Influenza Pandemic: DOD Combatant Commands' Preparedness Efforts Could Benefit from More Clearly Defined Roles, Resources, and Risk Mitigation
Published: 2007-06-20T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: An influenza pandemic could impair the military's readiness, jeopardize ongoing military operations abroad, and threaten the day-to-day functioning of the Department of Defense (DOD) due to a large percentage of sick or absent personnel. GAO was asked to examine DOD's pandemic influenza planning and preparedness efforts. GAO previously reported that DOD had taken numerous actions to prepare departmentwide, but faced four management challenges as it continued its efforts. GAO made recommendations to address these challenges and DOD generally concurred with them. This report focuses on DOD's combatant commands (COCOM) and addresses (1) actions the COCOMs have taken to prepare and (2) management challenges COCOMs face going forward. GAO reviewed guidance, plans, and after-action reports and interviewed DOD officials and more than 200 officials at the 9 COCOMs.
section_title: What GAO Found
paragraphs: COCOMs have taken numerous management and operational actions to prepare for an influenza pandemic, and the COCOMs' efforts are evolving. Each of DOD's nine COCOMs has established or intends to establish a working group to prepare for an influenza pandemic. Additionally, eight of the nine COCOMs have developed or are developing a pandemic influenza plan. Half of the COCOMs have conducted exercises to test their pandemic influenza plans and several are taking steps to address lessons learned. Five of the nine COCOMs have started to use various media, training programs, and outreach events to inform their personnel about pandemic influenza. Each of the geographic COCOMs has worked or plans to work with nations in its area of responsibility to raise awareness about and assess capabilities for responding to avian and pandemic influenza. Although COCOMs have taken numerous actions, GAO identified three management challenges that may prevent the COCOMs from being fully prepared to effectively protect personnel and perform missions during an influenza pandemic, two of which are related to issues GAO previously recommended that DOD address. First, the roles, responsibilities, and authorities of key organizations relative to others involved in DOD's planning efforts remained unclear in part due to the continued lack of sufficiently detailed guidance from the Secretary of Defense or his designee. As a result, the unity and cohesiveness of DOD's efforts could be impaired and the potential remains for confusion and gaps or duplication in actions taken by the COCOMs relative to the military services and other DOD organizations, such as in completing actions assigned to DOD in the Implementation Plan for the National Strategy for Pandemic Influenza. Second, GAO identified a disconnect between the COCOMs' planning and preparedness activities and resources, including funding and personnel, to complete these activities, in part, because DOD's guidance does not identify the resources required to complete these activities. The continued lack of a link between planning and preparedness activities and resources may limit the COCOMs' ability to effectively prepare for and respond to an influenza pandemic, including COCOMs' ability to exercise pandemic influenza plans in the future. Third, GAO identified factors that are beyond the COCOMs' control--such as limited detailed guidance from other federal agencies on support expected from DOD, lack of control over DOD's stockpile of antivirals, limited information on decisions that other nations may make during an influenza pandemic, reliance on civilian medical providers for medical care, and reliance on military services for medical materiel--that they have not yet fully planned how to mitigate. While GAO recognizes the challenge of pandemic influenza planning, not yet developing options to mitigate the effects of factors that are beyond their control may place at risk the COCOM commanders' ability to protect their personnel and perform missions during an influenza pandemic. For example, if a nation decides to close its borders at the start of a pandemic, COCOMs and installations may not be able to obtain needed supplies, such as antivirals.

section_title: Letter
paragraphs: An influenza pandemic—a novel influenza virus that has the ability to  infect and be passed efficiently among humans—could significantly impair  the military’s readiness, jeopardize ongoing military operations abroad,  and threaten the day-to-day functioning of the Department of Defense  (DOD) due to a large percentage of sick or absent personnel. The  vulnerability of U.S. armed forces to an influenza pandemic was  demonstrated during World War I when at least 43,000 U.S.  servicemembers died—about half of all of the deaths of U.S.  servicemembers during World War I—due to influenza or influenza-related  complications, and another 1 million servicemembers were hospitalized,  which limited the military’s ability to continue ongoing missions.  According to the Centers for Disease Control and Prevention, the “Spanish  flu” pandemic of 1918–1919 killed at least 50 million people worldwide,  including approximately 675,000 in the United States. According to the  World Health Organization (WHO), it is not a question of if, but when,  another influenza pandemic will occur. During the peak weeks of an  outbreak of a severe influenza pandemic, the Homeland Security Council  estimates that 40 percent of the U.S. workforce might not be at work due  to illness, the need to care for family members who are sick, or fear of  becoming infected. DOD military and civilian personnel and contractors  would not be immune and the department would face a similar absentee  rate.
Recent concerns about the possibility of an influenza pandemic have  arisen due to an unprecedented outbreak of H5N1, a deadly strain of avian  influenza which began in Hong Kong in 1997 and spread among bird  populations in parts of Asia, the Middle East, Europe, and Africa, with  limited infections in humans. According to WHO, 309 human cases of  H5N1 resulting in 187 human deaths had been reported worldwide as of  May 31, 2007. Scientists and public health officials agree that the rapid  spread of the virus in birds and the occurrence of limited infections in  humans have increased the risk that this disease may mutate into a form  that is easily transmissible among humans. According to WHO, three  conditions must be met before an influenza pandemic begins: (1) a new  influenza virus subtype that has not previously circulated in humans must  emerge, (2) the virus must be capable of causing disease in humans, and  (3) the virus must be capable of being passed easily among humans. The  H5N1 virus currently meets the first two of these three conditions.
To address the potential threat of an influenza pandemic, the Homeland  Security Council issued its National Strategy for Pandemic Influenza in  November 2005. The Implementation Plan for the National Strategy for  Pandemic Influenza (national implementation plan), which was released  in May 2006, tasked each federal agency with developing its own  implementation plan that addresses two issues: (1) how it would address  the actions assigned to the agency and (2) its approach to employee safety,  continuity of operations, and communications with stakeholders  departmentwide. DOD finalized its implementation plan for pandemic  influenza in August 2006 and released the plan publicly in May 2007. Of  the more than 300 actions in the national implementation plan, DOD is  responsible for 114 actions—31 actions as a lead agency and 83 actions as  a supporting agency. Appendix I lists these actions, the implementation  deadline, and the lead DOD organization responsible for implementing the  action.
DOD began its departmentwide planning and preparedness efforts in  September 2004, when the Assistant Secretary of Defense (ASD) for  Health Affairs issued guidance to the military departments on preparing  for an influenza pandemic. The Deputy Secretary of Defense designated  the ASD for Homeland Defense and Americas’ Security Affairs  (ASD), within the Office of the Under Secretary of Defense for  Policy, as the lead for DOD’s pandemic influenza planning efforts, and  DOD identified functional leads to oversee the 31 actions assigned to DOD  as a lead agency in the national implementation plan. The ASD(HD&ASA)  is the lead for those actions related to providing defense support of civil  authorities, the ASD for Health Affairs is the functional lead for force  health protection actions, and the Joint Staff oversees the combatant  commands’ (COCOM) planning and implementation efforts. In August  2006, the Secretary of Defense named the U.S. Northern Command  (NORTHCOM) the lead COCOM for directing, planning, and synchronizing  DOD’s global response to pandemic influenza.
As operational commanders, DOD’s unified COCOMs are an essential part  of the department’s pandemic influenza planning. There are currently nine  COCOMs—five with geographic responsibilities and four with functional  responsibilities. The five COCOMs with geographic responsibilities are the  U.S. Central Command (CENTCOM), U.S. European Command (EUCOM),  NORTHCOM, U.S. Pacific Command (PACOM), and U.S. Southern  Command (SOUTHCOM). Their geographic areas of responsibility are  shown in figure 1. The four functional COCOMs are the U.S. Joint Forces  Command (JFCOM) which, among other things, engages in joint training  and force provision; U.S. Special Operations Command (SOCOM), which  trains, equips, and deploys special operations forces to other COCOMs and  leads counterterrorist missions worldwide; U.S. Strategic Command  (STRATCOM), whose missions include space and information operations;  missile defense; global command and control; intelligence, surveillance,  and reconnaissance; strategic deterrence; and integration and  synchronization of DOD’s departmentwide efforts in combating weapons  of mass destruction; and U.S. Transportation Command (TRANSCOM),  which provides air, land, and sea transportation for DOD.
You asked that we examine DOD’s planning and preparedness efforts for  an influenza pandemic. In September 2006, we issued a report on DOD’s  efforts to prepare its workforce for an influenza pandemic. We reported  that since September 2004, DOD had taken a number of actions to prepare  for an influenza pandemic; however, DOD faced four management  challenges for its ongoing pandemic influenza preparedness efforts. We  found that DOD had not defined lead and supporting roles and  responsibilities, oversight mechanisms, or goals and performance  measures for its planning efforts; had not requested funding to support  pandemic influenza preparedness; had not fully defined or communicated  which types of personnel—military and civilian personnel, contractors,  dependents, and beneficiaries—would be included in vaccine and antiviral  distribution; and had not fully developed a communications strategy. We  recommended that DOD take actions to address these issues. DOD  generally concurred with our recommendations, but had not yet taken  actions to address our recommendations. While our September 2006  report focused on DOD’s planning and preparedness efforts  departmentwide, this report focuses on the COCOMs’ planning and  preparedness efforts for an influenza pandemic. Specifically, this report  addresses (1) the actions the COCOMs have taken to prepare for an  influenza pandemic and (2) management challenges the COCOMs face as  they continue their planning and preparedness efforts.
