjunction with the  World Organisation for Animal Health (OIE) in developing joint strategies  for highly pathogenic avian influenza.
section_title: Conclusions
paragraphs: In 2007, we recommended that the HSC establish a specific process and  time frame for updating the Plan to include a number of features we  identified as important elements of a national strategy, including a process  for monitoring and reporting on progress. While the Plan’s assumptions  are not matched to the 2009 H1N1 pandemic, making some of the action  items less relevant to current circumstances, the process for monitoring  and reporting on the status of pandemic plans is not particular to any one  type of pandemic scenario. The lessons learned from developing and  monitoring the 2006 Plan should be relevant to all future pandemic  planning efforts.
In particular, although the HSC, which is supported by the NSS, has  monitored progress on the Plan, it has not yet established a process for  updating the Plan, as previously reported, and we have found additional  areas for improvement in how the Plan has been monitored and the status  of action items assessed. For one thing, the NSS and the responsible  federal agencies have not been monitoring or reporting on action items in  the Plan intended for state and local governments and other nonfederal  entities, even though, in some instances, they have information available  that would allow them to do so, such as the interagency assessment of  state pandemic plans led by HHS. Given that the Plan states that in a  pandemic the primary response will come from states and communities,  this information should be in the progress reports, notwithstanding that it  may be available in other sources. Similarly, while agency operational  plans or guidance may provide the information under which the response- related action items would be undertaken, the Plan itself contains no such  information. As a result, it is unclear whether the information that would  be needed to activate the response-related action items in the Plan has  been identified or worked out in advance.
The HSC designated about 75 percent of the action items in the Plan as  completed, as of October 2008. However, based on our review of 49 of the  245 action items designated as complete, it is difficult to determine the  actual status of some of the selected action items designated as complete.  The HSC and the responsible federal agencies generally relied on the  measures of performance to assess progress in completing the selected  action items. However, for more than half of the selected action items, we  found that the measures of performance did not fully reflect all of the  activities called for in the action items’ descriptions. While the HSC’s  progress summaries sometimes corrected for this by referring to activities  in the action item’s description omitted from the measures of  performance, future progress reports would benefit from using measures  of performance that are more consistent with the action items’  descriptions. This would, in turn, provide a more consistent and complete  basis for describing progress in implementing the Plan.
Finally, although the administration has prepared an additional planning  document tailored specifically to the 2009 H1N1 pandemic, the Strategy  and Plan will still be needed for future events. Because most of the action  items were to be completed by May 2009, the Plan should be updated, as  we earlier recommended, to include all the elements identified in our 2007  report and to take into account the lessons learned from the 2009 H1N1  pandemic. As part of the process for monitoring the progress made in  preparing the nation for an influenza pandemic, the Plan should address  the monitoring and assessment improvements we identified in this report.
section_title: Recommendations for Executive Action
paragraphs: To improve how progress is monitored and completion is assessed under  the Plan and in future updates of the Plan, the HSC should instruct the  NSS to work with responsible federal agencies to    develop a monitoring and reporting process for action items that are  intended for nonfederal entities, such as state and local governments;  identify the types of information needed to decide whether to carry out  the response-related action items; and    develop measures of performance that are more consistent with the  descriptions of the action items.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to the Homeland Security Council  (HSC), and to the Secretaries of Agriculture, Defense, Health and Human  Services, Homeland Security, State, and Transportation for their review  and comment.
In written comments on our draft report, the Principal Deputy Counsel to  the President, on behalf of the administration, stated that our report is one  notable source of suggestions for improving national pandemic planning,  and that the administration would give consideration to our findings and  recommendations as it continues its work in this area. The HSC also  provided us with technical comments, which we incorporated as  appropriate.
HHS noted in its comments that important questions and analysis that  underpin our findings and recommendations were not presented or  addressed in this report, including whether (1) the original Plan was  adequate, (2) the priorities selected were appropriate, (3) the measures  selected for monitoring progress were appropriate, and (4) the monitoring  parameters selected were measurable or even achievable. We agree that  these are important questions. However, the objectives of this report were  to (1) determine how the HSC and responsible federal agencies monitor  the progress and completion of the Plan’s action items and (2) assess the  extent to which selected action items have been completed.  As such, we  believe that we have in fact addressed the issues raised by HHS in this  report in our examination of action items and related measures of  performance, as well as in our prior recommendation that has not yet been  implemented to incorporate into future updates of the Plan the lessons  learned from exercises and other events, such as the H1N1 pandemic.
