Influenza Pandemic: Federal Agencies Should Continue to Assist States to Address Gaps in Pandemic Planning
Published: 2008-06-19T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Implementation Plan for the National Strategy for Pandemic Influenza states that in an influenza pandemic, the primary response will come from states and localities. To assist them with pandemic planning and exercising, Congress has provided $600 million to states and certain localities. The Department of Homeland Security (DHS) established five federal influenza pandemic regions to work with states to coordinate planning and response efforts. GAO was asked to (1) describe how selected states and localities are planning for an influenza pandemic and who they involved, (2) describe the extent to which selected states and localities conducted exercises to test their influenza pandemic planning and incorporated lessons learned as a result, and (3) identify how the federal government can facilitate or help improve state and local efforts to plan and exercise for an influenza pandemic. GAO conducted site visits to five states and 10 localities.
section_title: What GAO Found
paragraphs: All of the five states and 10 localities reviewed by GAO had developed influenza pandemic plans. In fact, according to officials at the Centers for Disease Control and Prevention (CDC), which administers the federal pandemic funds, all 50 states have developed an influenza pandemic plan, in accordance with federal pandemic funding requirements. At the time of GAO's site visits, officials from the selected states and localities reviewed said that they involved the federal government, other state and local agencies, tribal nations, and nonprofit and private sector organizations in their influenza pandemic planning. Since GAO's site visits, the Department of Health and Human Services (HHS) has provided feedback to the states, territories, and the District of Columbia (hereafter referred to as states) on whether their plans addressed 22 priority areas, such as policy process for school closure and communication. On average the department found that states' plans had "many major gaps" in 16 of the 22 priority areas. In March 2008, HHS, DHS, and other federal agencies issued guidance to states to help them update their pandemic plans, which are due by July 2008, in preparation for another HHS-led review. According to CDC officials, all states and localities that received the federal pandemic funds have met the requirement to conduct an exercise to test their plans. Officials from all of the states and localities reviewed by GAO reported that they had incorporated lessons learned from influenza pandemic exercises into their influenza pandemic planning, such as buying additional medical equipment, providing training, and modifying influenza pandemic plans. For example, as a result of an exercise, officials at the Dallas County Department of Health and Human Services (Texas) reported that they developed an appendix to their influenza pandemic plan on school closures during a pandemic. The federal government has provided influenza pandemic guidance on a variety of topics including an influenza pandemic planning checklist for states and localities and draft guidance on allocating an influenza pandemic vaccine. However, officials of the states and localities reviewed by GAO told GAO that they would welcome additional guidance from the federal government in a number of areas to help them to better plan and exercise for an influenza pandemic, in areas such as community containment (community-level interventions designed to reduce the transmission of a pandemic virus). Three of these areas were also identified as having "many major gaps" in states' plans nationally in the HHS-led review. In January 2008, HHS and DHS, in coordination with other federal agencies, hosted a series of meetings of states in the five federal influenza pandemic regions to discuss the draft guidance on updating their pandemic plans. Although a senior DHS official reported that there are no plans to conduct further workshops, additional regional meetings could provide a forum for state and federal officials to address gaps in states' planning identified by the HHS-led review and to maintain the momentum of states' pandemic preparedness through this next governmental transition.

section_title: Letter
paragraphs: The Implementation Plan for the National Strategy for Pandemic  The Implementation Plan for the National Strategy for Pandemic  Influenza (National Pandemic Implementation Plan) states that in the  Influenza (National Pandemic Implementation Plan) states that in the  event of an influenza pandemic the distributed nature and sheer burden of  event of an influenza pandemic the distributed nature and sheer burden of  disease across the nation would mean that the federal government’s  disease across the nation would mean that the federal government’s  support to any particular community is likely to be limited, with the  support to any particular community is likely to be limited, with the  primary response to a pandemic coming from states and local  primary response to a pandemic coming from states and local  communities. However, given the unique nature of an influenza pandemic,  communities. However, given the unique nature of an influenza pandemic,  all sectors of society, including the federal government, states and local  all sectors of society, including the federal government, states and local  communities, the private sector, nonprofit organizations, tribal nations,  communities, the private sector, nonprofit organizations, tribal nations,  individual citizens, and global partners will need to be involved in  individual citizens, and global partners will need to be involved in  preparedness for and response to a pandemic.  preparedness for and response to a pandemic.
An influenza pandemic is a real and significant threat facing the United  An influenza pandemic is a real and significant threat facing the United  States and the world. There is widespread agreement that it is not a  States and the world. There is widespread agreement that it is not a  question of if, but when, such an influenza pandemic will occur. Some of  question of if, but when, such an influenza pandemic will occur. Some of  the issues associated with the preparation for and responses to an  the issues associated with the preparation for and responses to an  influenza pandemic are similar to those for any other type of disaster or  influenza pandemic are similar to those for any other type of disaster or  hazard. However, a pandemic poses some unique challenges. During the  hazard. However, a pandemic poses some unique challenges. During the  peak weeks of an outbreak of a severe influenza pandemic in the United  peak weeks of an outbreak of a severe influenza pandemic in the United  States, an estimated 40 percent of the United States workforce might not  States, an estimated 40 percent of the United States workforce might not  be at work due to illness, the need to care for family members who are  be at work due to illness, the need to care for family members who are  sick, or fear of becoming infected. Moreover, an influenza pandemic is  sick, or fear of becoming infected. Moreover, an influenza pandemic is  likely to occur in several waves, each lasting up to 6 to 8 weeks, with  likely to occur in several waves, each lasting up to 6 to 8 weeks, with  outbreaks occurring simultaneously across the country.  outbreaks occurring simultaneously across the country.
The National Strategy for Pandemic Influenza (National Pandemic  The National Strategy for Pandemic Influenza (National Pandemic  Strategy), which was issued in November 2005 by the President and his  Strategy), which was issued in November 2005 by the President and his  Homeland Security Council, is intended to provide a high-level overview of  Homeland Security Council, is intended to provide a high-level overview of  the approach that the federal government will take to prepare for and  the approach that the federal government will take to prepare for and  respond to an influenza pandemic. The National Pandemic Implementation  respond to an influenza pandemic. The National Pandemic Implementation  Plan, which was issued in May 2006 by the President and his Homeland  Plan, which was issued in May 2006 by the President and his Homeland  Security Council, lays out the broad implementation requirements and  Security Council, lays out the broad implementation requirements and  responsibilities among the appropriate federal agencies and defines  responsibilities among the appropriate federal agencies and defines  expectations of nonfederal entities for the National Pandemic Strategy.  expectations of nonfederal entities for the National Pandemic Strategy.  The National Pandemic Implementation Plan lays out the expectation that  The National Pandemic Implementation Plan lays out the expectation that  states and communities should have influenza pandemic preparedness  states and communities should have influenza pandemic preparedness  plans and conduct pandemic exercises. Exercises are crucial in testing and  plans and conduct pandemic exercises. Exercises are crucial in testing and  planning. Our work has shown the importance of ensuring that lessons  learned from exercises are incorporated into planning to address any gaps  or challenges identified. To assist in planning and coordinating efforts to  respond to an influenza pandemic, in December 2006, the Secretary of  Homeland Security established five federal influenza pandemic regions  across the United States to work with states to coordinate planning and  response efforts. In addition, cooperative agreements and grants from the  Department of Health and Human Services (HHS) and the Department of  Homeland Security (DHS) provide funds that state and local governments  can use to support planning and exercising for an influenza pandemic.  During fiscal year 2006, Congress provided HHS $600 million in  supplemental funding for state and local influenza pandemic planning and  exercising, which has been administered by the Centers for Disease  Control and Prevention (CDC), the last portion is to be distributed in 2008.  The federal government has communicated the importance of remaining  vigilant and sustaining pandemic preparedness. Continuing and  maintaining these efforts is particularly crucial now, given the upcoming  federal governmental transition in January 2009.
This report responds to your request that we (1) describe how selected  states and localities are planning for an influenza pandemic and how their  efforts are involving the federal government, other state and local  agencies, tribal nations, nonprofit organizations, and the private sector,   (2) describe the extent to which selected states and localities have  conducted exercises to test their influenza pandemic planning and  incorporated lessons learned into their planning, and (3) identify how the  federal government can facilitate or help improve state and local efforts to  plan and exercise for an influenza pandemic.