To address these objectives, we reviewed drafts of the five geographic  COCOMs’ plans and one functional COCOM’s plan that were available at  the time of our review. We did not evaluate the plans; rather, we used the  plans to determine the actions the COCOMs have taken and plan to take to  prepare for an influenza pandemic. We also reviewed a November 2005  Joint Staff planning order, an April 2007 Joint Staff planning order, DOD’s  implementation plan for pandemic influenza, the Implementation Plan for  the National Strategy for Pandemic Influenza, DOD budget requests and  appropriations, and after-action reports for exercises. We met with more  than 200 officials involved in pandemic influenza planning and  preparedness efforts at the nine COCOMs, service and special operations  subcomponents at two COCOMs (EUCOM and PACOM), and U.S. Forces  Korea. We also met with officials from the Office of the ASD(HD&ASA),  the Office of the ASD for Health Affairs, and the Joint Staff. Additionally,  we met with officials at the Department of State to discuss their pandemic  influenza planning and preparedness efforts in relation to the COCOMs’  efforts abroad. Finally, we compared COCOMs’ actions to date with best  practices we have identified in prior work on risk management, influenza  pandemics, emergency preparedness, and general management. We  conducted our review from September 2006 through April 2007 in  accordance with generally accepted government auditing standards.  Further details on our scope and methodology are in appendix II.
subsections: section_title: Background
paragraphs: Planning for an influenza pandemic is a difficult and daunting task,  particularly because so much is currently unknown about a potential  pandemic. While some scientists and public health experts believe that the  next influenza pandemic could be spawned by the H5N1 avian influenza  strain, it is unknown when an influenza pandemic will occur, where it will  begin, or whether a variant of H5N1 or some other strain would be the  cause. Moreover, the severity of an influenza pandemic, as well as the  groups of people most at risk for infection, cannot be accurately predicted.  Past pandemics have spread worldwide within months and a future  pandemic is expected to spread even more quickly given modern travel  patterns. The implication of such a rapid spread is that many, if not most,  countries will have minimal time to implement preparations and responses  once a pandemic virus begins to spread. However, as we have previously  reported, despite all of these uncertainties, sound planning and  preparedness could lessen the impact of any influenza pandemic.
Preparing for an influenza pandemic can be helpful not only to lessen a  pandemic’s impact, but also to help prepare for other disasters that may  occur. As we have previously reported, the issues associated with  preparation for and response to an influenza pandemic are similar to those  for any other type of disaster: clear leadership roles and responsibilities,  authority, and coordination; risk management; realistic planning, training,  and exercises; assessing and building the capacity needed to effectively  respond and recover; effective information sharing and communication;  and accountability for the effective use of resources. At the same time, a  pandemic poses some unique challenges. Rather than being localized in  particular areas and occurring within a short period of time, as do  disasters such as earthquakes, explosions, or terrorist incidents, an  influenza pandemic is likely to affect wide areas of the world and continue  for weeks or months. Past pandemics have spread globally in two and  sometimes three waves, according to WHO, and a pandemic is likely to  come in waves lasting months, according to the national implementation  plan. Additionally, responding to an influenza pandemic would be more  challenging than dealing with annual influenza. Each year, annual  influenza causes approximately 226,000 hospitalizations and 36,000 deaths  in the United States. According to WHO, an influenza pandemic would  spread throughout the world very quickly, usually in less than a year, and  could sicken more than a quarter of the global population, including  young, healthy individuals who are not normally as affected by the annual  flu.
WHO defines the emergence of an influenza pandemic in six phases (see  fig. 2). Based on this definition, the world currently is in phase 3, in which  there are human infections from a new influenza subtype, but no or very  limited human-to-human transmission of the disease. In addition, the  Homeland Security Council developed “stages” that characterize the  outbreak in terms of the threat that the pandemic virus poses to the U.S.  population. These stages, also shown in figure 2, provide a framework for  a federal government response to an influenza pandemic. Currently there  are new domestic animal outbreaks in an at-risk country, which  corresponds to the federal government’s stage 0.
section_title: COCOMs Have Taken Numerous Actions to Prepare for an Influenza Pandemic
paragraphs: COCOMs have taken numerous management and operational actions to  prepare for an influenza pandemic and the COCOMs’ efforts are evolving.  While the COCOMs are at different stages in their planning and  preparedness efforts, each has taken actions to plan and prepare for an  influenza pandemic. These actions include establishing working groups,  developing plans, exercising plans, implementing strategies to inform  personnel about pandemic influenza, and coordinating with other nations.  Table 1 summarizes the COCOMs’ actions to prepare for an influenza  pandemic.
subsections: section_title: COCOMs Have Established Working Groups to Address Pandemic Influenza
paragraphs: Each of the geographic COCOMs has established a working group to  address various aspects of pandemic influenza, and each of the functional  COCOMs has either established a working group or is planning to do so.  Medical and operational planning officials from the geographic COCOMs  told us they viewed pandemic influenza planning as both an operational  and force health protection issue and, accordingly, these groups are  generally led by officials in the operations or plans and policy directorates,  the office of the command surgeon, or a combination of these offices.  Officials from across the command, and in some cases service  subcomponents and other federal agencies, participate regularly or as  needed. These working groups oversee pandemic influenza plan  development and work on other aspects of pandemic influenza  preparation. For example, PACOM’s working group is headed by three  officials, one each from the operations directorate, plans and policy  directorate, and the Office of the Command Surgeon. According to a  PACOM official, intelligence, logistics, and public affairs officials regularly  attend meetings, and officials from other directorates and subcomponents  attend as needed. The group was established to develop a pandemic  influenza response plan covering PACOM’s geographic area of  responsibility based on the November 2005 Joint Staff order to plan for an  influenza pandemic.
In addition to its core pandemic influenza planning team, PACOM tasked  two of its service subcomponents to lead operational groups with  responsibilities for pandemic influenza preparation and response in  PACOM’s area of responsibility. PACOM designated its Marine  subcomponent, Marine Forces Pacific, to lead PACOM’s international  support response during an influenza pandemic, which will be conducted  through a multiservice task force formed to conduct relief operations  during an influenza pandemic. The task force may also conduct  noncombatant evacuation operations of Americans living abroad. PACOM  also tasked its Army subcomponent, U.S. Army Pacific, to assist partner  governments and conduct defense support of civil authorities in PACOM’s  domestic area of responsibility through a standing task force that defends  PACOM’s domestic region from external military threats. PACOM’s  domestic area of responsibility, in contrast to the command’s foreign area  of responsibility, consists of the state of Hawaii, and various U.S.  territories, possessions, and protectorates, including Guam, American  Samoa, and the Marshall Islands.
Normally in a supporting role, the functional COCOMs were not formally  tasked to plan for pandemic influenza by the November 2005 Joint Staff  planning order. However, each established or intends to establish a group  to prepare for pandemic influenza. For example, JFCOM is in the process  of establishing a pandemic influenza working group. Prior to establishing  the group, JFCOM’s operations directorate was leading its pandemic  influenza planning efforts. Once established, JFCOM’s working group will  include representatives from select directorates, the installation where  JFCOM’s headquarters is located, and the regional public health  emergency officer, according to JFCOM officials.
Additionally, in 2007 NORTHCOM established a working group, called the  Global Pandemic Influenza Working Group, to develop DOD’s global plan  for pandemic influenza that applies to all of DOD’s COCOMs, military  services, and defense agencies. The working group has met three times in  2007 and included representatives from the Office of the Secretary of  Defense; the Joint Staff; the geographic COCOMs; three of the four  functional COCOMs; the four military services; two defense agencies—the  Defense Intelligence Agency and the Defense Logistics Agency—and the  Air Force Medical Intelligence Center; and other interagency partners,  including the Departments of State, Health and Human Services,  Homeland Security, and Agriculture.
section_title: COCOMs Have Developed Pandemic Influenza Plans for Their Areas of Responsibility
paragraphs: At the time of our review, eight of the nine COCOMs had developed or  were developing a plan to prepare for and respond to a potential pandemic  influenza outbreak. Figure 3 illustrates when the COCOMs started their  pandemic influenza planning efforts.
In November 2005, the Joint Staff requested that the geographic COCOMs  develop or adapt existing pandemic influenza plans to address force health  protection, defense support of civil authorities, and humanitarian  assistance. Two geographic COCOMs, EUCOM and PACOM, began  developing plans before the November 2005 planning order. In August  2005, PACOM issued an instruction on pandemic influenza preparation  and response. Similarly, in August 2005, EUCOM began developing its plan  as a result of media reports of avian influenza cases. Although the Joint  Staff did not request that the functional COCOMs develop plans, three of  the four functional COCOMs are developing plans to preserve their ability  to continue their own operations or to address their support role during an  influenza pandemic. While SOCOM’s headquarters was not developing a  pandemic influenza plan, SOCOM planning officials said they expect each  of the geographically-based special operations commands will develop an  annex for their respective geographic COCOMs’ plan; the tasking to  develop these plans will come from the geographic COCOM, rather than  SOCOM. For example, PACOM’s special operations component is  developing a plan for special operations forces in PACOM’s area of  responsibility.
Each of the geographic COCOMs’ plans contain phases that indicate  various actions for the COCOMs to take prior to and during a potential  pandemic. DOD generally uses phases in its plans when conducting  complex joint, interagency, or multinational operations to integrate and  synchronize interrelated activities. The Joint Staff required that the  geographic COCOMs’ plans take into account the WHO phases for an  influenza pandemic; however, the COCOMs were not required to adopt the  same phases. This allowed the COCOMs to develop their own phasing  structures for their plans and, as a result, the COCOMs plans have  different phasing structures. By definition, an influenza pandemic would  simultaneously affect multiple geographic COCOMs’ areas of  responsibility and would, therefore, require unified and cohesive efforts to  respond. According to officials from the Office of the ASD(HD&ASA), the  Joint Staff, and two of the COCOMs, differing phasing structures may  result in the COCOMs’ plans having gaps and duplication of effort among  the COCOMs. Using a uniform phasing structure may increase the  likelihood that all COCOMs understand what actions to take and when to  take those actions, resulting in a unified and cohesive effort. At the time of  our review, NORTHCOM, as the lead COCOM for DOD’s planning efforts,  was drafting an overarching plan for the COCOMs’ response to an  influenza pandemic, which is to include a common phasing structure for  the COCOMs’ plans.
The COCOMs’ plans include not only actions to respond to an influenza  pandemic, but also actions to prepare for an influenza pandemic.