HHS also provided two other general comments.  First, regarding our  discussion related to the lack of details in the Plan on the information that  would be used to activate the response-related action items, HHS stated  that it would be inappropriate to set specific trigger points to activate  specific responses because an influenza virus has an infinite range of  potential characteristics, which are not predictable, and that flexibility is  necessary.  HHS further stated that it would be more appropriate to  discuss the “types” of circumstances and responses that should be planned  for. We agree that flexibility is necessary to assess the specific  circumstances under which to implement the response-related action  items in the Plan, given the changing nature of an influenza virus. We agree  with HHS that the Plan should discuss the types of circumstances that  should be planned for in a pandemic. We have made changes to the report  to clarify this point.
Second, with respect to our discussion of additional work conducted on  selected action items designated as complete, HHS noted that  preparedness is a continuous and  iterative improvement process based on  lessons learned, and that ongoing training and exercises should be  iterative and adapt to lessons learned.  We agree. As we noted in this  report, in some instances, continued efforts on action items may be  warranted—for example, when new information or circumstances might  require an update of guidance. Our concern, however, is that it is unclear  what additional work or progress had been made on these action items,  since the HSC had designated them as complete.
DHS stated that the information in our report is generally accurate and  had no substantive comments on the content of the report. DHS further  stated that while improvements can be made in the Plan as we outlined in  our report, there has been significant work accomplished in pandemic  preparedness as a direct result of the Plan.  For example, DHS noted that  significant collaboration at all levels of government and the private sector  has occurred, which enabled a more efficient and coordinated response  for the 2009 H1N1 pandemic.
DOT provided us with technical comments, which we incorporated. DOD,  DOS, and USDA informed us that they did not have any comments on the  draft report. The White House, HHS, and DHS provided written comments  on a draft of this report, which are reprinted in appendixes III, IV, and V,  respectively.
As agreed with your office, we plan no further distribution of this report  until 30 days from its date, unless you publicly announce its contents  earlier. At that time we will send copies to the HSC, Secretary of  Agriculture, Secretary of Defense, Secretary of Health and Human  Services, Secretary of Homeland Security, Secretary of State, Secretary of  Transportation, and other interested parties. In addition, this report will be  available at no charge on GAO’s Web site at http://www.gao.gov.
If you or your staff have any further questions about this report, please  contact me at (202) 512-6543 or steinhardtb@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made major contributions to  this report are listed in appendix VI.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: The objectives of this study were to (1) determine how the Homeland  Security Council (HSC) and the responsible federal agencies are  monitoring the progress and completion of the Implementation Plan for  the National Strategy for Pandemic Influenza (Plan) action items, and (2)  assess the extent to which selected action items have been completed,  whether activity has continued on the selected action items reported as  complete, and the nature of that work. We did not assess the response  efforts for the 2009 H1N1 pandemic in this report, but we continue to  monitor the outbreak and the federal government’s response.
To address these objectives, we conducted an in-depth analysis of a  random sample of 60 action items in the Plan. We drew a random sample  from the 286 action items involving six federal agencies with primary  responsibility for ensuring completion of the large majority (88 percent) of  the 324 action items. These six agencies are the Department of Defense  (DOD), Department of Health and Human Services (HHS), Department of  Homeland Security (DHS), Department of State (DOS), Department of  Transportation (DOT), and the Department of Agriculture (USDA). Of the  60 action items selected for our sample, the HSC reported that 49 were  completed, 3 were in progress, and 8 had no status updates in its 2-year  progress report. The purpose of this random sampling was not to be able  to generalize our findings to the entire population of 286; rather, it was to  produce a sample that had a distribution of items generally mirroring that  of the overall population of 286 using the following variables so that the  sample would include action items that represented (1) the six agencies  with primary responsibility for implementing the Plan, (2) the three pillars  in the Plan, (3) the presence of collaboration between federal agencies  and nonfederal entities (i.e. state, local, and tribal entities, the private  sector, international organizations, and nongovernmental organizations),  and (4) various time frames of when they should be completed, which  range from within 24 hours of an outbreak to 60 months from the release  of the Plan in May 2006, among other time frames. We do not generalize  the results of our analysis because the particular analytical steps we took  across the selected action items varied and as a result there was no  common underlying measure on which to generalize results to all of th action items in the Plan. In addition, we did not review all of the action  items in the Plan in depth because our analyses involved multiple  assessments for each action item, including the review of large volumes of  agency documentation in determining the level of evidence for completi on  of the action item.