To address these objectives, from June 2007 through September 2007, we  conducted site visits to the five most populous states: California, Florida,  Illinois, New York, and Texas. Recognizing that we would be limited in our  ability to report on all states in detail, we selected these five states for a  number of reasons, including that these states    comprised over one-third of the United States population,  received over one-third of the total funding from HHS and DHS that could  be used for planning or exercising for an influenza pandemic, and each  state received the highest amount of total HHS and DHS funding that could  be used for planning and exercising for an influenza pandemic respectively  within each of the five regions established by DHS for influenza pandemic  preparedness and emergency response, and   were likely entry points for individuals coming from another country given  that the states bordered either Mexico or Canada or contained major  ports, or both, and accounted for over one-third of the total number of  passengers traveling within the United States, and over half of both  inbound and outbound international air passenger traffic to and from the  United States.
In each state, we interviewed officials responsible for health, emergency  management, and homeland security. We also interviewed officials at 10  localities in these same states, which consisted of five urban areas and five  rural counties. We interviewed officials responsible for health and  emergency management at an urban area and a rural county in each of the  five states. The urban areas included Los Angeles County (California),  Miami (Florida), Chicago (Illinois), New York City (New York), and Dallas  (Texas). These urban areas were selected based on having the highest  population totals of all urban areas in the respective states and high levels  of international airport passenger traffic. Three of these urban areas also  received federal pandemic funds: Los Angeles County, Chicago, and New  York City. The rural counties we selected—Stanislaus County (California),  Taylor County (Florida), Peoria County (Illinois), Washington County  (New York), and Angelina County (Texas)—were each nominated by state  officials based on the following criteria: these counties had conducted  some planning or exercising for an influenza pandemic and they were  representative of challenges and needs that surrounding counties might  also be facing. In total we interviewed officials with 34 different agencies.  We also reviewed documentation from the selected state and local  governments.
While the states and localities selected provided a broad perspective, we  cannot generalize or extrapolate the information gleaned from the site  visits to the nation. In addition, since the states that we selected were  large, the most populous states, and likely entry points for people coming  into the United States, the information we collected may not be as relevant  to smaller, less populated states that are not likely entry points for people  coming into the United States.
We also interviewed HHS, CDC, and DHS officials about how they are  working with states and localities in planning and exercising for an  influenza pandemic and reviewed documentation that they provided,  including information on the HHS-led review of states’, five territories’,  and the District of Columbia’s influenza pandemic plans and the guidance  to assist them in updating their influenza plans for the next assessment of  their plans. In January 2008, we observed two of five influenza pandemic  regional workshops led by HHS and DHS, in coordination with other  federal agencies. The purpose of the workshops was to obtain state  leaders’ input on guidance to assist their governments in updating their  pandemic plans in preparation for a second HHS-led review of these plans.  In addition, we interviewed officials from the National Governors  Association, Association of State and Territorial Health Officials, National  Association of County and City Health Officials, and the National  Emergency Management Association who are working on issues related to  state and local influenza pandemic activities. We also reviewed relevant  literature and prior GAO work.
We conducted this performance audit from March 2007 to June 2008 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. In addition, a list of related GAO  products is included at the end of this report.
subsections: section_title: Background
subsections: section_title: Federal Emergency Response Framework
paragraphs: In the event of a disaster, such as an influenza pandemic, states may  request federal assistance to maintain essential services pursuant to the  Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford  Act) of 1974. The Stafford Act primarily establishes the programs and  processes for the federal government to provide disaster assistance to  state and local governments and tribal nations, individuals, and qualified  private nonprofit organizations. Federal assistance may include technical  assistance, the provision of goods and services, and financial assistance.  The Federal Emergency Management Agency (FEMA), which is part of  DHS, is responsible for carrying out the functions and authorities of the  Stafford Act. For Stafford Act incidents, upon the recommendation of the  Secretary of Homeland Security and the FEMA Administrator, the  President may appoint a Federal Coordinating Officer (FCO) to manage  and coordinate federal resource support activities provided pursuant to  the Stafford Act.
DHS has recently updated the National Response Plan, now called the  National Response Framework (NRF). To assist in planning and  coordinating efforts to respond to an influenza pandemic, in December  2006, the Secretary of Homeland Security predesignated a national  Principal Federal Official (PFO) and FCO for influenza pandemic, and  established five federal influenza pandemic regions each with a regional  PFO and FCO. This structure was formalized in the NRF. The PFO  facilitates federal support to establish incident management and  assistance activities for prevention, preparedness, response, and recovery  efforts while the FCO manages and coordinates federal resource support  activities provided pursuant to the Stafford Act. The PFO is to provide a  primary point of contact and situational awareness for the Secretary of  Homeland Security. In addition, according to an official in HHS’ Office of  the Assistant Secretary for Preparedness and Response (ASPR), HHS has  also predesignated a national Senior Federal Official (SFO) and a regional  SFO for influenza pandemic in each of the five federal influenza pandemic  regions who serve as ambassadors for public health to states, territories,  and the District of Columbia, which aligns with the PFO and FCO  structure. The federal influenza pandemic regions, each of which consists  of two standard federal regions, are shown below.
In addition, under the Public Health Service Act, the Secretary of Health  and Human Services has the authority to declare a public health  emergency and to take actions necessary to respond to that emergency  consistent with his/her authorities. These actions may include making  grants, entering into contracts, and conducting and supporting  investigations into the cause, treatment, or prevention of the disease or  disorder that caused the emergency. According to the National Pandemic  Implementation Plan, as the lead agency responsible for public health and  medical care, HHS would lead efforts during an influenza pandemic while  DHS would be responsible for overall nonmedical support such as  domestic incident management and federal coordination.
In December 2006, Congress passed the Pandemic and All-Hazards  Preparedness Act (PAHPA) which codifies preparedness and response  federal leadership roles and responsibilities for public health and medical  emergencies by designating the Secretary of Health and Human Services  as the lead federal official for public health and medical preparedness and  response. The act also prescribes several new preparedness  responsibilities for HHS. Among these, the Secretary must develop and  disseminate criteria for an effective state plan for responding to an  influenza pandemic. Additionally, the Secretary is required to develop and  require the application of evidence-based benchmarks and objective  standards that measure the levels of preparedness for public health  emergencies in consultation with state, local, and tribal officials and  private entities, as appropriate. Application of these benchmarks and  standards is required of entities receiving funds under HHS public health  emergency preparedness grant and cooperative agreement programs.  Beginning in fiscal year 2009, the Secretary of Health and Human Services  is to withhold certain amounts of funding under these grant and  cooperative agreement programs where a state has failed to develop an  influenza pandemic plan that is consistent with the criteria established by  HHS or where an entity has failed to meet the benchmarks or standards  established.
section_title: Various Federal Funds Are Available to States and Localities for Influenza Pandemic Planning and Exercising
paragraphs: In addition to the federal pandemic funds provided for states and localities  by Congress in fiscal year 2006, HHS and DHS receive funds for public  health and emergency management grant programs that can be used by  states and localities to continue to support influenza pandemic efforts. In  fiscal year 2006, Congress appropriated $5.62 billion in supplemental  funding to HHS for, among other things, (1) monitoring disease spread to  support rapid response, (2) developing vaccines and vaccine production  capacity, (3) stockpiling antivirals and other countermeasures,   (4) upgrading state and local capacity, and (5) upgrading laboratories and  research at CDC.
As shown in figure 2, a total of $770 million, or about 14 percent, of this  supplemental funding went to states and localities for preparedness  activities. Of the $770 million, $600 million was specifically provided by  Congress for state and local planning and exercising while the remaining  $170 million was allocated for state antiviral purchases. According to HHS,  as of May 2008, states had purchased $21.9 million of treatment courses of  influenza antivirals for their state stockpiles. In addition to these state  stockpiles of antivirals, HHS has also acquired antivirals that are in the  HHS-managed Strategic National Stockpile, which is a national repository  of medical supplies that is designed to supplement and resupply local  public health agencies in the event of a public health emergency.
In addition to the federal pandemic funds specifically provided by  Congress, which are administered for HHS by CDC, HHS officials said that  states and localities could use funds provided under two other HHS public  health emergency preparedness cooperative agreement programs to  continue to support their influenza pandemic activities.