According to planning officials, each of the geographic COCOMs is  implementing actions from the initial phases of their plans. Planning  officials at four of the five geographic COCOMs told that us that advance  preparation was essential for an effective pandemic response.
section_title: COCOMs Have Conducted Exercises for Pandemic Influenza Plans
paragraphs: To test their pandemic influenza plans, five of the nine COCOMs have  conducted a pandemic influenza-related exercise. Three of the geographic  COCOMs—CENTCOM, EUCOM, and PACOM—and one of the functional  COCOMs—STRATCOM—conducted a pandemic or avian influenza- specific exercise. For example, EUCOM conducted its Avian Wind  exercise in June 2006, which included more than 100 participants  representing partner nations, other federal agencies, and DOD and  EUCOM components. The exercise was designed to identify and enhance  the coordination of actions to plan for, respond to, contain, and mitigate  the effects of avian or pandemic influenza within EUCOM’s area of  responsibility. The other three COCOMs held smaller tabletop exercises to  familiarize participants with pandemic influenza in general and the  COCOMs’ plans more specifically. Additionally, two of the geographic  COCOMs—NORTHCOM and PACOM—included a pandemic influenza  scenario within another exercise. SOUTHCOM planning and medical  officials said they have not yet conducted a pandemic influenza exercise  because they are waiting for information from the countries in their area  of responsibility to determine the status of pandemic influenza planning  and preparedness of those countries which, in turn, will help SOUTHCOM  recommend exercises to address gaps in those countries’ preparedness.  Until SOUTHCOM has a clearer assessment of its partner nations’  capabilities, SOUTHCOM officials do not believe generic pandemic  influenza-related exercises are cost-efficient. In the absence of pandemic  influenza-related exercises, medical and operational planning officials  from SOUTHCOM said the command is coordinating with interagency  partners, such as the Pan American Health Organization and the U.S.  Agency for International Development, to gather information on other  countries’ capabilities and planning efforts. Although SOUTHCOM plans to  conduct its own regional tabletop exercise later in fiscal year 2007,  SOUTHCOM officials said the command will not (and cannot) get ahead of  the Department of State as the lead federal agent—and other interagency  partners—in such activities. Each of the geographic COCOMs and three of  the four functional COCOMs are planning to conduct pandemic influenza- specific exercises or include pandemic influenza scenarios in future  exercises. For example, STRATCOM plans to conduct three tabletop  exercises—an internal exercise for STRATCOM’s staff; an exercise with  the installation where STRATCOM’s headquarters is located (Offutt Air  Force Base, Nebraska); and an exercise with STRATCOM’s staff, the  installation, and the civilian community—to test STRATCOM’s pandemic  influenza plan to continue its own operations.
Officials from the five COCOMs that have held exercises said they  identified some lessons as a result of their exercises and are starting to  take steps to address these lessons. Some of these lessons were general  and related to overall planning efforts. For example, in March 2006,  CENTCOM conducted a tabletop exercise to familiarize participants with  the command’s pandemic influenza plan. The results of the exercise  facilitated establishing an operational planning team to continue to  address pandemic influenza efforts, according to CENTCOM’s lead  planning official. Similarly, an official responsible for planning PACOM’s  exercises said the command included avian influenza in one scenario in its  Cobra Gold exercise in May 2006, a regularly scheduled multinational  exercise hosted by Thailand. In the exercise, PACOM, the Royal Thai  Army, and the Singapore Army planned for implications and conducted  operations supporting humanitarian assistance in an area where H5N1  avian influenza was a factor. According to a planning official, PACOM  determined that the command needs to hold a separate pandemic  influenza exercise to effectively test its pandemic influenza plan. However,  an official responsible for planning PACOM’s exercises said it has been a  challenge to meet another exercise requirement without additional  resources, including personnel and funding. Similarly, U.S. Forces Korea  planning officials said the command has not held a pandemic influenza- specific exercise or included a pandemic influenza scenario in any war- planning exercises because of the time required and lack of funding for  such a scenario. Influenza pandemic exercises have not been a priority  because U.S. Forces Korea has been focused on events involving North  Korea. According to a representative from one of the U.S. Army garrisons  in South Korea, the key lesson learned from a tabletop exercise was that  they are “very unprepared” for an influenza pandemic. Lessons learned  from other exercises pertained to more specific aspects of plans. For  example, officials involved in EUCOM’s Avian Wind exercise identified the  need to update the command’s continuity of operations plan to increase  the likelihood that critical missions, essential services, and functions could  continue during an influenza pandemic. As a result, EUCOM planning  officials report that the command plans to update its continuity of  operations plan in spring 2007 to include pandemic influenza.
section_title: COCOMs Have Started to Provide Information to Personnel about Pandemic Influenza
paragraphs: Five of the nine COCOMs—EUCOM, NORTHCOM, PACOM, SOUTHCOM,  and STRATCOM—have started to provide information to their personnel,  including military and civilian personnel, contractors, dependents, and  beneficiaries, about a potential influenza pandemic. COCOMs have used  various strategies to inform personnel about pandemic influenza, including  using various media outlets, training programs, and outreach events.
Each of the COCOMs that have started to provide information to their  personnel used radio or television commercials, news articles, briefings,  or a combination of these means, to inform personnel about avian and  pandemic influenza. Additionally, three of the COCOMs had a page on  their publicly available Web sites that included some avian and pandemic  influenza information and links to other Web sites, such as the federal  government’s pandemic influenza Web site, www.pandemicflu.gov.
Three COCOMs—EUCOM, PACOM, and STRATCOM—offered training  courses to inform personnel about pandemic influenza. Both EUCOM and  PACOM offered training for public health emergency officers. In May 2006  and September 2006, EUCOM’s training for its public health emergency  officers included general information about pandemic and avian influenza  as well as strategies about how to communicate pandemic influenza- related information to beneficiaries. According to STRATCOM officials, in  October 2006, STRATCOM required military and civilian personnel to  complete a computer-based training module about pandemic and avian  influenza that included information on force health protection measures,  among other issues.
Additionally, three COCOMs—PACOM, STRATCOM, and EUCOM—have  used outreach programs to inform personnel, including military and  civilian personnel, contractors, dependents, and beneficiaries, about  pandemic influenza. A group of military medical professionals at PACOM  conducted a series of public outreach events at military exchanges in  Hawaii that combined providing seasonal flu vaccinations to military  personnel, dependents, and beneficiaries with educating personnel by  distributing information about general preventive health measures, as well  as pandemic influenza. For example, the PACOM officials distributed  pamphlets on cough etiquette, how to prepare for an influenza pandemic,  and a list of items to keep on hand in an emergency kit. Figure 4 shows  one of PACOM’s military medical professionals sharing information with  dependents and beneficiaries at a November 2006 event at the Navy  Exchange in Honolulu, Hawaii. Similarly, STRATCOM held an outreach  event, called “Pandemic Influenza Focus Day,” in November 2006 for its  military and civilian personnel and contractors. During the Focus Day,  each directorate or office met to discuss the impact that a 40 percent  absenteeism rate due to personnel being sick, caring for someone who  was sick, or afraid to come to work, would have on the individual  directorate or office. Additionally, in March 2006, EUCOM directed  service subcomponents that had not already done so to hold installation- level meetings to inform military and civilian personnel, contractors,  dependents, and beneficiaries about the threat of avian influenza and  related preventive measures.
section_title: COCOMs Have Coordinated with Other Nations
paragraphs: Each of the geographic COCOMs has started to work or plans to work  with nations in its area of responsibility to raise awareness about and  assess capabilities for responding to avian and pandemic influenza.  COCOMs undertook some of these outreach efforts as a result of an action  assigned to DOD as a lead agency in the national implementation plan to  conduct assessments of avian and pandemic influenza preparedness and  response plans of the militaries in partner nations (action 4.1.1.3). For  example, CENTCOM’s lead planning official reported that CENTCOM  performed assessments and identified gaps for Afghanistan’s pandemic  influenza preparedness and response and has obtained funding for  projects with the Afghanistan National Army and the Ministries of Public  Health, Agriculture, and Higher Education. The CENTCOM official also  noted, among other outreach efforts in the region, a meeting with a  military medical delegation from Pakistan to discuss assessing the  Pakistani military’s pandemic influenza preparedness and response efforts.  Officials involved in EUCOM’s pandemic influenza planning and  humanitarian assistance programs reported that EUCOM plans to  complete the assessments through its regular coordination efforts with  militaries in partner nations. While EUCOM obtained $1 million from the  Combatant Commander Initiative Fund to complete actions assigned to  DOD as a lead agency in the national implementation plan, EUCOM  officials cited resources, including funding, as a challenge to completing  these assessments by the November 2007 deadline.