For both objectives, we interviewed officials and obtained documentat from the six federal agencies. We reviewed the HSC’s 6-month 2-year progress reports and the HSC’s 1-year summary report on the  implementation of the action items in the Plan. In addition, we interv a senior HSC official from the previous administration and the Director of aff  Medical Preparedness Policy for the White House National Security St (NSS) in the current administration responsible for overseeing the  implementation of the Plan.  We also relied on our prior pandemic work  to inform our analysis.  ion  , 1-year, and  To address the first objective on how the HSC and responsible federal  agencies are monitoring the progress and completion of the Plan’s action  items, we assessed information from interviews and documentation, such  as the HSC’s progress reports, on how the HSC and the selected agencies  monitored the progress and completion of all action items. We also  requested information from the six agencies on how the NSS is currently  overseeing the interagency process used for monitoring the  implementation of action items in the Plan. We also interviewed  representatives from nine nonfederal entities, such as the World  Organisation for Animal Health (OIE) and the Denver Health Medical  Center, which agency officials had identified as working collaboratively  with them on four action items in our sample, and asked these  representatives whether the agencies asked for information on the  progress of implementing these action items. In addition, we reviewed the Plan and the HSC’s 2-year progress report to identify specific  circumstances that would trigger the response-related action items that  are activated by an animal outbreak or pandemic. We also collected  information from the four selected agencies that had primary  responsibility for the 10 response-related action items in our sample  regarding criteria that would trigger these action items.
To address the second objective, we analyzed the 49 action items in our  random sample that the HSC’s 2-year progress report designated as  complete. We also collected documentation and conducted interview with selected agency officials from the six agencies and a senior HSC  official from the prior administration. To describe the extent to which  action items had been completed, we analyzed information on the 49  selected action items in the Plan, the HSC progress reports, and  supporting documentation provided by the six agencies with primary  f the 49 action items to demonstrate how the  responsibility for each o measures of performance were achieved based on the HSC’s criteria for  completion. Specifically, we analyzed the 49 selected action items  designated as complete to assess whether  1.  the measures of performance fully addressed, partially addressed, or  did not address their respective action item description;  2.  the summaries contained in the HSC’s 2-year progress report fully  addressed, partially addressed, or did not address how th performance were achieved; and  3.  the measures of performance could be accomplished solely b responsible entities that are tasked to work on the action items.
To evaluate the extent of work that has continued on the 49 ac in our sample that were designated as complete, and the nature of that  work, we gathered information in two ways. First, we compared the H 1-year and 2-year progress reports for 34 selected action items designated as complete as of the 1-year report by analyzing each actio item’s summary in the HSC’s 1- and 2-year progress repor information on work conducted. Second, we asked the six agencies with n  ts for any new  primary responsibility if they had performed additional work after action items were designated as complete and, if so, to provide a brief desc of the nature of that work. For 27 of the 49 action items designated as  complete, the agencies indicated that they had performed additional w after the action items were designated as complete. For 22 of those 27  action items, the agencies also specified the nature of the additional w GAO  To ensure consistency and accuracy of our analysis, at least two  analysts independently analyzed the data we received for the 49 select action items in our sample designated as complete and then compared their results. In cases where there were discrepancies, the two analysts  reconciled their differences for a final response. Additionally,  methodologists in GAO’s Applied Research an independent analysis and verification of our assessment by reviewing  whether the measures of performance addressed its respective descriptio and whether the HSC summaries addressed how the measure performance were achieved for all 49 action items designated as complete.  In cases where there were discrepancies between the analysts’ and  methodologists’ teams, a joint reconci response.  ork. liation was conducted for a final  We conducted this performance audit from July 2008 to November 2009 in  accordance with generally accepted government auditing standards. Those  standards require that w appropriate evidence to provide a reasonable basis for our findings and  e plan and perform the audit to obtain sufficient,  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 II: Sample of 60 Selected Action Items in the Implementation Plan for the National Strategy for Pandemic Influenza
subsections: section_title: The Department of State ( engagement in and follow- build cooperation and cap internationally, including th initiatives (inventory of res pandemic influenza, a regi Emerging Infectious Disea Regional Emerging Diseas the U.S.-China Joint Initiat Indonesia-Singapore Joint should develop a strategy cooperating with U.S. and against pandemic influenz
paragraphs: Finalized action plans that outline goals be achieved and timeframes in which th will be achieved. e Asia-Pacific Economic Cooperation  ources and regional expertise to fight  onwide tabletop exercise, a Symposium on  ses to be held in Beijing in April 2006 and the  e Intervention (REDI) Center in Singapore),  ive on Avian Influenza, and the U.S.-  Avian Influenza Demonstration Project; and  to expand the number of countries fully  /or international technical agencies in the fight  a, within 6 months.