The Public Health Emergency Preparedness Program (PHEP), which is a  cooperative agreement administered by CDC, is intended to improve state  and local public health security capabilities. Specifically, the Cities  Readiness Initiative, a component of PHEP, is intended to ensure that  major cities and metropolitan areas are prepared to distribute medicine  and medical supplies during a large-scale public health emergency.
The Hospital Preparedness Program, which is administered by HHS ASPR,  is intended to improve surge capacity and enhance community and  hospital preparedness for public health emergencies.
DHS officials also said that states and localities could use funds provided  under three of the Homeland Security Grant Program grants, which are  administered by DHS’s Office of Grants and Training, to continue to  support influenza pandemic activities.
The State Homeland Security Grant Program’s purpose includes  supporting, building, and sustaining capabilities at the state and local  levels through planning, equipment, training, and exercise activities.
The Metropolitan Medical Response System Program is intended to  support an integrated, systematic mass casualty incident preparedness  program that enables an effective response during the first crucial hours of  an incident such as an epidemic outbreak, natural disaster, and a large- scale hazardous materials incident.
The Urban Area Security Initiative Grant Program is intended to address  the unique planning, equipment, training, and exercise needs of high- threat, high-density urban areas.
section_title: States and Localities Have Planned for an Influenza Pandemic and Have Involved Others in Their Planning, but HHS Has Found Major Gaps in States’ Plans
paragraphs: All of the five states and 10 localities we reviewed, both urban and rural,  had developed influenza pandemic plans. As directed by the federal  pandemic funding guidance, all 50 states and localities that received direct  funding through the PHEP and Hospital Preparedness Program were  required to plan and exercise for an influenza pandemic. According to  CDC officials, all 50 states have developed an influenza pandemic plan. Of  the $600 million designated by Congress for states and localities for  planning and exercising, CDC divided the funding into three phases.  Recipients included 50 states, five territories, three Freely Associated  States of the Pacific, three localities, and the District of Columbia. CDC  awarded $100 million for Phase I in March 2006, $250 million for Phase II  in two disbursements—July 2006 and March 2008—and $250 million for  Phase III in two disbursements—September 2007 and October 2007.  Phase III is to be completed in 2008 and will be the final phase for  dedicated federal pandemic funds to states and localities that received  direct federal funding.
For Phase I, recipients were expected to comply with the following  requirements, among others:    establish a committee or consortium at the state and local levels with  which the recipient is engaged that represents all relevant stakeholders in  the jurisdiction, such as public health, emergency response, business,  community-based, and faith-based sectors; implement a planning framework for influenza pandemic preparedness  and response activities to support public health and medical efforts;   collaborate among public health and medical preparedness, influenza,  infectious disease, and immunization programs and state and local  emergency management to maximize the effect of funds and efforts;    coordinate activities between state and local jurisdictions, tribes, and  military installations; among local agencies; with hospitals and major  health care facilities; and with adjacent states;   conduct exercises to test the plans of states or localities that receive the  funding directly and prepare an after-action report, which is a summary of  lessons learned highlighting necessary corrective actions;   assess gaps in pandemic preparedness using CDC’s self-assessment tool to  evaluate the jurisdiction’s current state of preparedness;   submit a proposed approach to filling the identified gaps; and    provide an associated budget for the critical tasks necessary to address  those gaps.
According to CDC officials, all entities that received direct federal funding  have met the requirements for Phase I of the federal pandemic funds.
For Phase II, recipients were expected to comply with the following four  priority activities, among others:    development of a jurisdictional work plan to address gaps identified by the  CDC self-assessment process in Phase I;    development of and exercise an antiviral drug distribution plan;    development of a pandemic exercise program that includes medical surge,  mass prophylaxis, and nonpharmacological public health   interventions and a community containment plan with emphasis on  closing schools and discouragement of large public gatherings at a  minimum; and   submission of an influenza pandemic operational plan to CDC.
According to HHS, CDC has reviewed whether recipients met the  requirements identified in the Phase II guidance.
In addition, recipients were asked to document the process used to engage  Indian tribal governments in Phases I and II and to develop and implement  an influenza pandemic preparedness exercise program involving  community partners to exercise their capabilities and prepare an after- action report highlighting necessary corrective actions. Unlike Phase I in  which there is no mention of DHS’s Homeland Security Exercise and  Evaluation Program (HSEEP), in Phase II CDC encouraged, but did not  require, recipients to use HSEEP for disaster planning and exercising  efforts. HSEEP guidance defines seven different types of exercises, each  of which is either discussions-based or operations-based. Discussions- based exercises are a starting point in the building block approach of  escalating exercise complexity. These types of exercises typically highlight  existing plans, policies, interagency and interjurisdictional agreements,  and procedures and focus on strategic, policy-oriented issues. An example  of a discussions-based exercise is a tabletop exercise that can be used to  assess plans, policies, and procedures or to assess the systems needed to  guide the prevention of, response to, and recovery from a defined incident.  Operations-based exercises are characterized by an actual reaction to  simulated intelligence; response to emergency conditions; mobilization of  apparatus, resources, and networks; and commitment of personnel,  usually over an extended period. These exercises are used to validate the  plans, policies, agreements, and procedures assessed in discussions-based  exercises. An example of an operations-based exercise is a full-scale  exercise, which is a multiagency, multijurisdictional, multiorganizational  exercise that validates many facets of preparedness. CDC’s federal  pandemic funding guidance for Phase I and II did not explicitly specify the  type of exercises to be conducted; the exception was the mass prophylaxis  exercise for Phase II, which was required to be an operations-based  exercise. In order to be compliant with HSEEP protocols, there are four  distinct performance requirements. They include (1) conducting an annual  training and exercise plan workshop and developing and maintaining a  multiyear training and exercise plan, (2) planning and conducting  exercises in accordance with the guidelines set forth by HSEEP,   (3) developing and submitting an after-action report, and (4) tracking and  implementing corrective actions identified in the after-action report.
For Phase II, the National Governors Association conducted a series of  nine influenza pandemic regional workshops for states between April 2007  and January 2008 to enhance intergovernmental and interstate  coordination. In a February 2008 issue brief, the National Governors  Association reported its results from five regional influenza pandemic  preparedness workshops involving 27 states and territories conducted  between April and August 2007. The workshops were designed to identify  gaps in state influenza pandemic preparedness—specifically in non-health- related areas such as continuity of government, maintenance of essential  services, and coordination with the private sector, and to examine  strengths and weaknesses of coordination activities among various levels  of government. The workshops also included a discussions-based exercise  focused on regional issues.
For Phase III, recipients were asked to describe ongoing influenza  pandemic–related priority projects that would improve exercising and  response capabilities specifically for an influenza pandemic. Phase III  required recipients to fill planning gaps identified in Phase I and II. In  addition, recipients were expected to comply with the following  requirements, among others:    submit workplans that included specific influenza pandemic planning,  implementation, and evaluation of activities;   update the existing influenza pandemic operational plan based on CDC’s  assessment on six priority thematic areas, by January 2008;   create an exercise strategy and schedule; and    utilize the tools developed by DHS’s HSEEP to create planning, training,  and exercise evaluation programs, which includes an after-action report,  improvement plan, and corrective action program for each seminar,  tabletop, functional, or full-scale exercise conducted.
subsections: section_title: States Have Made Progress in Developing Their Influenza Pandemic Plans
paragraphs: Over the past several years, states have made progress in developing  pandemic plans. In 2006, CDC reported that most states did not have  complete influenza pandemic plans addressing areas such as enhancing  surveillance and laboratory capacity, managing vaccines and antivirals,  and implementing community containment measures to reduce influenza  transmission. However, all 50 states, territories, and the District of  Columbia now have influenza pandemic plans according to CDC officials.  Trust for America’s Health, a health advocacy nonprofit organization,  reported that the type of publicly available influenza pandemic plan varied  from a comprehensive influenza pandemic plan to free-standing annexes  to emergency management plans, to mere summaries of a state’s influenza  pandemic plan.