COCOMs also have started to take or plan to take other actions to work  with other nations related to pandemic influenza. For example,  SOUTHCOM plans to hold regional conferences focused on pandemic  influenza to help educate partner nations, assess the preparedness of  nations in the region, and identify appropriate contacts within the nations.  SOUTHCOM planning and medical officials said they have two  conferences tentatively planned, but noted that the number of conferences  they can hold will be determined by the availability of funding. According  to these officials, the conferences will address a variety of topics related to  pandemic influenza, including developing plans and interagency  collaboration. Moreover, officials from PACOM, Marine Forces Pacific,  U.S. Forces Japan, and U.S. Forces Korea participated in a multilateral  workshop with officials from Japan and South Korea to discuss the  potential threat of a pandemic influenza in the Asia-Pacific region.  Participants shared information about national strategies and military  response plans and discussed ways to leverage existing partnerships,  enhance interoperability, and integrate planning efforts to minimize the  health and economic impact of an influenza pandemic.
section_title: COCOMs Face Three Management Challenges as They Continue to Prepare for an Influenza Pandemic
paragraphs: While COCOMs have taken numerous actions to prepare for an influenza  pandemic, we identified three management challenges that the COCOMs  face as they continue their planning and preparedness efforts. First, the  roles, responsibilities, and authorities of key organizations involved in the  COCOMs’ planning and preparedness efforts relative to other lead and  supporting organizations remained unclear. As a result, the unity and  cohesiveness of DOD’s pandemic influenza preparation could be impaired  and the potential remains for confusion among officials and gaps and  duplication in actions taken by the COCOMs relative to the military  services and other DOD organizations in implementing tasks, such as the  actions assigned to DOD as a lead agency in the national implementation  plan. Second, we identified a disconnect between the COCOMs’ planning  and preparedness activities and resources, including funding and  personnel, to complete those activities. The continued disconnect between  activities and resources may limit the COCOMs’ ability to effectively  prepare for and respond to an influenza pandemic. Third, we identified  some factors that are beyond the COCOMs’ control—such as limited  detailed guidance from other federal agencies on the support expected  from DOD, lack of control over DOD’s antiviral stockpile, limited  information on decisions that other nations may make during an influenza  pandemic, reliance on civilian medical providers for medical care, and  reliance on military services for medical materiel—that they have not yet  fully planned how to mitigate. While we recognize the difficulty in  planning for an influenza pandemic, not yet developing options to mitigate  the effects of such factors may place at risk the COCOM commanders’  ability to protect their personnel—including military and civilian  personnel, contractors, dependents, and beneficiaries—or to perform their  missions during an influenza pandemic.
subsections: section_title: Roles, Responsibilities, and Authorities of Key Organizations Relative to Others Are Not Fully and Clearly Defined
paragraphs: The roles, responsibilities, and authorities of key organizations involved in  DOD’s pandemic influenza planning and preparedness efforts relative to  other organizations leading and supporting the department’s pandemic  influenza planning efforts—including NORTHCOM as the lead for DOD’s  planning and the individual COCOMs—remained unclear because of the  continued lack of sufficiently detailed guidance from the Secretary of  Defense or his designee. We have previously reported that in preparing for  and responding to any type of disaster, leadership roles and  responsibilities must be clearly defined, effectively communicated, and  well understood to facilitate rapid and effective decision making. As a  result of not yet issuing guidance fully and clearly defining the roles,  responsibilities, authorities, and relationships of key organizations, the  unity and cohesiveness of DOD’s pandemic influenza preparation could be  impaired, and the potential remains for confusion among COCOM officials  and gaps or duplication in actions taken by the COCOMs relative to the  military services and other DOD organizations.
In our September 2006 report, we identified the absence of clear and fully  defined guidance on roles, responsibilities, and lines of authority for the  organizations involved in DOD’s pandemic influenza preparedness efforts  as a potential hindrance to DOD’s ability to effectively prepare for an  influenza pandemic, and recommended that DOD take actions to address  this issue, but DOD had not yet done so. Officials from the Office of the  ASD(HD&ASA), the Office of the ASD for Health Affairs, and the Joint  Staff responded to the recommendations in our September 2006 report by  stating that DOD’s implementation plan for pandemic influenza clearly  establishes the roles and responsibilities for organizations throughout  DOD. In its implementation plan, DOD established offices of primary  responsibility for policy oversight of various tasks and outlined medical  support tasks assigned to various organizations, but we found that the  plan stopped short of fully and clearly identifying roles, responsibilities,  and lines of authority for all key organizations, including the COCOMs.  Since planning has occurred concurrently within DOD at various levels  from the Office of the Secretary of Defense to installations, a more  extensive delineation of roles, responsibilities, and lines of authority could  lead to a more efficient and effective effort.
DOD has outlined NORTHCOM’s roles and responsibilities as the lead  COCOM for the department’s pandemic influenza planning efforts. In  August 2006, the Secretary of Defense named NORTHCOM the lead  COCOM for directing, planning, and synchronizing DOD’s global response  to pandemic influenza, or the “global synchronizer” for DOD’s pandemic  influenza planning. In April 2007, the Joint Staff issued a planning order  that, among other things, outlined NORTHCOM’s roles and responsibilities  as global synchronizer, including    serving as a conduit between the Joint Staff or Office of the Secretary  of Defense and the COCOMs, military services, and defense agencies  on pandemic influenza-related issues;    assessing and advocating for resources for the COCOMs, military  services, and defense agencies; and  leading planning efforts for the COCOMs, military services, and defense  agencies, but not the execution of those plans in the other COCOMs’  areas of responsibility.
While DOD has outlined NORTHCOM’s roles and responsibilities as the  global synchronizer, the command’s roles, responsibilities, and authorities  relative to the lead offices for DOD’s overall pandemic influenza planning  efforts, as well as the relationships between the organizations, were not  yet fully and clearly defined. The ASD(HD&ASA) is the lead, in  coordination with the ASD for Health Affairs, for DOD’s pandemic  influenza planning and preparedness efforts departmentwide, and the  Joint Staff also plays a key role in DOD’s pandemic influenza planning.  However, neither the Secretary of Defense nor his designee had yet issued  guidance fully and clearly stating how NORTHCOM’s roles and  responsibilities as the lead for the COCOMs’ planning efforts differed from  the roles and responsibilities of the other lead offices for pandemic  influenza preparedness efforts, including the Joint Staff, which led to  varying expectations among some COCOM officials. For example, COCOM  officials had different expectations about whether NORTHCOM would  provide guidance to the COCOMs. Planning officials from two geographic  COCOMs noted that the Joint Staff, not NORTHCOM, has the primary  authority to provide guidance to the COCOMs. However, planning officials  from at least three COCOMs were expecting NORTHCOM to provide  guidance on key issues, such as quarantine, social distancing, treatment of  DOD beneficiaries, and troop rotation. Additionally, there was confusion  among the COCOMs on which organization was responsible for overseeing  interagency coordination. Planning officials at one COCOM, as well as  officials from the Office of the ASD(HD&ASA), the Office of the ASD for  Health Affairs, and the Joint Staff, said offices within the Office of the  Secretary of Defense and the Joint Staff would remain the points of  contact for the actions assigned to DOD in the national implementation  plan and would also remain the primary contacts for coordinating with  other federal government agencies. However, a planning official from  another geographic COCOM said that the global synchronizer role meant  that NORTHCOM would coordinate with other federal government  agencies for pandemic influenza planning. At the time of our review,  officials leading NORTHCOM’s planning and preparedness efforts  acknowledged that the command’s roles and responsibilities relative to the  Joint Staff and offices within the Office of the Secretary of Defense were  not well-defined, especially concerning direct coordination and sharing  information with the other federal agencies, and that the command needed  further guidance from the Office of the Secretary of Defense and the Joint  Staff to more clearly establish its roles and responsibilities.
Similarly, the roles, responsibilities, and authorities of the individual  COCOMs for DOD’s pandemic influenza planning and preparedness efforts  were not yet fully and clearly defined. While there is guidance—such as  the Unified Command Plan and 10 U.S.C. § 164—that describes the overall  roles, responsibilities, and authorities of the COCOMs, we found that the  COCOMs’ roles, responsibilities, and authorities related to DOD’s  pandemic influenza planning and preparedness efforts were unclear. For  example, medical and operational planning officials from three COCOMs  said it was not clear to them which of the 31 actions assigned to DOD as a  lead agency in the national implementation plan the COCOMs were to help  complete. Officials from two of these COCOMs said that officials within  the Office of the Secretary of Defense and the Joint Staff had not yet  clearly stated which actions assigned to DOD in the national  implementation plan should be implemented by COCOMs and which by  the military services. Officials from the Office of the ASD(HD&ASA) and  the Joint Staff said the COCOMs were responsible for implementing few of  the actions assigned to DOD as a lead agency in the national  implementation plan. However, in the absence of clear guidance, each of  the COCOMs identified the actions they believed they are partly  responsible for implementing. COCOM officials told us they determined  they were partly responsible for between 12 and 18 of the 31 actions for  which DOD is a lead agency, as shown in table 2. We identified some  inconsistency in which actions the geographic COCOMs saw as their  responsibility to fulfill.
COCOM officials’ varying interpretations of which actions applied to them  could lead to gaps in the completion of actions assigned to DOD or  duplications in effort. For example, operational and medical planning  officials from the Joint Staff, the Office of the ASD(HD&ASA), and the  Office of the ASD for Health Affairs told us that there were no additional  force health protection actions assigned to COCOMs, but COCOM medical  and planning officials told us they shared responsibility for some of the  force health actions, including actions relating to monitoring force health  (action 4.2.2.6), analyzing medical materiel needs (action 6.1.6.3), and  implementing infection control campaigns (action 6.3.2.5). Officials from  the Joint Staff and the Office of the ASD(HD&ASA) told us this confusion  was evident in the collection of information on funding needs from  COCOMs, as the COCOMs identified funding needs for actions these  officials thought the COCOMs were not intended to fulfill.
In addition, we identified that there was little guidance on what  constituted fulfillment of the actions, some of which were open to  interpretation and potentially were quite broad. For example, one action,  which the Joint Staff issued to the geographic COCOMs, calls for DOD to  assess the avian and pandemic influenza response plans of partner  militaries, develop solutions for national and regional gaps, and develop  and execute military-to-military influenza exercises to validate such plans  (action 4.1.1.3), by November 2007. The wide scope for interpretation of  the actions meant that COCOMs could expend unnecessary effort or fail to  complete actions intended for them. Without fully and clearly identifying  the roles, responsibilities, and authorities of the COCOMs, including a  clear delineation of which actions apply to which organizations and what  constitutes fulfillment of an action, DOD’s preparation for an influenza  pandemic risks gaps in efforts by failing to execute some actions by  assuming that an action will be fulfilled by other organizations; duplicating  efforts, as COCOMs may undertake actions that other DOD organizations  are meant to complete; or both.