The Department of Health REDI Center in Singapore  and Human Services (HHS) shall staff the   within 3 months.
U.S. government staff provided to REDI  Center.
The United States Departm United States Agency for I Partnership, shall support  and the World Organisatio instrument to assess priori prevention, surveillance, a veterinary rapid response  animal surveillance, diagn countries, within 9 months ent of Agriculture (USDA), working with the  nternational Development (USAID) and the  the Food and Agriculture Organization (FAO)  n for Animal Health (OIE) to implement an  ty countries’ veterinary infrastructure for  nd control of animal influenza and increase  capacity by supporting national capacities for  ostics, training, and containment in at-risk  .
Per the OIE’s Performance, Vision and  Strategy Instrument, assessment tools  exercised and results communicated to  the Partnership, and priority countries are  developing, or have in place, an  infrastructure capable of supporting their  national prevention and response plans  for avian or other animal influenza.
Majority of registered U.S. citizens have access to accurate and current  information on influenza. ments, to enable them to make informed  riate personal measures.
Briefing materials and an action plan in  place for engaging with relevant federal,  state, tribal, and local authorities. n the United States consistent with U.S.  ons within 6 months.
All priority countries and partner  organizations have received relevant  information on influenza vaccines and  application strategies.
The Department of Justice (DOJ) and DOS, in coordination with HHS,  shall consider whether the U.S. Government, in order to benefit from the  protections of the Defense Appropriations Act, should seek to negotiate  liability-limiting treaties or arrangements covering U.S. contributions to  an international stockpile of vaccine and other medical  countermeasures, within 6 months.
Review initiated and decision rendered.
USDA, in collaboration with FAO and OIE, shall develop and provide  best-practice guidelines and technical expertise to countries that  express interest in obtaining aid in the implementation of a national  animal vaccination program, within 4 months.
Interested countries receive g and other assistance within 3 months of  their request.
DOS, in coordination with other agencies, shall work on a continu basis through the Partnership and through bilateral and multilater diplomatic contacts to promote transparency, scientific cooperation, an rapid reporting of avian and human influenza cases by other nations  within 12 months.
All high-risk countries activ in improving capacity for transparent,  rapid reporting of outbreaks.
HHS shall support the World Health Organization (WHO) Secre enhance the early detection, identification and reporting of infectious  disease outbreaks through the WHO’s Influenza Network and Glob al  Outbreak and Alert Response Network within 12 months.
Expansion of the network to regions not  currently part of the network.
HHS shall enhance surveillance and response to high pr disease, including influenza with pandemic potential, by training  physicians and public health workers in disease surve illance, applied  epidemiology and outbreak response at its Global Disease Detection  Response Centers in Thailand and China and at the U.S.-China  Collaborative Program on Emerging and Re-Emerging Infectious  Diseases, within 12 months.
50 physicians and public health workers  living in priority countries receive training  in disease surveillance applied  epidemiology and outbreak response.
DOD, in coordination with DOS and with the cooperation of the host nation, shall assist with influenza surveillance of host nation population s  in accordance with existing treaties and international agreements, within  24 months.
Medical surveillance “watchboard ”  expanded to include host nations.
HHS shall develop and imple programs in basic laboratory techniques related to influenza sample  preparation and diagnostics in priority countries within 9 months.
25 laboratory scientists trained in  influenza sample preparation and  diagnostics.
HHS and USAID shall work with the WHO Secretariat and private sect partners, through existing bilateral agreements, to provide support for  human health diagnostic laboratories by developing and giving  assistance in implementing rapid international laboratory diagnostics  protocols and standards in priority countries, within 12 months.
75 percent of priority countri improved human diagnostic laboratory  capacity.
DOD, in coordination with HHS, shall prioritize international DOD  laboratory research efforts to develop, refine, and validate diagnostic  methods to rapidly identify pathogens, within 18 months.
Completion of prioritized research plan,  resources identified, and tasks assigned  across DOD medical research facilities.
DOD shall work with priority nations’ military forces to assess existin ortable field assay  laboratory capacity, rapid response teams, and p testing equipment, and fund essential commodities and training  necessary to achieve an effective national military diagnostic capability within 18 months.
Assessments completed, proposals  accepted, and funding made available to  priority countries.