At the time of our review, all five states we reviewed had influenza  pandemic plans that focused on leadership, surveillance and laboratory  testing, vaccine and antiviral distribution, and communications. Some  state plans included sections on education and training, and infection  control. Two of the three localities that received the federal pandemic  funds in our study addressed similar types of topics, such as disease  surveillance and laboratory testing, health care planning, vaccine and  antiviral distribution, mental health response, and communications in their  influenza pandemic plans. Most of the remaining urban and rural localities  also primarily addressed similar topics.
section_title: States and Localities We Reviewed That Received Federal Pandemic Funds Involved HHS and CDC in Planning
paragraphs: In planning for an influenza pandemic, officials from three of the five  states and two of the three localities that received the federal pandemic  funds told us that they interacted with HHS and CDC in planning for a  pandemic. However, federal officials did not reach out to states and  localities when the National Pandemic Implementation Plan was being  developed and the PFOs for influenza pandemic had limited interaction  with the selected states and localities.
At the time of our site visits, officials from three of the five states and two  of the three localities that received direct federal funding reported  interacting with HHS and CDC in planning for an influenza pandemic to  clarify funding requirements and expectations. CDC officials in the  Coordinating Office for Terrorism Preparedness and Emergency Response  also told us that they reviewed reports from the states and local  government recipients on how they had met the federal pandemic funding  requirements. CDC then provided feedback to the states and localities on  how well they were meeting the requirements. In addition, CDC officials  told us that they provided technical assistance when requested.
While the federal government has provided some support to states in their  planning efforts, states and localities have had little involvement in  national planning for an influenza pandemic. The National Pandemic  Implementation Plan lays out a series of actions and defines  responsibilities for those actions. The National Pandemic Implementation  Plan includes 324 action items, 17 of which call for states and local  governments to lead national and subnational efforts, and 64 in which  their involvement is needed. In our August 2007 report, we highlighted that  key stakeholders such as state and local governments were not directly  involved in developing the action items in the National Pandemic  Implementation Plan and the performance measures that are to assess  progress, even though the National Pandemic Implementation Plan relies  on these stakeholders’ efforts. Stakeholder involvement during the  planning process is important to ensure that the federal government’s and  nonfederal entities’ responsibilities and resource requirements are clearly  understood and agreed upon. Moreover, HHS ASPR officials confirmed  that the National Pandemic Implementation Plan was developed by the  federal government without any state input. Officials from all of the states  and localities reviewed told us that they were not directly involved in  developing the National Pandemic Implementation Plan. Officials from all  five of the states and seven of the localities were aware of the National  Pandemic Implementation Plan. Officials from Taylor County (Florida),  Peoria County (Illinois) and Washington County (New York) had not seen  the National Pandemic Implementation Plan. State officials from Florida,  New York, and Texas, and officials from two localities in California and  one locality in New York reported that they used its action items for their  own planning efforts.
In addition, states and localities reported limited interaction with the  predesignated federal PFOs and FCOs in coordinating influenza pandemic  efforts. According to the national PFO for influenza pandemic, the PFOs  for influenza pandemic had limited interaction with state governments for  influenza pandemic efforts because it was unclear whether the PFO  structure for an influenza pandemic would remain in the National  Response Framework until it was issued in January 2008, and finalized in  March 2008. The Secretary of Homeland Security sent letters in December  2006 and in March 2008 to state Governors on the PFO structure, and the  PFO structure was discussed at the HHS- and DHS-led workshops in the  five federal pandemic regions. At the time of our site visits, we found that  only state officials in California and New York were aware of these  federally predesignated officials. In addition, in its issue brief on the five  state influenza pandemic workshops, the National Governors Association  reported that the presence of the PFOs for influenza pandemic at two of  their workshops was the first opportunity for most states to interact with  these officials.
section_title: States and Localities We Reviewed Involved Other State and Local Agencies, Tribal Nations, Nonprofit Organizations, and the Private Sector in Pandemic Planning
paragraphs: In every state and locality reviewed, officials told us that they involved  other state and local agencies within their jurisdiction in accordance with  federal pandemic funding requirements. Health and emergency  management officials at some of the states and localities reviewed said  they collaborated with each other to develop the influenza pandemic plan  for public health response as required by the federal pandemic funds and  the influenza pandemic annex for emergency response where applicable.  For example, the Miami-Dade County Health Department (Florida)  collaborated with the Miami-Dade County Pandemic Influenza Workgroup,  which included stakeholders such as the Miami-Dade County Department  of Emergency Management and Homeland Security, CDC Miami  Quarantine Station, Medical Examiner Department, and the Miami-Dade  Corrections and Rehabilitation Department to develop its influenza plan.  This plan is also used as an annex to the Miami-Dade County Department  of Emergency Management and Homeland Security’s Comprehensive  Emergency Management Plan. In some cases, both the health and  emergency management departments at the state and local levels  developed separate influenza pandemic plans to address health and  emergency response efforts respectively, while in other cases the  emergency management departments used the health department’s  influenza pandemic plan as an annex to their emergency operations plans.
In addition to developing their own influenza pandemic plans, state public  health agencies in all the states reviewed assisted their local counterparts  with their influenza pandemic plans. For example, officials from the  Florida Department of Health said they used a standardized assessment  tool to assess county influenza pandemic plans on 36 elements such as  surveillance, response and containment, and community-based control  and mitigation interventions. The tool also included a section on strengths  and areas for improvement for each element. Further, New York State  Department of Health officials said that they reviewed all of the county- level influenza pandemic plans and provided feedback. We also found that  in some cases, localities consulted other localities’ influenza pandemic  plans to help them to develop their own plans. For example, officials from  Stanislaus County Health Services Agency (California), Miami-Dade  County Health Department (Florida), and Dallas County Health and  Human Services (Texas) said they reviewed King County’s (Washington)  influenza pandemic plan to help them develop their own plans.
Officials at all 15 of the states and localities reviewed also said they  assisted other state and local agencies within their jurisdiction in their  influenza pandemic efforts by reviewing each other’s plans or sharing  information. For example, New York State Department of Health officials  said that as the lead agency responsible for influenza pandemic planning  efforts, they participated in and coordinated meetings with other state  agencies such as the Unified Court System and Department of  Correctional Services to discuss areas such as infection control and  community containment, visitation policies during an influenza pandemic,  management of sick inmates, emergency staffing plans, and employee  education and training.
Officials from 6 of the 15 states and localities we reviewed reported that  they had tribal nations within their jurisdictions. Of these 6, only officials  from California, Florida, New York state, and Miami told us that they had  included tribal nations in their influenza planning efforts, as required by  the federal pandemic funds. For example, officials from the New York  State Department of Health said they provided guidance to the Mohawk  and Seneca tribes in developing influenza pandemic plans. Tribal nation  representatives also had access to the state’s health provider network and  were invited to influenza pandemic training sessions and monthly  influenza pandemic conference calls. Officials from Texas and Taylor  County (Florida) reported that they did not include tribal nations in their  influenza planning efforts. Texas Department of State Health Services  officials reported that there are three tribes within the state with which the  respective counties are coordinating. In Taylor County (Florida), officials  reported that they had not yet involved their local tribe, the Miccosukee  tribe, in their influenza pandemic planning efforts.
Officials from all five states and four localities also reported that they  provided guidance or technical assistance for continuity planning efforts  to nonprofit organizations, and officials from all five states and seven  localities told us that they provided the same assistance to the private  sector. States and localities that received direct federal pandemic funding  are required to involve nonprofit organizations and the private sector in  planning for an influenza pandemic. For example, Peoria City/County  Health Department (Illinois) officials told us that in addition to contracting  with the Red Cross in providing bulk food distribution services during an  influenza pandemic, they had initial discussions on how to implement  isolation and quarantine. Officials from the New York City Department of  Health and Mental Hygiene (New York) stated that they partnered with the  New York City Department of Small Business Services and conducted six  focus groups with approximately 60 participants from nonprofit and for- profit organizations to provide general information related to influenza  pandemic, and to discuss the continuity strategies from CDC’s Business  Pandemic Influenza Planning Checklist and feasibility in adopting them.