Furthermore, the roles, responsibilities, and authorities of COCOMs  relative to the military services for DOD’s pandemic influenza planning  and preparedness efforts were also not yet fully and clearly defined. The  memorandum that names NORTHCOM the lead for directing, planning,  and synchronizing DOD’s global response to pandemic influenza is not  limited to the efforts of the COCOMs; however, planning officials from one  COCOM said it was unclear what authority NORTHCOM had over the  military services. The April 2007 planning order directs the military  services to coordinate with NORTHCOM to ensure that the services’  pandemic influenza plans are synchronized with DOD’s global pandemic  influenza plan but does not define what this coordination entails. In  addition to the need for more information on which actions the COCOMs  were to complete compared to the military services discussed above,  COCOM medical and planning officials sought clarification on the  differences in the roles and responsibilities of the COCOMs and military  services in implementing force health protection actions and moving  medical assets within the area of responsibility. The November 2005 Joint  Staff planning order tasked COCOMs to include force health protection in  their plans for pandemic influenza. Planning officials from two of the  geographic COCOMs said that, in general, COCOMs set the requirements  for force health protection in their areas of responsibility and the military  services are responsible for ensuring that their forces meet these  requirements. However, medical and planning officials from one COCOM  viewed the November 2005 Joint Staff planning order as assigning force  health protection activities to the COCOMs and noted that pandemic  influenza is the only area where the COCOMs are responsible for medical  issues. Moreover, medical and planning officials from one of the COCOM’s  service subcomponents noted that because the COCOM’s plan includes a  “shaping” phase, which currently is being implemented, the COCOMs have  a greater responsibility for force health protection than in other  operations. A medical official from one COCOM noted that COCOMs can  identify many of the things needed to prepare for and respond to an  influenza pandemic, but the COCOMs lack the day-to-day authority over  installations and resources to direct that these measures be taken during  the initial phases of the COCOM’s plan because force health protection  typically is the responsibility of the military services. Similarly, planning  officials at two geographic COCOMs reported concerns that they would  not have the authority in a pandemic to move medical assets, such as  antivirals, from one base in their area of responsibility controlled by one  military service to another base controlled by a different service. An  official from the Office of the ASD for Health Affairs confirmed that this is  an issue, particularly within the United States, and noted that the military  services and COCOMs will have to resolve this issue on their own because  the Office of the ASD for Health Affairs is not part of the COCOMs’ or  military services’ chains-of-command.
The unity and cohesiveness of DOD’s pandemic influenza planning,  preparation, and response efforts could be hindered by the continued lack  of fully and clearly defined roles, responsibilities, authorities, and  relationships of organizations throughout DOD involved in these efforts.  While the April 2007 planning order outlines NORTHCOM’s roles and  responsibilities, the lack of clarity of the roles, responsibilities, and  authorities of key organizations involved in the COCOMs’ planning and  preparedness efforts relative to other lead and supporting organizations  has created the potential for confusion, gaps, and overlaps in areas such as  the actions assigned to DOD in the national implementation plan as well as  force health protection measures for DOD’s personnel. Without more fully  and clearly defined roles and responsibilities, various organizations could  fail to carry out certain actions or, alternatively, may perform actions that  other organizations were to complete. Additionally, it may be difficult for  DOD to accurately capture funding requirements without a clear  delineation of which actions are to be executed by which organizations, as  well as the scope of the actions. Finally, COCOM planning and response  could be less effective if commanders do not have a clear sense of the  assets under their control, such as medical materiel at service-controlled  installations.
section_title: DOD Has Not Identified Resources to Complete Planning and Preparedness Activities
paragraphs: We identified a disconnect between the COCOMs’ planning and  preparedness activities and resources, including funding and personnel, to  complete those activities. This disconnect is, in part, because DOD  guidance, including DOD’s implementation plan for pandemic influenza  and the Joint Staff planning order that directed the COCOMs to plan, did  not identify the resources required to complete these activities. We have  previously reported that information on required resources is critical for  making sound analyses of how to pursue goals. Without realistic  information on required resources, decision makers cannot determine  whether a strategy to achieve those goals is realistic and cost-effective or  make trade-offs against other funding priorities. In September 2006, we  reported that DOD had not yet identified an appropriate funding  mechanism or requested funding tied to its departmentwide goals, which  could impair the department’s overall ability to prepare for a potential  pandemic, and recommended that DOD take actions to address this issue.  DOD generally concurred with our recommendation, but had not yet taken  actions to address this recommendation. The continued lack of a link  between the COCOMs’ planning and preparedness activities and the  resources required for them may limit the COCOMs’ ability to effectively  prepare for and respond to an influenza pandemic.
DOD did not request dedicated funding for its pandemic influenza  preparedness activities in its fiscal year 2007 or fiscal year 2008 budget  requests because, according to the Principal Deputy to the  ASD(HD&ASA), several baseline plans, including the national  implementation plan, DOD’s implementation plan, and the geographic  COCOMs’ plans, needed to be drafted before DOD could assess its  potential preparedness costs. Officials from the Office of the  ASD(HD&ASA) and the Office of the ASD for Health Affairs were aware of  the disconnect between the COCOMs’ planning and preparedness  activities and resources to accomplish these activities. The officials said  that when the Homeland Security Council originally developed the  national implementation plan, the officials expected to receive  supplemental funding to complete the actions assigned to DOD. However,  in the absence of sustained supplemental funding, the officials said they  are struggling to find programs from which to divert resources to fund the  department’s planning and preparedness activities. In December 2005,  DOD received $130 million in supplemental appropriations for pandemic  influenza; $120 million was for expenses, including health-related items for  its own personnel, and $10 million was to provide equipment and  assistance to partner nations. However, as the Congressional Research  Service reported, tracking federal funds for influenza preparedness is  difficult because funds designated for pandemic influenza preparedness  do not reflect the sum of all relevant activities, including developing the  department’s pandemic influenza plan. The COCOMs have a certain  amount of discretion over their operations and maintenance budgets to  fund pandemic influenza-related activities. Although COCOM officials  have started to identify funding requirements through multiple Joint Staff  inquiries regarding COCOM funding needs, planning, medical, and budget  officials from the geographic COCOMs said there is still not an accurate  assessment of actual funding needs and DOD has not yet requested  funding for the department’s planning and preparedness activities. An  official from the Office of the ASD(HD&ASA) said obtaining funding to  fully establish NORTHCOM as the global synchronizer for the  department’s efforts is the office’s top priority. After NORTHCOM  establishes its global synchronizer role, the official said one of  NORTHCOM’s responsibilities will be to assist the Joint Staff in  determining how much funding is required for DOD’s pandemic influenza  planning and preparedness activities.
Without resources identified for planning and preparedness activities,  COCOMs have reallocated resources from other sources to undertake  these activities. For example, budget officials at EUCOM said, in the  absence of dedicated funding for pandemic influenza-related activities,  EUCOM spent about $145,000 of its Operations and Maintenance funding  in fiscal year 2006 for travel to pandemic influenza-related conferences  and for its Avian Wind exercise. COCOMs have also diverted planners  from other areas to develop pandemic influenza plans. Planning officials  from four of the five geographic COCOMs and four of the subcomponents  we met with said pandemic influenza planning was one of many  responsibilities for the personnel involved in their pandemic influenza  planning and preparedness efforts, and often their other responsibilities  were a higher priority. For example, planning officials from U.S. Forces  Korea stated that they cannot dedicate the level of effort that pandemic  influenza planning requires because of other more immediate priorities on  the Korean peninsula. Similarly, members of CENTCOM’s pandemic  influenza planning team said they were distracted by a variety of other  tasks calling for immediate action, many of which are related to the wars  in Iraq and Afghanistan, and devoted a small percentage of their time to  pandemic influenza; only the lead planner in the team was able to devote a  significant percentage of time to pandemic influenza planning.
As a result of the lack of identified resources for DOD’s pandemic  influenza planning and preparedness activities, planning officials from at  least three COCOMs said that they will likely be unable to complete some  important activities. For example, although the Joint Staff planning order  tasked geographic COCOMs to exercise their pandemic influenza plans at  least once a year, officials responsible for CENTCOM’s planning and  PACOM’s planning and exercises told us they need additional resources to  conduct these exercises. While EUCOM has conducted an exercise,  planning officials told us that they have had to reconsider future exercises  because of the lack of resources. Additionally, officials from each of the  COCOMs said they lack resources to complete some of the actions in the  national implementation plan. For example, while the Joint Staff tasked all  of the geographic COCOMs to assess the avian and pandemic influenza  response plans of partner militaries, develop solutions for national and  regional gaps, and develop and execute military-to-military influenza  exercises to validate such plans (action 4.1.1.3), planning and medical  budget officials from each of the geographic COCOMs said that they may  be unable to complete this action by the November 2007 deadline because  of the lack of resources, including funding.
section_title: COCOMs Have Not Yet Developed Options to Mitigate the Effects of Factors beyond Their Control
paragraphs: We identified factors that are beyond the COCOMs’ control—such as  limited detailed guidance from other federal agencies on the support  expected from DOD, lack of control over DOD’s antiviral stockpile, limited  information on decisions that other nations may make during an influenza  pandemic, reliance on civilian medical providers for medical care, and  reliance on military services for medical materiel—that they have not yet  fully planned how to mitigate. While we recognize the difficulty of  planning for an influenza pandemic, not yet developing options to mitigate  the effects of such factors may limit the COCOM commanders’ ability to  protect their personnel—including military and civilian personnel,  contractors, dependents, and beneficiaries—or to perform their missions  during an influenza pandemic.