HHS and USAID shall develop, in coordination with the WHO  Secretariat and other donor countries, rapid response protocols for use  in responding quickly to credible reports of human-to-human  transmission that may indicate the beginnings of an influenza pandemic,  within 12 months.
Adoption of protocols b stakeholders.
USDA shall provide technical assistance to priority countries to increas safety of animal products by identifying potentially contaminated a products, developing screening protocols, regulations, and enforcem capacities that conform to OIE avian influenza standards for  transboundary movement of animal products, within 36 months.
All priority countries have protocols and  regulations in place or in process.
DOS, in coordination with HHS, USAID, USDA, DOD, and the  Department of Homeland Security (DHS), shall lead an interagency  public diplomacy group to develop a coordinated, integrated, and  prioritized plan to communicate U.S. foreign policy objectives relating to  our international engagement on avian and pandemic influenza to key  stakeholders (e.g., the American people, the foreign public, NGOs,  international businesses),within 3 months.
Number and range of target audiences reached with core public affai rs and public  diplomacy messages, and impact of these  messages on public responses to avian  and pandemic influenza.
USDA, in coordination with DHS, the United States Trade  Representative (USTR), and DOS, shall ensure that clear and  coordinated messages are provided to international trading partners  regarding animal disease outbreak response activities in the United  States.
Within 24 hours of an outbreak,  appropriate messages will be shared with key animal/animal product trading  partners.
DOD, in coordination with DHS, the Department of Transportation(DOT), DOJ, and DOS, shall conduct an assessment of military su related to transportation and b orders that may be requested during a  pandemic and develop a comprehensive contingency plan for Defens Support to Civil Authorities, within 18 months.
Defense Support to Civil Authorities plan  in place that addresses emergency  transportation and border support.
DHS, in coordination with DOT, the Department of Labor (DOL), the  Office of Personnel Management, and DOS, shall disseminate  workforce protection information to stakeholders, conduct outreach stakeholders, and implement a comprehensive program for all Federa transportation and border staff within 12 months.
100 percent of workforce has or has  access to information on pandemic  influenza risk and appropriate prot measures.
DHS, DOT, and HHS, in coordination with transportation and border  stakeholders, and appropriate state and local health authorities, shall  develop aviation, land border, and maritime entry and exit protocols  and/or screening protocols, and education materials for non-medical,  front-line screeners and officers to identify potentially infected persons or cargo, within 10 months.
Protocols and training materials  developed and disseminated.
DHS and HHS, in coordination with DOT, DOJ, and appropriate State  and local health authorities, shall develop detection, diagnosis,  quarantine, isolation, emergency medical services (EMS) transport,  reporting, and enforcement protocols and education materials for  travelers, and undocumented aliens apprehended at and between po of entry, who have signs or symptoms of pandemic influenza or w ho  may have been exposed to influenza, within 10 months.
Protocols developed and distributed to all  ports of entry.
Revised process for withdrawing permits  of high-risk importers.
Risk based protocols established and in  use.
USDA, DHS, and DOI, in coordination with DOS, HHS, and the  Department of Commerce (DOC), shall conduct outreach and expand  education campaigns for the public, agricultural stakeholders, wildlife  trade community, and cargo and animal importers/exporters on import  and export regulations and influenza disease risks, within 12 months.
100 percent of key stakeholders are  aware of current import and export  regulations and penalties for non- compliance.
DOS and DHS, in coordination with DOT, DOC, HHS, the Depa the Treasury (Treasury), and USDA, shall work with foreign counterp to limit or restrict travel from affected regions to the United States,  appropriate, and notify host government(s) and the traveling public.
Measures imposed within 24 hours of th decision to do so, after appropriate  notifications made.
DHS, in coordination with DOS, USDA and DOI, shall provide countries with guidance to increase scrutiny of cargo and other imported items  through existing programs, such as the Container Security Initiative, and  impose country-based restrictions or item-specific embargoes.
Guidance, which may incl on restrictions, is provided for increased  scrutiny of cargo and other imported  items, within 24 hours upon notifi an outbreak.
DHS, in coordination with USDA, DOS, DOC, DOI, and shippers, sha rapidly implement and enforce cargo restrictions for export or import  potentially co ntaminated cargo, including embargo of live birds, and  notify international partners/shippers.
Measures implemented within 6 ho decision to do so.
DHS, if needed, will implement contingency plans to maintain border  control during a period of pandemic influenza induced mass migration.
Contingency plan activated within 24 hours of notification.
All regulatory waivers as needed balance  need to expedite services with safety.