While all five selected states and seven localities have coordinated with  the private sector for influenza pandemic planning, several officials from  state agencies in Florida and Illinois, and local agencies in Los Angeles  County (California), Chicago (Illinois), and Dallas County (Texas) have  focused specifically on critical infrastructure sectors, such as  transportation (highway and motor carriers), food and agriculture, water,  energy (electricity), and telecommunications (communications). Officials  from the Dallas County Department of Health and Human Services (Texas)  said that they assisted a local power company and a grocery chain on  continuity of operations planning for an influenza pandemic. The National  Governors Association reported in its February 2008 issue brief that few  states from its five regional workshops had defined the roles and  responsibilities of private sector entities. Moreover, potential shortages  of critical goods and services—specifically, food, electricity, and  transportation capacity—were cited as key areas of concern across all five  National Governors Association-led workshops. While Idaho, Minnesota,  Montana, North Dakota, South Dakota, and Utah were less concerned  about the food supply due to longstanding practices of stockpiling against  severe weather and other threats, other participating states were  concerned that they did not have agreements in place with the private  sector food distribution and retail systems.
section_title: HHS Has Found Major Gaps in States’ Influenza Pandemic Plans
paragraphs: Since we visited these states and localities, HHS provided feedback to the  states in November 2007 on whether their influenza pandemic plans  addressed certain priority areas, such as fatality management, and found  that there were major gaps nationally in the plans in these priority areas.  In response to an action item in the National Pandemic Implementation  Plan, HHS led a multidepartment effort to review pertinent parts of states’  influenza pandemic plans in 22 priority areas along with other federal  agencies such as the Departments of Agriculture, Commerce, Education,  Homeland Security, Justice, Labor, and State under the auspices of the  Homeland Security Council. For example, DHS was responsible for  reviewing the priority area of how states worked with the private sector to  ensure critical essential services. States were required to submit parts of  their plans that addressed the priority areas to CDC by March 2007. The  participating departments reviewed the pertinent parts of the plans and  HHS compiled the results into individual draft interim assessments, which  included the status of planning for each entity and how they measured  against the national average for the priority areas, and provided this  feedback to the states.
As shown in table 1, on average, states had major gaps in all areas, with a  ranking of “many major gaps” in 16 of the 22 priority areas and “a few  major gaps” in the remaining 6 priority areas, as defined by HHS. An  official in HHS ASPR told us that generally, the states fared better in the  public health priority areas such as mass vaccination and antiviral drug  distribution plans than in other areas such as school closures and  sustaining critical infrastructure. As we will discuss in more detail later in  the report, we found that the areas in which state and local officials were  looking for additional federal guidance were often the same areas that  were rated by HHS as having “many major gaps” in planning.
Every state received individual comments from CDC on the strengths and  weaknesses of their influenza pandemic plans in six priority areas.  According to HHS officials in ASPR, states also received feedback in some  of the remaining priority areas. In addition, states received general  comments from the Departments of Agriculture, Commerce, Labor,  Homeland Security, and Justice. The Departments of Commerce, Labor,  and Homeland Security noted that many state influenza pandemic plans  did not address the effect of social distancing in private workplaces or  state agencies. Nor did they address issues related to loss of jobs and  income for workers, particularly for those needing to stay home to care for  children dismissed from school or to care for themselves or ill relatives.  Further, they concluded that many states needed to develop occupational  safety and health plans that dealt with infection control and other  influenza pandemic issues such as worker behavioral and mental health  concerns.
HHS, DHS, and other federal agencies issued guidance to states in March  2008 to assist them in updating their current influenza pandemic plans.  These updated plans are due in July 2008. HHS will provide feedback to  them on the strengths and weaknesses of their plans as they did for the  previous review of plans.
section_title: All States and Localities Reviewed Have Conducted or Participated in at Least One Exercise to Test Their Planning for an Influenza Pandemic and Have Incorporated Lessons Learned
paragraphs: Disaster planning, including for an influenza pandemic, needs to be tested  and refined with a rigorous and robust exercise program to expose  weaknesses in planning and allow planners to address the weaknesses.  Exercises—particularly for the type and magnitude of emergency  incidents such as a severe influenza pandemic for which there is little  actual experience—are essential for developing skills and identifying what  works well and what needs further improvement.
The first phase of the federal pandemic funds required states and localities  that received this funding to test their influenza pandemic plan. CDC  officials stated that their expectation was that the recipients would  conduct a gap analysis using CDC’s self-assessment tool to identify  objectives to exercise to improve their plans and then exercise the  identified vulnerabilities of their plans, rather than testing their entire  plan. According to CDC officials, all states and localities that received this  funding have met the requirement to conduct a discussions-based or  operations-based exercise to test their influenza pandemic plans and to  prepare an after-action report. The second phase of funding required  states and localities that receive the funding directly to conduct an  exercise that would test an antiviral drug distribution plan and to develop  an influenza pandemic exercise schedule that included medical surge,  mass prophylaxis, and nonpharmaceutical public health interventions  such as closing schools and discouragement of large public gatherings. As  noted earlier, HHS stated that CDC has reviewed whether recipients met  the requirements identified in the Phase II guidance.
All of the states and localities except for two of the localities in our review  had conducted at least one influenza pandemic exercise to test their  influenza pandemic planning. The two localities that had not conducted  their own exercise had participated in discussions-based exercises in  other jurisdictions. Among the states and localities that had conducted an  exercise, one state and two localities conducted at least one discussions- based and an operations-based exercise, one state and one locality  conducted at least one operations-based exercise, and the remaining three  states and five localities conducted at least one discussions-based  influenza pandemic exercise. For example, the Stanislaus County Health  Services Agency (California) conducted an influenza pandemic  discussions-based exercise and the New York City Department of Health  and Mental Hygiene (New York) conducted both influenza pandemic  discussions-based exercises and operations-based exercises. In addition,  state agencies in New York, Texas, and Illinois conducted or funded  regional influenza pandemic exercises that included multiple jurisdictions  within each state. For example, the Peoria City/County Health Department  (Illinois) participated in an influenza pandemic discussions-based exercise  with nine other counties. According to the National Governors  Association, the states’ influenza pandemic exercises have been almost  exclusively discussions-based exercises and few have held regional or  multistate exercises. In addition, health departments conducted influenza  pandemic exercises at all but one of the states and localities that had  conducted at least one influenza pandemic exercise. In all but one of the  states and localities reviewed, emergency management officials had either  conducted or participated in an influenza pandemic exercise.
subsections: section_title: Officials from All States and Localities Reviewed Reported That Lessons Learned from Exercises Were Incorporated into Influenza Pandemic Planning
paragraphs: Officials of all states and localities reviewed reported they had  incorporated lessons learned from exercises into their influenza pandemic  planning. Officials told us that the changes made as a result of an exercise  included buying additional medical equipment and providing training. For  example, officials at the New York City Department of Health and Mental  Hygiene (New York) informed us that an influenza pandemic exercise  resulted in identifying a potential shortage of ventilators. In response, they  purchased 70 ventilators that were relatively easy to train staff to use,  which were being used by selected hospitals. Other influenza pandemic  exercises resulted in providing additional training. For example, Stanislaus  County Health Services Agency (California) officials identified the need  for their staff to be trained in the National Incident Management System  (NIMS), which is a consistent nationwide approach to enable all  government, private-sector, and nongovernmental organizations to work  together to prepare for, respond to, and recover from domestic incidents.  All county staff have been subsequently trained in NIMS.
Furthermore, state and local officials stated that influenza pandemic  exercises led to modifying policies or influenza pandemic plans. Officials  at the Illinois Department of Public Health realized during an exercise that  a judge’s ruling would be needed to quarantine an individual with a  suspected contagious disease. As a result, the department sought and  obtained amendments to its department’s authority that if voluntary  compliance cannot be obtained, then the department can quarantine an  individual with a suspected contagious disease for 2 days before a judge’s  ruling is necessary. In addition, officials at the Dallas County Department  of Health and Human Services (Texas) reported that they identified the  need for, and subsequently developed, an appendix to their influenza  pandemic plan on school closures during a pandemic that included factors  for schools to consider in deciding when to close schools and for how  long.
section_title: HHS and DHS Could Further Assist States in Addressing Gaps Identified in Pandemic Planning
paragraphs: HHS (including CDC), DHS and other federal agencies have provided a  variety of influenza pandemic information and guidance for states and  local governments through Web sites and state and regional meetings.  HHS and CDC have disseminated pandemic preparedness checklists for  workplaces, individuals and families, schools, health care, and community  organizations, with one geared for state and local governments. HHS and  CDC have also provided additional influenza pandemic guidance including  Interim Pre-pandemic Planning Guidance: Community Strategy for  Pandemic Influenza Mitigation in the United States (February 2007).  CDC and other federal agencies are currently considering the Interim  Guidance for the Use of Intervals, Triggers, and Actions in Pandemic  Influenza Planning that was developed by HHS and CDC and provides a  framework and thresholds for implementing student dismissal and school  closure. HHS also issued Interim Public Health Guidance for the Use of  Facemasks and Respirators in Non-Occupational Community Settings  during an Influenza Pandemic, and funded Providing Mass Medical  Care with Scarce Resources: A Community Planning Guide (November  2006). CDC officials stated that the journal CHEST published four papers  on providing mass critical care with scarce resources for all-hazards in  May 2008. In addition, HHS funded guidance on exercising for an influenza  pandemic, including discussions-based exercises for influenza pandemic  preparedness for local public health agencies. Furthermore, the federal  planning guidance for states to update their influenza pandemic plans  provided by HHS, DHS, and other federal agencies includes references to  federal guidance that pertains to the topics on which the states’ plans will  be assessed. The guidance includes preparedness and planning advice and  information on specific tasks and capabilities that the states’ plans should  contain for each of the priority areas for which the states will be assessed.  The guidance contains information on several of the priority areas that  state and local officials were looking for additional guidance on and that  were rated as having “many major gaps” in planning in the first  assessment, such as fatality management and community containment.  However, while the guidance document states what the states’ plans  should contain for each of the topics, it does not include how to  implement these tasks and capabilities.