We have recommended a comprehensive risk-management approach as a  framework for decision making. Risk involves three elements: (1) threat,  which is the probability that a specific event will occur; (2) the  vulnerability of people and specific assets to that particular event; and   (3) the adverse effects that would result from the particular event should it  occur. We define risk management as a continuous process of assessing  risks; taking actions to reduce, where possible, the potential that an  adverse event will occur; reducing vulnerabilities as appropriate; and  putting steps in place to reduce the effects of any event that does occur.  Since it is not possible for the COCOMs to reduce the potential for an  influenza pandemic, it is important they reduce their vulnerabilities and  put in place steps to mitigate the effects of a potential pandemic.
subsections: section_title: COCOMs Have Not Yet Developed Options to Mitigate the Effects of Limited Detailed Guidance from Other Federal Agencies
paragraphs: Planning officials from four of the five COCOMs told us they had received  limited detailed guidance from other federal agencies on what support  they might be asked to provide during an influenza pandemic or  information that could help the COCOMs estimate such potential support.  This is one factor that has hindered their ability to plan to provide support  to other federal agencies domestically and abroad during an influenza  pandemic. DOD was designated as a supporting agency for pandemic  influenza response in the national implementation plan. After Hurricane  Katrina, we reported that the military has significant and sometimes  unique capabilities, but additional actions are needed to ensure that its  contributions are clearly understood and well planned and integrated.  Additionally, we reported that many challenges faced in the response to  Hurricane Katrina point to the need for plans that, among other things,  identify capabilities that could be available and provided by the military.  Planning officials from each of the geographic COCOMs said they  anticipate that, during an influenza pandemic, the COCOM will provide  support domestically and abroad as requested by other federal agencies  and approved by the Secretary of Defense. However, planning officials  from four of the five geographic COCOMs said they had not yet received  detailed information from the Department of State on what assistance  other nations may request from the United States. Without this  information, the officials said they cannot effectively plan to provide  support. Department of State officials told us they would not know what  specific kinds of support other nations may need until an influenza  pandemic occurred, but they had developed a list of priority countries for  the U.S. government’s pandemic influenza response. Additionally,  Department of State officials said they had started to assess what kinds of  support may be needed for embassies and they have developed a request  for information about the level of assistance DOD may be able to provide  at a specific list of posts deemed most vulnerable from a medical and  security standpoint should an influenza pandemic emerge. Department of  State officials expected that the request for information would be sent to  DOD by the end of June 2007. At least one COCOM has taken steps to  mitigate the effects of limited information, pending further information  from the Department of State. PACOM established multiservice teams to  work with nations, territories, possessions, and protectorates in its area of  responsibility to identify potential needs during an influenza pandemic.  For example, in September 2006 about 15 PACOM officials went to  Malaysia to provide an avian and pandemic influenza “train the trainer”  workshop, obtain information on the country’s pandemic influenza  planning efforts, and identify areas of mutual collaboration to increase the  likelihood of a coordinated response to the current threat of avian  influenza and a potential influenza pandemic. Planning officials from three  COCOMs and two service subcomponents that we met with said planning  to provide support at the last minute could lead to a less effective and less  efficient use of resources. While identifying what capabilities may be  needed and available at an indefinite point in the future is difficult, taking  these steps now could allow the COCOMs to be better prepared to provide  support to other federal agencies domestically and abroad during an  influenza pandemic.
section_title: COCOMs Have Not Yet Developed Options to Mitigate the Effects of a Lack of Control over DOD’s Antiviral Stockpile
paragraphs: COCOM medical and planning officials have expressed concern about how  they would gain access to and use DOD’s stockpile of antivirals. These  officials reported that their lack of control over DOD’s stockpile of  antivirals has limited their ability to plan to use this resource. The ASD for  Health Affairs procured antivirals and prepositioned DOD’s antiviral  stockpile in the continental United States, Europe, and the Far East. The  ASD for Health Affairs retained the authority to release the antivirals to  allow more flexibility to direct these limited resources where they are  needed the most, according to an official in the Office of the ASD for  Health Affairs. However, according to planning and medical officials at  three of the COCOMs, the absence of information about these assets has  made it more difficult to plan for their use because the COCOM officials  did not know when they would receive the antivirals or how many doses  they would receive. For example, EUCOM planning and medical officials  said that during a NORTHCOM exercise in 2006, it took 96 hours for the  ASD for Health Affairs to authorize the release of antivirals. The EUCOM  officials expressed concern that a lengthy release process could impact  the effectiveness of antivirals, as they are most effective if given within 48  hours of showing influenza-like symptoms. According to the officials, the  lack of information on when the COCOMs might receive antivirals and  how many antivirals they may receive limits the COCOMs’ ability to plan  for how they will use these resources and what steps they may need to  take to transport, store, and secure these resources after the ASD for  Health Affairs releases the stockpile. To help address this issue, the Office  of the ASD for Health Affairs distributed about 470,000 treatment courses  of an antiviral to military treatment facilities, which can be administered  as determined by the facility’s commander. Additionally, at least two  service subcomponents purchased their own supply of antivirals to be  used for critical personnel during an influenza pandemic. However, by not  yet taking steps to mitigate the effect of not having sufficient information  to plan to use antivirals in their areas of responsibility, COCOMs may not  be prepared to effectively and efficiently use these resources or protect  their personnel.
section_title: COCOMs Have Not Yet Developed Options to Mitigate the Effects of Limited Information on Other Nations’ Decisions
paragraphs: Planning officials at four of the geographic COCOMs and one of the  functional COCOMs mentioned the need for information on decisions  other nations may make during an influenza pandemic, such as closing  borders or restricting transportation into and out of the country, as a  factor that has hindered their ability to plan to continue ongoing missions  during an influenza pandemic. For example, currently most  servicemembers injured in Iraq and Afghanistan, in the CENTCOM area of  responsibility, travel to Germany for essential medical care. EUCOM  planning officials noted that Germany has reserved the right to close off  access to Ramstein Air Base, Germany, which is a key European transit  point for EUCOM and CENTCOM. Additionally, CENTCOM planning  officials said that the borders of Kuwait and Qatar could be shut down in a  pandemic, causing problems for transporting personnel and supplies into  Iraq and Afghanistan. EUCOM planning officials said they discussed the  need for information on decisions other nations may make with officials  from the Department of State to help mitigate the effect of limited  information from other countries. However, according to the EUCOM  officials, most countries are not at a point in their planning to make  decisions on border closures or transportation restrictions. The EUCOM  officials said they will assume there will be movement restrictions for the  purpose of developing their plan, but will not develop specific plans for  addressing the movement restrictions until they receive more information.  However, information on other nations’ decisions may not be available  before an influenza pandemic. Developing plans at the last minute to  address other nations’ decisions could limit the COCOMs’ ability to obtain  or use certain assets, placing at risk the COCOMs’ ability to effectively  protect personnel and continue missions due to potential restrictions by  other nations on ground, sea, and air transportation during an influenza  pandemic. For example, if a nation decides to close its borders at the start  of a pandemic, COCOMs and installations may not be able to obtain  needed supplies, such as antivirals. Identifying specific options to mitigate  the effects of other nations’ possible decisions in advance of an influenza  pandemic may help the COCOMs more fully develop their pandemic  influenza plans, provide more flexibility in the COCOMs’ response to an  influenza pandemic, and better allow the COCOMs to continue ongoing  missions.
section_title: COCOMs Have Not Yet Develped Options to Mitigate the Effects of Reliance on Civilian Medical Care
paragraphs: Officials at each of the geographic COCOMs expressed concern that the  COCOMs are reliant on civilian medical providers in the United States and  abroad to provide medical care for military personnel, dependents, and  beneficiaries. This is a factor that has hindered the COCOMs’ ability to  plan for how personnel will access medical care during an influenza  pandemic. In fiscal year 2006, DOD provided health care to more than 9  million active duty personnel, retirees, and their dependents through the  department’s TRICARE program. TRICARE beneficiaries can obtain health  care through DOD’s direct care system of military hospitals and clinics or  through DOD’s purchased care system of civilian providers. We reported  that, in fiscal year 2005, an estimated 75 percent of inpatient care and 65  percent of outpatient care for TRICARE beneficiaries was delivered by  civilian providers. Medical and planning officials at each of the five  geographic COCOMs expressed concern that civilian medical facilities  would not be able to meet the medical needs of their military personnel,  dependents, and beneficiaries during an influenza pandemic, either  because there may not be sufficient capacity in the civilian medical  facilities or civilian medical facilities may choose to treat their own  citizens ahead of these personnel. While COCOMs realistically cannot  reduce their reliance on civilian medical capabilities, at least one COCOM  has taken actions to mitigate the effect of the military’s reliance on civilian  medical care. EUCOM planning officials said they have invited host nation  officials to planning conferences and met with at least two medical  providers in Germany to coordinate efforts. However, the COCOMs do not  control the civilian medical system and, therefore, cannot allocate  resources or guarantee treatment for personnel in the civilian medical  system during an influenza pandemic. Without options to mitigate the  effects of DOD’s reliance on the civilian medical system, COCOMs’ risk  being unable to protect personnel and carry out their missions during an  influenza pandemic.
section_title: COCOMs Have Not Yet Developed Options to Mitigate the Effects of Reliance on Military Services for Medical Materiel
paragraphs: Planning officials from eight of the nine COCOMs expressed concern that  their headquarters are tenants on military services’ installations and,  therefore, are reliant on the military services to distribute medical materiel  and other supplies. This is a factor that has hindered the COCOMs’ ability  to fully address how their headquarters will receive medical materiel and  other supplies during an influenza pandemic. Medical and planning  officials at two COCOMs expressed concern with the variance among the  military services’ health-related policies and priorities. For example, the  officials said that each military service has a different doctrine or policy on  pandemic influenza-related health issues, such as the distribution of  vaccines, antivirals, and other drugs. Although guidance from the ASD for  Health Affairs is the same for all of the military services, it could be  applied differently among the military services. For example, medical and  planning officials from four of the COCOMs noted that the military  services would determine how vaccines and antivirals would be used  because these supplies would be provided through the military services.  This variance in policy implementation could lead to different  preparedness levels and limit the operational control COCOM  commanders have during a pandemic, which could impair the COCOMs’  ability to carry out their missions. At least two of the COCOMs—JFCOM  and STRATCOM—have taken steps to mitigate the impact of this issue by  participating in pandemic influenza planning efforts with the installation  where their headquarters are located, according to planning officials. The  reliance of COCOMs’ headquarters on the military services for plans,  decisions, and supplies and the COCOMs’ lack of plans to mitigate the  impact of that dependence could impact the COCOMs’ ability to maintain  their own operations and missions during an influenza pandemic.