DOT, in coordination with DHS, state, local, and tri the private sector, shall monitor system closures, assess effects on the  transportation system, and implement contingency plans. bal governments, and  Timely reports transmitted to DHS and  other appropriate entities, containi relevant, current, and accurate information on the status of the transportation sector and impacts  resulting from the pandemic; when  appropriate, contingency plans  implemented within no more than 24  hours of a report of a transportation  sector impact or issue.
DOT, in support of DHS and in coordination with other emergency  support function (ESF) #1 support agencies, shall work closely with the  private sector and state, local, and tribal entities to restore the  transportation system, including decontamination and reprioritization of  essential commodity shipments.
Backlogs or shortages of essential  commodities and goods quickly  eliminated, returning production and  consumption to prepandemic levels.
DHS, in coordination with HHS, DOJ, DOT, and DOD, shall be prepared to provide emergency response element training (e.g., incident  management, triage, security, and communications) and exercise  assistance upon request of state, local, and tribal communities and  public health entities within 6 months.
Percentage of requests for training and  assistance fulfilled.
HHS, in coordination with DHS, DOD, and the Department of Ve Affairs (VA), shall develop a joint strategy defining the objectives,  conditions, and mechanisms for deployment under which the National  Disaster Medical System assets, U.S. Public Health Service  Commissioned Corps, Epidemic Intelligence Service officers, and  DOD/VA health care personnel and public health officers would be  deployed during a pandemic, within 9 months.
Interagency strategy completed and  tested for the deployment of federalmedical personnel during a pande mic.
HHS, in coordination with DHS, DOS, DOD, VA, and other federal  partners, shall develop, test, and implement a federal government pu health emergency communications plan (describing the government’s  strategy for responding to a pandemic, outlining U.S. international  commitments and intentions, and reviewing containment measures that  the government believes will be effective as well as those it regards as  likely to be ineffective, excessively costly, or harmful) within 6 mo nths.
Containment strateg response materials completed and  published on www.pandemicflu.gov;  communications plan implemented.
HHS, in coordination with DHS, DOD, and the VA, and in collaboration  with state, local, and tribal health agencies and the academic  community, shall select and retain opinion leaders and medical experts  to serve as credible spokespersons to coordinate and effectively  communicate important and informative messages to the public, within 6  months.
National spokespersons engaged in  communications campaign.
DOT, in cooperation with HHS, DHS, and DOC, shall develop model  protocols for 9-1-1 call centers and public safety answering points that  address the provision of information to the public, facilitate caller  screening, and assist with priority dispatch of limited emergency m services, within 12 months.
Model protocols deve disseminated to 9-1-1call centers and  public safety answering points.
Domestic vaccine manufacturing capacity  of  in place to produce 300 million courses  vaccine within 6 months of development  of a vaccine reference strain during a  pandemic.
DOT, in coordination with HHS, DHS, state, local, and tribal officials and  other EMS stakeholders, shall develop suggested EMS pandemic  influenza guidelines for statewide adoption that address: clinical  standards, education, treatment protocols, decontamination procedures,  medical direction, scope of practice, legal parameters, and other issues,  within 12 months.
EMS pandemic influenza guidelines completed.
HHS, in coordination with DOD, VA, and in collaboration with state,  territorial, tribal, and local partners, shall develop/refine mechanisms to:  (1) track adverse events following vaccine and antiviral administration;  (2) ensure that individuals obtain additional doses of vaccine, if  necessary; and (3) define protocols for conducting vaccine- and  antiviral-effectiveness studies during a pandemic, within 18 months.
Mechanism(s) to track vaccine and  antiviral medication coverage and  adverse events developed; vaccine- a nd  antiviral-effectiveness study protocolsdeveloped.
HHS, in coordination with DHS and sector-specific agencies, DOS, DOD, DOL, and VA, shall establish a strategy for shifting priorities  based on at-risk populations, supplies and efficacy of countermeasu against the circulating pandemic strain, and characteristics of the virus  within 9 months.
Clearly articulated p rocess in place for  evaluating and adjusting prepandemic  recommendations of groups receiving  priority access to medical  countermeasures.
HHS shall support the renovation of existing U.S. manufacturing  facilities that produce other Food and Drug Administration licensed cell- based vaccines or biologics and the establishment of new domestic cell- based influenza vaccine manufacturing facilities, within 36 months.
Contracts awarded for renovation or  establishment of domestic cell-based  influenza vaccine manufacturing capaci ty.