HHS and DHS, in coordination with other federal agencies, have also  developed draft guidance on how to allocate limited supplies of vaccines,  including target groups for individuals, and are working on similar  guidance for antivirals. They are also working on guidance on the  prophylactic use of antivirals (administering antivirals to individuals who  had not shown symptoms). However, HHS and DHS officials  acknowledged that the federal government has not provided guidance on  some of the influenza pandemic-specific topics that state and local  officials had told us that they would like guidance on from the federal  government, such as ethical decision making and liability and legal issues.
There are also two federal Web sites that contain influenza pandemic  information. The purpose of the Web site www.pandemicflu.gov is to be  one-stop access to U.S. government avian and pandemic flu information.  The site includes guidance and information on state and local planning and  response activities, such as all state influenza pandemic plans. The Web  site www.llis.dhs.gov is a national network of lessons learned and best  practices for emergency response providers and homeland security  officials and contains information on many different topic areas, such as  cyber security and wildland fires. Lessons Learned Information Sharing  System (LLIS) officials stated that the best practices are vetted by working  groups of subject matter experts. LLIS has an influenza pandemic topic  area that includes news, upcoming events, plans and guidance, after-action  reports, and best practices. An LLIS representative also informed us that  there is an influenza pandemic forum that acts as a message board for  LLIS users to discuss topics, which have included how to implement  teleworking during an influenza pandemic. In addition, there is an  influenza pandemic channel on the Web site that has a document and  resource library and a message board, including topics such as antiviral  and vaccine planning. HHS officials stated that CDC and LLIS have created  a secure channel for state and local health departments to post and share  influenza pandemic exercise information. According to an LLIS  representative, the secure channel contains the influenza pandemic  exercise schedules for states and localities that receive the funding  directly and there are plans to include after-action reports from the  exercises on the Web site.
There are also several nonfederal Web sites that contain influenza  pandemic practices on particular topics. The Center for Infectious Disease  Research and Policy at the University of Minnesota has collected and peer- reviewed influenza pandemic “promising practices” that can be adapted or  adopted by public health stakeholders. Their Web site  (http://www.pandemicpractices.org/practices/list.do?topic-id=13) has  practices on three themes: models for care (surge capacity, standards of  care, triage strategies, out-of-hospital care, collaborations),  communications (risk communications, community engagement, and  resiliency), and mitigation (nonpharmaceutical interventions). In addition,  National Public Health Information Coalition officials said that they are  planning to post influenza pandemic communications on their Web site.  CDC officials also stated that CDC has a cooperative agreement with the  Association of State and Territorial Health Officials and the National  Association of County and City Health Officials to provide influenza  pandemic best practices and tools that states and localities can download  from their respective Web sites.
In addition to providing guidance, HHS has also convened state influenza  pandemic planning summits and funded regional state influenza pandemic  workshops. To help coordinate influenza pandemic planning, HHS and  other federal agencies, including DHS, held “State Pandemic Planning  Summits” with the public health and emergency response community in all  states in 2005 and 2006. As part of the summits, the Secretary of Health  and Human Services signed memorandums of understanding (MOU) with  each state that identified shared common goals and shared and  independent responsibilities between HHS and the individual state for  influenza pandemic planning and preparedness. For example, the MOU  between HHS and the state of California noted that states and local  communities are responsible under their own authorities for responding to  an influenza pandemic outbreak within their jurisdictions and having  comprehensive influenza pandemic preparedness plans and measures in  place to protect their citizens. In addition, to further assist states and  localities with their influenza pandemic preparedness efforts, HHS funded  the National Governors Association to conduct a series of influenza  pandemic regional workshops for states, the first five of which are  discussed earlier. A National Governors Association official stated the  association held nine workshops between April 2007 and January 2008 and  that it is not planning to conduct additional influenza pandemic  workshops for states.
In addition, in May 2008, FEMA hosted an influenza pandemic exercise  and seminar for senior executives. The purpose of the exercise, which  involved FEMA officials, the Pandemic Region A PFO team, and a number  of states in Pandemic Region A, was to determine best practices for  communication and coordination during an influenza pandemic response.  The senior executive seminar, which included officials from CDC, HHS,  DHS, and a number of states in Pandemic Region C, was intended to  address pandemic risk, challenges, and issues, both regionally and  nationally. FEMA is also planning to host another influenza pandemic  seminar in May 2008 for the other states in Pandemic Region C that did not  participate in the previous seminar.
subsections: section_title: State and Local Officials Reported That They Wanted Additional Federal Influenza Pandemic Guidance
paragraphs: Despite these efforts, state and local officials from all of the states and  localities we interviewed told us that they would like additional federal  influenza pandemic guidance from the federal government on specific  topics to help them to better plan and exercise for an influenza pandemic.  Although, as discussed earlier, there is federal guidance for some of these  topics, the existing guidance may not have reached state and local officials  or may not address the particular concerns or circumstances of the state  and local officials we interviewed.
Three of the areas on which state and local officials reported that they  wanted federal influenza pandemic guidance were rated as having “many  major gaps” nationally among states’ influenza pandemic plans in the first  HHS-led review of their influenza pandemic plans. These areas were   (1) implementing the community interventions, such as closing schools,  discussed in the Interim Pre-pandemic Planning Guidance: Community  Strategy for Pandemic Influenza Mitigation in the United States (which  is called community containment in the federal priority topics), (2) fatality  management, and (3) facilitating medical surge. Two other areas that  state and local officials told us that they would like additional federal  influenza pandemic guidance on, mass vaccination and antiviral drug  distribution, were also rated as having “a few major gaps” nationally. State  and local officials also told us that they would like the federal government  to provide guidance on additional topics: ethical decision making,  prophylactic use of antivirals, Strategic National Stockpile utilization,  liability and legal issues, and personal protective equipment.
While officials from some state and local governments were looking for  guidance from the federal government, others were developing the  information on their own. For example, while California Department of  Health officials stated that they were developing standards and guidelines  for health care professionals to use in any medical surge (including an  influenza pandemic), which has since been released, Peoria City/County  Health Department (Illinois) officials told us that they wanted guidance on  how to deal with medical surge. In addition, the Texas Department of State  Health Services developed an antiviral prioritization plan, while Illinois  Department of Public Health officials said they would like the federal  government to provide guidance on antiviral prioritization.
Two recent reports found similar concerns among state and local officials.  In its February 2008 issue brief, the National Governors Association  reported that states were grappling with many of the same issues that we  found: community containment (school closures), antiviral prioritization,  prophylactic use of antivirals, and legal issues. Similarly, an October 2007  Kansas City Auditor’s Office report on influenza pandemic preparedness in  the city noted that Kansas City Health Department officials would like the  federal government to provide additional guidance on some of the same  issues we found: clarifying community interventions such as school  closings and the criteria that will trigger these measures, antiviral and  vaccine prioritization, and the type of personal protective equipment to  use (e.g., type of face mask).
section_title: Additional HHS and DHS State Influenza Pandemic Meetings Could Be Held to Assist States in Addressing Gaps in States’ Influenza Pandemic Plans
paragraphs: According to the National Pandemic Implementation Plan, it is essential  for states and localities to have plans in place that support the full  spectrum of societal needs over the course of an influenza pandemic and  for the federal government to provide clear guidance on the manner in  which these needs can be met. As discussed earlier, the HHS-led  assessment of the states’ pandemic plans was in response to an action  item in the National Pandemic Implementation Plan that states that HHS,  in coordination with DHS, shall review and approve states’ influenza  pandemic plans. The assessment found “many major gaps” in 16 of the 22  priority areas in the states’ pandemic plans.