section_title: Conclusions
paragraphs: The COCOMs have taken numerous actions to plan and prepare for an  influenza pandemic, and their efforts continue. However, the COCOMs  have faced some management challenges that have and will continue to  impair their ability to plan and prepare for an influenza pandemic in a  unified and cohesive manner. Planning in an environment of tremendous  uncertainty is an extremely difficult and daunting task, but the potential  impact of an influenza pandemic on DOD’s personnel and operations  makes sound planning all the more crucial. Additionally, preparing for a  pandemic can be helpful for preparing for and responding to other  disasters that may occur. While we recognize that DOD’s planning and  preparedness efforts departmentwide continue to evolve, failure to  address these challenges could affect DOD’s ability to protect its  personnel, maintain the military’s readiness, conduct ongoing operations  abroad, carry out day-to-day functions of the department, and provide civil  support at home and humanitarian assistance abroad during an influenza  pandemic. Clarifying what is expected of COCOMs and other  organizations within DOD in planning and preparing for an influenza  pandemic, what constitutes fulfillment of planning tasks, and the roles and  responsibilities of key organizations involved in DOD’s pandemic influenza  planning and preparedness efforts could help lessen the potential for  confusion among COCOM officials, limit gaps or duplication in DOD’s  efforts, and increase the likelihood that DOD will be prepared to  efficiently and effectively respond to an influenza pandemic. Additionally,  linking expectations to resources should help the COCOMs establish  appropriate priorities and accomplish the actions assigned to them from  the national implementation plan, as well as other planning and  preparedness activities. Finally, while the COCOMs cannot control certain  factors that have hindered their preparedness efforts, they can take  various steps to mitigate their effects on certain aspects of the COCOMs’  plans, including developing options to address these factors. Without  taking steps to address these challenges, DOD risks being insufficiently  prepared to respond in a unified manner to protect its personnel and  conduct its missions during an influenza pandemic.
section_title: Recommendations for Executive Action
paragraphs: To reduce the potential for confusion, gaps, and duplications in the  COCOMs’ pandemic influenza planning and preparedness efforts and  enhance the unity and cohesiveness of DOD’s efforts, we recommend that  the Secretary of Defense instruct the ASD(HD&ASA) to issue guidance  that specifies the following:    Which of the actions assigned to DOD in the Implementation Plan for  the National Strategy for Pandemic Influenza and other pandemic  influenza-related planning tasks apply to the individual COCOMs,  military services, and other organizations within DOD, as well as what  constitutes fulfillment of these actions.
NORTHCOM’s roles and responsibilities as global synchronizer relative  to the roles and responsibilities of the various organizations leading  and supporting the department’s pandemic influenza planning.
To increase the likelihood that the COCOMs can effectively continue their  pandemic influenza planning and preparedness activities, including  accomplishing actions assigned to DOD in the national implementation  plan within established time frames, we recommend that the Secretary of  Defense instruct the ASD(HD&ASA) to work with the Under Secretary of  Defense (Comptroller) to identify the sources and types of resources that  COCOMs need to accomplish their pandemic influenza planning and  preparedness activities.
To increase the likelihood that COCOMs are more fully prepared to  protect personnel and perform ongoing missions during an influenza  pandemic, we recommend that the Secretary of Defense instruct the Joint  Staff to work with the COCOMs to develop options to mitigate the effects  of factors that are beyond the COCOMs’ control, such as limited detailed  information from other federal agencies on the support expected from  DOD, lack of control over DOD’s antiviral stockpile, limited information  on decisions that other nations may make during an influenza pandemic,  reliance on civilian medical providers for medical care, and reliance on  military services for medical materiel.
section_title: Agency Comments and Our Evaluation
paragraphs: In written comments on a draft of this report, DOD concurred with all of  our recommendations and noted that the department is confident that  future plans will adequately address specific roles, resources, and risk  mitigation. DOD also provided us with technical comments, which we  incorporated in the report, as appropriate. DOD’s comments are included  in appendix III. We also provided the Department of State an opportunity  to comment on a draft of the report, but the department had no comments.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution of it until 30 days from  the date of this letter. We will then send copies of this report to the  Chairman and Ranking Member of the Senate and House Committees on  Appropriations, Subcommittees on Defense; Senate and House  Committees on Armed Services; Senate Committee on Homeland Security  and Governmental Affairs; House Committee on Homeland Security; and  other interested congressional parties. We are also sending copies of this  report to the Secretary of Defense; Secretary of State; Director, Office of  Management and Budget; Chairman of the Joint Chiefs of Staff;  Commanders of CENTCOM, EUCOM, JFCOM, NORTHCOM, PACOM,  SOCOM, SOUTHCOM, STRATCOM, and TRANSCOM; and the  Commander, U.S. Forces Korea. We will also provide copies to others  upon request. 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 questions concerning this report, please  contact me at (202) 512-5431 or by e-mail at dagostinod@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 contributions  to this report are listed in appendix IV.
section_title: Appendix I: Actions Assigned to DOD as a Lead Agency in the National Implementation Plan
paragraphs: DOD, in coordination with the Department of State and other  appropriate federal agencies, host nations, and regional alliance  military partners, shall, within 18 months: (1) conduct bilateral and  multilateral assessments of the avian and pandemic preparedness  and response plans of the militaries in partner nations or regional  alliances, such as NATO, focused on preparing for and mitigating  the effects of an outbreak on assigned mission accomplishment;  (2) develop solutions for identified national and regional military  gaps; and (3) develop and execute bilateral and multilateral  military-to-military influenza exercises to validate preparedness and  response plans.
Measure of performance: all countries with endemic avian influenza  engaged by U.S. efforts; initial assessment and identification of  exercise timeline for the military of each key partner nation  completed.
DOD, in coordination with the Department of State, host nations,  and regional alliance military partners, shall assist in developing  priority country military infection control and case management  capability through training programs, within 18 months.
Measure of performance: training programs carried out in all priority  countries with increased military infection control and case  management capability.
The Department of Health and Human Services and DOD, in  coordination with the Department of State, shall enhance open  source information sharing efforts with international organizations  and agencies to facilitate the characterization of genetic sequences  of circulating strains of novel influenza viruses within 12 months.
Measure of performance: publication of all reported novel influenza  viruses which are sequenced.
DOD shall develop active and passive systems for inpatient and  outpatient disease surveillance at its institutions worldwide, with an  emphasis on index case and cluster identification, and develop  mechanisms for utilizing DOD epidemiological investigation experts  in international support efforts, to include validation of  systems/tools and improved outpatient/inpatient surveillance  capabilities, within 18 months.
Measure of performance: monitoring system and program to utilize  epidemiological investigation experts internationally are in place.
DOD shall monitor the health of military forces worldwide (bases in  the continental United States and outside of the continental United  States, deployed operational forces, exercises, units, etc.), and in  coordination with the Department of State, coordinate with allied,  coalition, and host nation public health communities to investigate  and respond to confirmed infectious disease outbreaks on DOD  installations, within 18 months.
Measure of performance: medical surveillance “watchboard”  reports show results of routine monitoring, number of validated  outbreaks, and results of interventions.
DOD, in coordination with the Department of State and with the  cooperation of the host nation, shall assist with influenza  surveillance of host nation populations in accordance with existing  treaties and international agreements, within 24 months.
Measure of performance: medical surveillance “watchboard”  expanded to include host nations.
DOD, in coordination with the Department of Health and Human  Services, shall develop and refine its overseas virologic and  bacteriologic surveillance infrastructure through Global Emerging  Infections Surveillance and Response System and the DOD  network of overseas labs, including fully developing and  implementing seasonal influenza laboratory surveillance and an  animal/vector surveillance plan linked with World Health  Organization (WHO) pandemic phases, within 18 months.
Measure of performance: animal/vector surveillance plan and DOD  overseas virologic surveillance network developed and functional.
DOD, in coordination with the Department of Health and Human  Services, shall prioritize international DOD laboratory research  efforts to develop, refine, and validate diagnostic methods to  rapidly identify pathogens, within 18 months.
Measure of performance: 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  existing laboratory capacity, rapid response teams, and portable  field assay testing equipment, and fund essential commodities and  training necessary to achieve an effective national military  diagnostic capability, within 18 months.
Measure of performance: assessments completed, proposals  accepted, and funding made available to priority countries.
DOD shall incorporate international public health reporting  requirements for exposed or ill military international travelers into  the geographic combatant commanders’ pandemic influenza plans  within 18 months.
Measure of performance: reporting requirements incorporated into  geographic combatant commanders’ pandemic influenza plans.
DOD, in coordination with the Department of State, the Department  of Health and Human Services, the Department of Transportation,  and the Department of Homeland Security, shall limit official DOD  military travel between affected areas and the United States.
Measure of performance: DOD identifies military facilities in the  United States and outside of the continental United States that will  serve as the points of entry for all official travelers from affected  areas, within 6 months.
DOD, in coordination with the Department of Homeland Security,  the Department of Transportation, the Department of Justice, and  the Department of State, shall conduct an assessment of military  support related to transportation and borders that may be  requested during a pandemic and develop a comprehensive  contingency plan for Defense Support of Civil Authorities, within 18  months.
Measure of performance: Defense Support of Civil Authorities plan  in place that addresses emergency transportation and border  support.
DOD, in coordination with the Department of Homeland Security  and the Department of State, shall identify those domestic and  foreign airports and seaports that are considered strategic  junctures for major military deployments and evaluate whether  additional risk-based protective measures are needed, within 18  months.
Measure of performance: identification of critical air and seaports  and evaluation of additional risk-based procedures, completed.
DOD, when directed by the Secretary of Defense and in  accordance with law, shall monitor and report the status of the  military transportation system and those military assets that may be  requested to protect the borders, assess impacts (to include  operational impacts), and coordinate military services in support of  federal agencies and state, local, and tribal entities.
Measure of performance: when DOD activated, regular reports  provided, impacts assessed, and services coordinated as needed.
DOD, as part of its departmental implementation plan, shall  conduct a medical materiel requirements gap analysis and procure  necessary materiel to enhance Military Health System surge  capacity, within 18 months.
Measure of performance: gap analysis completed and necessary  materiel procured.