HHS, in coordination with DHS, shall develop and test new point-of- and laboratory-based rapid influenza diagnostics for screening and  surveillance, within 18 months. care  New grants and contracts awarded to  researchers to develop and evaluate new  diagnostics.
HHS shall provide guidance to public health and clinical laboratories on  the different types of diagnostic tests and the case definitions to use for  influenza at the time of each pandemic phase. Guidelines for the curren pandemic alert phase will be disseminated within 3 months.
Dissemination on www.pandemicflu.go v  and through other channels of guidance  on the use of diagnostic tests for H5N and other potential pandemic influenz subtypes.
HHS, in coordination with DHS, DOD, and VA, and in collaboration with  state, local, and tribal authorities, shall be prepared to collect, analyze,  integrate, and report information about the status of hospitals and health care systems, healthcare critical infrastructure, and medical materiel  requirements, within 12 months.
Guidance provided to states and tribal  entities on the use and modification o components of the National Hospital  ies and  Available Beds for Emergenc Disasters system for implementation at  the local level.
All HHS-,  develop, test, and be prepared to implement infection control campaigns  for pandemic influenza, within 3 months.
Guidance materials on infection control  developed and disseminated on  www.pandemicflu.gov and through other  channels.
HHS, in coordination with DHS, VA, and DOD, shall develop and  disseminate guidance that ex plains steps individuals can take to  decrease their risk of acquiring or transmitting influenza infection dur a pandemic, within 3 months.
Guidance disseminated  onwww.pandemicflu.gov and through VA  and DOD channels.
USDA and DOI shall perform research to understand better how av er to  influenza viruses circulate and are transmitted in nature, in ord improve information on biosecurity distributed to local animal owners,  producers, processors, markets, auctions, wholesalers, distributors,  retailers, and dealers, as well as wildlife management agencies,  rehabilitators, and zoos, within 18 months.
Completed research studies provide new  information, or validate current   the most useful  information, on biosecurity measures to be taken to  effectively prevent introduction, and limit  or prevent sp read, of avian influenza  viruses in domestic and captive animal  populations.
An effective avian influenza vaccine that  can be delivered simultaneously to  multiple birds ready for commercial  development.
DOI and USDA shall collaborate with state wildlife agencies,  universities, and others to increase surveillance of wild birds, par migratory water birds and shore birds, in Alaska and other appropriate  locations elsewhere in the United States and its territories, to detect  influenza viruses with pandemic potential, including highly pathogenic  avian influenza H5N1, and establish baseline data for wild birds, within  12 months.
Reports detailing geographically  appropriate w and influenza virus testing results.
USDA shall work with state and tribal entities, and industry groups perform surveys of game birds and waterfowl raised in captivity, and  implement surveillance of birds at auctions, swap meets, flea markets,  and public exhibitions, within 12 months.
Samples collected at 50 percent of th largest auctions, swap meets, flea  markets, and public exhibitions held in at  least five states or tribal entities believed  to be at highest risk for an avian influen introduction.
USDA shall activate plans to distribute veterinary medical  countermeasures and materiel from the National Veterinary Stockpile  (NVS) to federal, state, local, and tribal influenza outbreak responders  within 24 hours of confirmation of an outbreak in animals of influenza  with human pandemic potential, within 9 months.
NVS mater of confirmation of an outbreak.
DHS, in coordination with DOJ, HH pandemic influenza tabletop exercise for state, local, and tribal law  enforcement/public safety officials that they can conduct in concert w public health and medical partners, and ensure it is distributed  nationwide within 4 months.
Percent of state, local, and tribal law  enforcement/public safety agencies that  have received the pandemic influenza  tabletop exercise.
DHS, in coordination with DOJ, DOD, DOT, HHS, and other appropriate  federal sector-specific agencies, shall engage in contingency plan ning  and related exercises to ensure they are prepared to sustain EMS , fire,  emergency management, public works, and other emergency response  functions during a pandemic, within 6 months.
Completed exercise(s)) for supporting EMS, fire,  emergency management, public works,  and other emergency response functions.
DHS, in coordination with states, localities and tribal entities, shall  support private sector preparedness with education, exercise, training,  and information sharing outreach programs, within 6 months.
Preparedness exercises established with  private sector partners in all states and  U.S. territories.
DHS shall develop and operate a national-level monitoring and  information sharing system for core essential services to provide  status  updates to critical infrastructure dependent o n these essential services,  and aid in sharing real-time impact information, monitoring actions, and  prioritizing national support efforts for preparedness, response, and  recovery of critical infrastructure sectors within 12 months.