HHS and DHS, in coordination with the Homeland Security Council, Office  of Personnel Management, and the Departments of Agriculture,  Commerce, Defense, Education, Homeland Security, Justice, Labor, State,  Transportation, the Treasury, and Veteran Affairs, led a series of five  workshops for states in the five influenza pandemic regions shown in  figure 1 in January 2008. Prior to the meetings, HHS ASPR officials told us  that the workshops would be an opportunity for states to request  additional influenza pandemic guidance from the federal government. We  observed two of the five workshops, and received summaries from HHS of  all five workshops. The discussions at the workshops mainly focused on  the draft guidance and evaluation criteria for the second round of  assessing the state pandemic plans, but the participants also raised  concerns and requested guidance. Some of the common high-level  themes discussed at some of these workshops included a need for more  involvement from federal agencies in communicating with state  counterparts. The March 2008 planning guidance included a list of  contacts and phone numbers in federal agencies for the state officials to  help them to communicate with their federal counterparts as they update  their pandemic plans. Participants also requested guidance on various  topics. Among the five workshops conducted, state officials in three of the  workshops sought guidance on how to handle school closures and ports of  entry issues while state officials in two of the workshops wanted to know  how to plan with CDC quarantine stations. In addition, in three of the  workshops, state officials discussed wanting more critical infrastructure  information or guidance. For example, state officials discussed that there  are challenges for state health departments to work with the critical  infrastructure sectors because they have no authority to influence their  participation in influenza pandemic planning. However, there was not an  opportunity to explore these issues in greater depth during the meetings. A  senior DHS official in the Office of Health Affairs reported that there are  no plans to conduct further regional state workshops on influenza  pandemic.
HHS, DHS, and the Department of Labor hosted three Web seminars that  provided an overview of the March 2008 planning guidance and included  time for discussion. In addition, according to HHS, state-specific  assistance has been provided through conference calls.
Additional meetings of states by federal influenza pandemic region, led by  HHS and DHS, and in coordination with other relevant federal agencies,  could be held and their purpose broadened to provide a forum for state  and federal officials to address the identified gaps in states’ planning. The  federal agencies that were the lead departments for rating priority areas in  the states’ influenza pandemic plans could provide additional  corresponding information and guidance on their respective priority areas  to the states on their common challenges. Federal agencies could provide  assistance to the states on the priority areas that they rated as having  “many major gaps” in planning nationally. For example, the Department of  Justice could provide assistance on the coordination of law enforcement,  the Department of Agriculture could provide assistance on the operational  status of state-inspected slaughter and food processing establishments,  and the Department of Education on the policy process for school  closures and communication. With plans due in July 2008 for a second  round of review, states’ plans may still have major gaps that could be  addressed by federal and state governments working together to address  these challenges.
The meetings could also provide a forum for states to build networks with  one another and federal officials. In our October 2007 report related to  critical infrastructure protection challenges that require federal and  private sector coordination for an influenza pandemic, we found that for  influenza pandemic efforts, DHS has used critical infrastructure  coordinating councils primarily to share influenza pandemic information  across sectors and government levels rather than to address many of the  identified challenges. Thus, we recommended that DHS lead efforts to  encourage the councils to consider and address the range of identified  challenges, such as clarifying roles and responsibilities between federal  and state governments, for a potential influenza pandemic. DHS  concurred with our recommendation and is planning initiatives—with  some underway—to address our recommendation, such as the  development of pandemic contingency plan guidance tailored to each  critical infrastructure sector. Similarly, during the National Governors  Association’s workshops, state officials reported that they would be  interested in the influenza pandemic response activities initiated in  neighboring states, but few, if any mechanisms, exist for states to gain  regional situational awareness. According to the National Governors  Association’s report, the networks that do exist are informal  communications among peers, which are built on personal relationships  and are not integrated into any formal communications capacity or  system. The National Governors Association also reported that states must  coordinate their plans among state, local, and federal agencies and that  this coordination should be tested through exercises with neighboring  states and with relevant federal officials. In addition, the March 2008  planning guidance to help states update their plans notes that among the  keys for successful preparation for an influenza pandemic are  collaborating with other states to share promising practices and lessons  learned and to collaborate with regional PFOs. Both of these collaborative  relationships with other states and with the federal government could be  facilitated by additional meetings and discussions within the framework of  the federal pandemic regional structure.
section_title: Conclusions
paragraphs: HHS is to complete distribution in 2008 of all the federal pandemic funds  provided by Congress for states and localities, but HHS, DHS, and other  federal agencies can continue to provide other types of support to states.  Although all states have developed influenza pandemic plans, the HHS-led  review of states’ influenza pandemic plans in coordination with other  federal agencies found “many major gaps” in planning nationally in 16 out  of 22 priority areas. While the federal government has provided influenza  pandemic guidance on a variety of topics, state and local officials told us  they would welcome additional guidance. These requests highlight some  of the areas where federal guidance does not exist and other areas where  guidance may exist, but may not have reached state and local officials or  may not have addressed their particular concerns. In addition, three of the  topics that state and local officials told us that they wanted federal  influenza pandemic guidance on—community containment, fatality  management, and facilitating medical surge—were rated as having “many  major gaps” nationally among states’ influenza pandemic plans in the first  HHS-led review of states’ influenza pandemic plans. Moreover, the  National Governors Association’s workshops and the March 2008 planning  guidance underscore the value of states collaborating with each other and  the federal government for pandemic planning. With plans due in July 2008  for a second round of review, states’ plans may still have major gaps that  can only be addressed by federal and state governments working together  to address these challenges.
Although a senior DHS official in the Office of Health Affairs reported that  there are no plans to hold additional workshops in the five pandemic  regions, these workshops could be a useful model both for sharing  information across states and building relationships within regions and to  address the identified gaps in states’ planning, and to maintain the  momentum that has already been started by HHS and DHS to continue to  work with the states on pandemic preparedness given the upcoming  governmental transition.
section_title: Recommendation for Executive Action
paragraphs: To help maintain a continuity of focus on state pandemic planning efforts  and to further assist states in their pandemic planning, we recommend that  the Secretaries of Health and Human Services and Homeland Security, in  coordination with other federal agencies, convene additional meetings of  the states in the five federal influenza pandemic regions to help them  address identified gaps in their planning.
section_title: Agency Comments
paragraphs: We provided a draft of the report of the Secretaries of Health and Human  Services and Homeland Security for their review and comment. HHS  generally concurred with our recommendation in an e-mail. The  department stated that additional regional workshops would be  impractical in the short-term because of HHS’ current involvement in the  update of the states’ pandemic plans. However, the department believes  that the regional workshops already held were uniformly successful and is  prepared to arrange for similar sessions in the future if states would find  such sessions useful. HHS also provided us with technical comments,  which we incorporated as appropriate. DHS generally agreed with the  contents of the report and concurred with our recommendation. DHS’s  comments are reprinted in appendix II. We also provided draft portions of  the report to the state and local officials from the five states and 10  localities we reviewed to ensure technical accuracy. We received no  comments from these states and localities.
As agreed with your offices, 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 of this report to the Secretary of  Health and Human Services and the Secretary of Homeland Security; and  other interested parties. We will also make copies available to others upon  request. In addition, this report is available at no charge on the GAO 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. Major contributors to this report include Sarah  Veale, Assistant Director; Maya Chakko, Analyst-in-Charge; Susan Sato;  Susan Ragland; Karin Fangman; David Dornisch; and members of GAO’s  Pandemic Working Group.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: The objectives of this study were to (1) describe how selected states and  localities are planning for an influenza pandemic and how their efforts are  involving the federal government, other state and local agencies, tribal  nations, nonprofit organizations, and the private sector, (2) describe the  extent to which selected states and localities have conducted exercises to  test their influenza pandemic planning and incorporated lessons learned  into their planning, and (3) identify how the federal government can  facilitate or help improve state and local efforts to plan and exercise for an  influenza pandemic.