National-level critical infrastructure  monitoring and information-sharing  system established and operational.
Data are from the Implementation Plan for the Nation al Strategy for Pandemic Influenza.
24 action items, of ogress, and 8 with no reported status.  sons why it was difficult to determine the actua ere designated as complete.
section_title: Appendix III: Comments from the White House
section_title: Appendix IV: Comments from the Department o
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Sarah Veale, Assistant Director;  In addition to the contact named above, Sarah Veale, Assistant Director;  Maya Chakko; Susan Sato; David Fox; Melissa Kornblau; Kara Marshall;  Maya Chakko; Susan Sato; David Fox; Melissa Kornblau; Kara Marshall;  Mark Ryan; David Dornisch; Andrew Stavisky; and members of GAO’s  Mark Ryan; David Dornisch; Andrew Stavisky; and members of GAO’s  Pandemic Working Group made key contributions to this report.  Pandemic Working Group made key contributions to this report.
section_title: Related GAO Products
paragraphs: Influenza Pandemic: Key Securities Market Participants Are Making  Progress, but Agencies Could Do More to Address Internet Congestion  and Encourage Readiness. GAO-10-8. Washington, D.C.: October 26, 2009.
Influenza Pandemic: Gaps in Pandemic Planning and Preparedness  Need to Be Addressed. GAO-09-909T. Washington, D.C.: July 29, 2009.
Influenza Pandemic: Greater Agency Accountability Needed to Protect  Federal Workers in the Event of a Pandemic. GAO-09-783T. Washington,  D.C.: June 16, 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: Federal Agencies Should Continue to Assist States  to Address Gaps in Pandemic Planning. GAO-08-539. Washington, D.C.:  June 19, 2008.
Emergency Preparedness: States Are Planning for Medical Surge, but  Could Benefit from Shared Guidance for Allocating Scarce Medical  Resources. GAO-08-668. Washington, D.C.: June 13, 2008.
Influenza Pandemic: Efforts Under Way to Address Constraints on  Using Antivirals and Vaccines to Forestall a Pandemic. GAO-08-92.  Washington, D.C.: December 21, 2007.
Influenza Pandemic: Opportunities Exist to Address Critical  Infrastructure Protection Challenges That Require Federal and Private  Sector Coordination. GAO-08-36. Washington, D.C.: October 31, 2007.
Influenza Pandemic: Federal Executive Boards’ Ability to Contribute t Pandemic Preparedness.  GAO-07-1259T. Washington, D.C.: September 2 2007.
Influenza Pandemic: Opportunities Exist to Clarify Federal Leadersh Roles and Improve Pandemic Planning. GAO-07-1257T. Washington, D September 26, 2007.
Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer  Federal Leadership Roles and an Effective National Strategy.  GAO-07-781. Washington, D.C.: August 14, 2007.
Emergency Management Assistance Compact: Enhancing EMAC Collaborative and Administrative Capacity Should Impr Disaster Response. GAO-07-854. Washington, D.C.: June 29, 2007.
Influenza Pandemic: DOD Combatant Commands’ Preparedness Efforts  Could Benefit from More Clearly Defined Roles, Resources, and Risk  Mitigation. GAO-07-696. Washington, D.C.: June 20, 2007.
Influenza Pandemic: Efforts to Forestall Onset Are Under Way;  Identifying Countries at Greatest Risk Entails Challenges. GAO-07-604.  Washington, D.C.: June 20, 2007.
Avian Influenza: USDA H Outbreaks, but Better Planning Could Improve Response. GAO-07-652.  Washington, D.C.: June 11, 2007.  as Taken Important Steps to Prepare for  The Federal Wo Federal Executive Boards’ Ability to Contribute to Emergency  Operations. GAO-07-515. Washington, D.C.: May 4, 2007.  rkforce: Additional Steps Needed to Take Advantage of  Financial Market Preparedness: Significant Progress Ha but Pandemic Planning and Other Challenges Remain. GAO-07-399.  Washington, D.C.: March 29, 2007.
Influenza Pandemic: DOD Has Taken  Accountability, Funding, and Communications Need to be Clearer and  Focused Departmentwide. GAO-06-1042. Washington, D.C.: Sept 2006.
Catastrophic Disasters: Enhanced Leadership, Capabilities, and  Accountability Controls Will Improve the Effectiveness of the Nation’s  Preparedness, Response, and Recovery System. GAO-06-618. Washington,  D.C.: September 6, 2006.