To identify how selected states and localities are planning and exercising  for an influenza pandemic and how the federal government can assist their  efforts, from June 2007 to September 2007, we conducted site visits to the  five most populous states: California, Florida, Illinois, New York, and  Texas. Recognizing that we would be limited in our ability to report on all  states in detail, we selected these five states for a number of reasons,  including that these states    comprised over one-third of the United States population;  received over one-third of the total funding from the Department of Health  and Human Services (HHS) and the Department of Homeland Security  (DHS) that could be used for planning or exercising for an influenza  pandemic, and each state received the highest amount of total HHS and  DHS funding that could be used for planning and exercising for an  influenza pandemic respectively within each of the five regions established  by DHS for influenza pandemic preparedness and emergency response;  and   were likely entry points for individuals coming from another country given  that the states bordered either Mexico or Canada or contained major  ports, or both, and accounted for over one-third of the total number of  passengers traveling within the United States, and over half of both  inbound and outbound international air passenger traffic to and from the  United States. areas were selected based on having the highest population totals of all  urban areas in the respective states as of July 2006 and high levels of  international airport passenger traffic as of 2005. Three of these urban  areas, Los Angeles County, Chicago, and New York City, also received  federal pandemic funds.
In addition, we asked the state officials to nominate a rural county for us  to interview in their states based on the following criteria: (1) has  conducted some planning or exercising for an influenza pandemic; and   (2) is representative of challenges and needs that other surrounding rural  counties might also be facing. The state officials in each state nominated  only one rural county. We interviewed officials responsible for health and  emergency management in the nominated counties of Stanislaus County  (California), Taylor County (Florida), Peoria County (Illinois), Washington  County (New York), and Angelina County (Texas). In total we interviewed  officials with 34 different agencies, which included for each state the  health, emergency management, and homeland security agencies, except  for Texas which had a combined emergency management and homeland  security agency, and officials responsible for health and emergency  management for each urban area and rural county in the five states. In  both states and localities we also typically interviewed several officials  from each of the agencies. In addition, in four states and four localities  reviewed, we interviewed the state or local government agencies  individually, and for the remainder we interviewed the state or local  government agencies together. We interviewed both urban and rural  counties in order to obtain the perspectives of officials at both densely  populated urban areas and rural areas. We report the results of our  interviewing as counts at the level of the 15 states and localities. In  general, if any one of the officials we interviewed in a particular state or  locality stated a factor or issue, such as lessons learned from exercises  being applied to pandemic planning, then we considered that statement to  apply to the state or locality as a whole. However, a limitation of our  interview methodology is that we did not comprehensively or  systematically survey all interviewees across the range of interview  questions.
We did not interview tribal nations, and except in two cases when urban  areas included private and nonprofit officials in our interviews with their  agency, we did not interview private sector entities or nonprofit  organizations. We focused on state and local government officials and  asked these officials about their interaction with tribal nations, private  sector entities, and nonprofit organizations. Finally, we interviewed the  selected state and urban area’s auditors on any current or planned related  audits. While the states and localities selected provided a broad  perspective, we cannot generalize or extrapolate the information gleaned  from the site visits to the nation. In addition, since the states that we  selected were large, the most populous states, and likely entry points for  people coming into the United States, the information we collected may  not be as relevant to smaller, less populated states that are not likely entry  points for people coming into the United States.
We also reviewed the influenza pandemic planning and exercise  documents from the selected states and localities. We reviewed the state  and local influenza pandemic plans for common topics, however we did  not analyze the quality of the documents systematically amongst those  states and localities. Instead, we relied on the HHS-led assessment of  whether state’s influenza pandemic plans contained 22 priority areas. We  reviewed the reliability of the data reported from that assessment and  determined that the data were sufficiently reliable for the purposes of this  engagement. We also reviewed the states’ and localities’ exercise  documents for commonalities across jurisdictions.
We also interviewed HHS, Centers for Disease Control and Prevention  (CDC), and DHS officials about how they are working with states and  localities in planning and exercising for an influenza pandemic and  reviewed documentation that they provided, including the HHS-led  feedback to states on their influenza pandemic plans and the March 2008  planning guidance to assist them in updating their influenza pandemic  plans. Within HHS, we met with or received information from the Deputy  Director of the Office of Policy and Strategic Planning within the Office of  Assistant Secretary for Preparedness and Response; the Senior Advisor to  the Director, Coordinating Office for Terrorism Preparedness and  Emergency Response at CDC; the Regional Inspector General, Office of  Inspector General; and their staff. Within DHS, we met with and or  received information from the Director and Associate Chief Medical  Officer for Medical Readiness, Office of Health Affairs; the Branch Chief,  National Integration Center, Federal Emergency Management Agency; the  National Principal Federal Official for influenza pandemic, United States  Coast Guard; the Program Director, Lessons Learned Information System;  and the Deputy Inspector General, the Office of the Inspector General; and  their staff. In January 2008, we observed two of the five influenza  pandemic regional workshops led by HHS and DHS, in coordination with  other federal agencies. The purpose of the workshops was to obtain state  leaders’ input on guidance to assist their governments in updating their  pandemic plans in preparation for a second HHS-led review of these plans.
In addition, we reviewed prior GAO work and other relevant literature. We  also interviewed officials from the National Governors Association,  Association of State and Territorial Health Officials, National Association  of County and City Health Officials, and the National Emergency  Management Association who are working on issues related to state and  local influenza pandemic activities. We obtained information on state and  local activities from the state and local auditors in Kansas City, Missouri;  Portland, Oregon; and New York state, who as members of the GAO  Comptroller General’s Domestic Working Group, all participated in a  collaborative effort to assess influenza pandemic planning in their  jurisdictions.
We conducted this performance audit from March 2007 to June 2008, 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 II: Comments from the Department of Homeland Security
section_title: Related GAO Products
paragraphs: 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 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.
Homeland Security: Observations on DHS and FEMA Efforts to Prepare  for and Respond to Major and Catastrophic Disasters and Address  Related Recommendations and Legislation. GAO-07-1142T. Washington,  D.C.: July 31, 2007.
The Federal Workforce: Additional Steps Needed to Take Advantage of  Federal Executive Boards’ Ability to Contribute to Emergency  Operations. GAO-07-515. Washington, D.C.: May 4, 2007.
Financial Market Preparedness: Significant Progress Has Been Made,  but Pandemic Planning and Other Challenges Remain. GAO-07-399.  Washington, D.C.: March 29, 2007.
Public Health and Hospital Emergency Preparedness Programs:  Evolution of Performance Measurement Systems to Measure Progress.  GAO-07-485R. Washington, D.C.: March 23, 2007.
Homeland Security: Preparing for and Responding to Disasters. GAO-07- 395T. Washington, D.C.: March 9, 2007.
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.
Hurricane Katrina: GAO’s Preliminary Observations Regarding  Preparedness, Response, and Recovery. GAO-06-442T. Washington, D.C.:  March 8, 2006.
Emergency Preparedness and Response: Some Issues and Challenges  Associated with Major Emergency Incidents. GAO-06-467T. Washington,  D.C.: February 23, 2006.
Statement by Comptroller General David M. Walker on GAO’s  Preliminary Observations Regarding Preparedness and Response to  Hurricanes Katrina and Rita. GAO-06-365R. Washington, D.C.: February  1, 2006.
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.
Flu Vaccine: Recent Supply Shortages Underscore Ongoing Challenges.  GAO-05-177T. Washington, D.C.: November 18, 2004.
Emerging Infectious Diseases: Review of State and Federal Disease  Surveillance Efforts. GAO-04-877. Washington, D.C.: September 30, 2004.
Infectious Disease Preparedness: Federal Challenges in Responding to  Influenza Outbreaks. GAO-04-1100T. Washington, D.C.: September 28,  2004.
Public Health Preparedness: Response Capacity Improving, but Much  Remains to Be Accomplished. GAO-04-458T. Washington, D.C.: February  12, 2004.
Hospital Preparedness: Most Urban Hospitals Have Emergency Plans  but Lack Certain Capacities for Bioterrorism Response. GAO-03-924.  Washington, D.C.: August 6, 2003.
Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have  Improved Public Health Response Capacity, but Gaps Remain. GAO-03- 654T. Washington, D.C.: April 9, 2003.