The Department of Health and Human Services, DOD, the  Department of Veterans Affairs, and the states shall maintain  antiviral and vaccine stockpiles in a manner consistent with the  requirements of the Food and Drug Administration’s Shelf Life  Extension Program and explore the possibility of broadening the  Shelf Life Extension Program to include equivalently maintained  state stockpiles, within 6 months.
Measure of performance: compliance with the Shelf Life Extension  Program requirements documented; decision made on broadening  the Shelf Life Extension Program to state stockpiles.
DOD shall establish stockpiles of vaccine against H5N1 and other  influenza subtypes determined to represent a pandemic threat  adequate to immunize approximately 1.35 million persons for  military use within 18 months of availability.
Measure of performance: sufficient vaccine against each influenza  virus determined to represent a pandemic threat in DOD stockpile  to vaccinate 1.35 million persons.
DOD shall procure 2.4 million treatment courses of antiviral  medications and position them at locations worldwide within 18  months. Measure of performance: aggregate 2.4 million treatment  courses of antiviral medications in DOD stockpiles.
DOD shall supply military units and posts, installations, bases, and  stations with vaccine and antiviral medications according to the  schedule of priorities listed in the DOD pandemic influenza policy  and planning guidance, within 18 months.
Measure of performance: vaccine and antiviral medications  procured; DOD policy guidance developed on use and release of  vaccine and antiviral medications; and worldwide distribution drill  completed.
DOD shall enhance influenza surveillance efforts within 6 months  by: (1) ensuring that medical treatment facilities monitor the  Electronic Surveillance System for Early Notification of Community- based Epidemics and provide additional information on suspected  or confirmed cases of pandemic influenza through their service  surveillance activities; (2) ensuring that Public Health Emergency  Officers report all suspected or actual cases through appropriate  DOD reporting channels, as well as to the Centers for Disease  Control and Prevention, state public health authorities, and host  nations; and (3) posting results of aggregated surveillance on the  DOD Pandemic Influenza Watchboard; all within 18 months.
Measure of performance: number of medical treatment facilities  performing Electronic Surveillance System for Early Notification of  Community-based Epidemics surveillance greater than 80 percent;  DOD reporting policy for public health emergencies, including  pandemic influenza, completed.
Department of Health and Human Services-, DOD-, and  Department of Veterans Affairs-funded hospitals and health  facilities shall have access to improved rapid diagnostic tests for  influenza A, including influenza with pandemic potential, within 6  months of when tests become available.
DOD and the Department of Veterans Affairs shall be prepared to  track and provide personnel and beneficiary health statistics and  develop enhanced methods to aggregate and analyze data  documenting influenza-like illness from their surveillance systems  within 12 months.
Measure of performance: influenza tracking systems in place and  capturing beneficiary clinical encounters.
As appropriate, DOD, in consultation with its combatant  commanders, shall implement movement restrictions and individual  protection and social distancing strategies (including unit shielding,  ship sortie, cancellation of public gatherings, drill, training, etc.)  within its posts, installations, bases, and stations. DOD personnel  and beneficiaries living off-base should comply with local  community containment guidance with respect to activities not  directly related to the installation. DOD shall be prepared to initiate  within 18 months.
Measure of performance: the policies/procedures are in place for  at-risk DOD posts, installations, bases, stations, and for units to  conduct an annual training evaluation that includes restriction of  movement, shielding, personnel protection measures, health unit  isolation, and other measures necessary to prevent influenza  transmission.
All Department of Health and Human Services-, DOD-, and  Department of Veterans Affairs-funded hospitals and health  facilities shall develop, test, and be prepared to implement infection  control campaigns for pandemic influenza, within 3 months.
Measure of performance: guidance materials on infection control  developed and disseminated on www.pandemicflu.gov and through  other channels.
DOD shall enhance its public health response capabilities by: (1)  continuing to assign epidemiologists and preventive medicine  physicians within key operational settings; (2) expanding ongoing  DOD participation in the Centers for Disease Control and  Prevention’s Epidemic Intelligence Service program; and (3) within  18 months, fielding specific training programs for Public Health  Emergency Officers that address their roles and responsibilities  during a public health emergency.
Measure of performance: all military Public Health Emergency  Officers fully trained within 18 months; increase military trainees in  the Centers for Disease Control and Prevention’s Epidemic  Intelligence Service program by 100 percent within 5 years.
DOD and Department of Veterans Affairs assets and capabilities  shall be postured to provide care for military personnel and eligible  civilians, contractors, dependants, other beneficiaries, and veterans  and shall be prepared to augment the medical response of state,  territorial, tribal, or local governments and other federal agencies  consistent with their Emergency Support Function #8—Public  Health and Medical Services support roles, within 3 months.
Measure of performance: DOD and Department of Veterans Affairs’  pandemic preparedness plans developed; in a pandemic, adequate  health response provided to military and associated personnel.
DOD shall develop and implement guidelines defining conditions  under which Reserve Component medical personnel providing  health care in nonmilitary health care facilities should be mobilized  and deployed, within 18 months.
Measure of performance: guidelines developed and implemented.
DOD and the Department of Veterans Affairs, in coordination with  the Department of Health and Human Services, shall develop and  disseminate educational materials, coordinated with and  complementary to messages developed by the Department of  Health and Human Services but tailored for their respective  departments, within 6 months.
Measure of performance: up-to-date risk communication material  published on DOD and  Department of Veterans Affairs pandemic influenza Web sites,  Department of Health and Human Services Web site  www.pandemicflu.gov, and in other venues.
DOD, in consultation with the Department of Justice and the  National Guard Bureau, and in coordination with the states as such  training applies to support state law enforcement, shall assess the  training needs for National Guard forces in providing operational  assistance to state law enforcement under either federal (Title 10)  or state (Title 32 or State Active Duty) in a pandemic influenza  outbreak and provide appropriate training guidance to the states  and territories for units and personnel who will be tasked to provide  this support, within 18 months.
Measure of performance: guidance provided to all states.
DOD, in consultation with the Department of Justice, shall advise  state governors of the procedures for requesting military equipment  and facilities, training, and maintenance support as authorized by  10 U.S.C. §§ 372-74, within 6 months.
Measure of performance: all state governors advised.
The Department of Justice, the Department of Homeland Security,  and DOD shall engage in contingency planning and related  exercises to ensure they are prepared to maintain essential  operations and conduct missions, as permitted by law, in support of  quarantine enforcement and/or assist state, local, and tribal entities  in law enforcement emergencies that may arise in the course of an  outbreak, within 6 months.
Measure of performance: completed plans (validated by  exercise) for supporting quarantine enforcement and/or law  enforcement emergencies.
section_title: Appendix II: Scope and Methodology
paragraphs: To determine the actions the combatant commands (COCOM) have taken  to date to prepare for an influenza pandemic, we reviewed drafts of the  five geographic COCOMs’ plans and one functional COCOM’s plan that  were available at the time of our review. We did not evaluate these plans;  rather we used the plans to determine what actions the COCOMs have  taken and plan to take to prepare for an influenza pandemic. Additionally  we reviewed planning orders issued by the Joint Staff to the COCOMs in  November 2005 and April 2007, DOD’s implementation plan for pandemic  influenza issued in August 2006, the Implementation Plan for the  National Strategy for Pandemic Influenza issued by the Homeland  Security Council in May 2006, DOD’s budget requests for fiscal years 2007  and 2008 and appropriations for fiscal year 2007, and after-action reports  from exercises related to pandemic influenza. Furthermore, we met with  more than 200 officials involved in pandemic influenza planning and  preparedness efforts at the nine COCOMs, including operational, medical,  logistics, and continuity of operations planners; budget analysts;  intelligence analysts and planners; public affairs professionals;  humanitarian assistance liaisons; and representatives from the office of  the command surgeon, including officials involved in force health  protection activities. To better understand the extent of the COCOMs’  efforts to plan and prepare for an influenza pandemic, we met with  officials or, in one case, received written responses to our questions from  the following COCOMs and their subcomponents:    Headquarters, U.S. Central Command, MacDill Air Force Base, Florida;    Headquarters, U.S. European Command, Patch Barracks, Germany;    Marine Forces Europe, Patch Barracks, Germany;    Naval Forces Europe, Patch Barracks, Germany;    Special Operations Command Europe, Patch Barracks, Germany;    U.S. Air Forces Europe, Ramstein Air Base, Germany;    U.S. Army Europe, Campbell Barracks, Germany;  Installation Management Command Europe, Campbell Barracks,  Germany;    European Regional Medical Command, Campbell Barracks,    U.S. Army Medical Materiel Command Europe, Pirmasens,    Headquarters, U.S. Joint Forces Command, Norfolk, Virginia;    Headquarters, U.S. Northern Command, Peterson Air Force Base,    Headquarters, U.S. Pacific Command, Camp H.M. Smith, Hawaii;    Marine Forces Pacific, Camp H.M. Smith, Hawaii;    Pacific Air Force, Hickam Air Force Base, Hawaii;    Pacific Fleet, Naval Station Pearl Harbor, Hawaii;    Special Operations Command Pacific, Camp H.M. Smith, Hawaii;    U.S. Army Pacific, Fort Shafter, Hawaii;    U.S. Forces Korea, Yongsan Army Garrison, South Korea;    U.S. Naval Forces Korea, Yongsan Army Garrison, South Korea;    7th Air Force, Osan Air Base, South Korea;    18th Medical Command, Yongsan Army Garrison, South Korea;  Installation Management Command Korea Regional Office,  Yongsan Army Garrison, South Korea;  Installation Management Command Pacific, Fort Shafter, Hawaii;    Tripler Army Medical Center, Hawaii;    Headquarters, U.S. Southern Command, Miami, Florida;    Headquarters, U.S. Special Operations Command, MacDill Air Force    Headquarters, U.S. Strategic Command, Offutt Air Force Base,    Headquarters, U.S. Transportation Command, Scott Air Force Base,  We elected to meet with officials from the military service and special  operations subcomponents at the U.S. European Command and U.S.  Pacific Command because these two commands have had to address  outbreaks of H5N1 avian influenza in their areas of responsibility. We  selected U.S. Forces Korea because of the number of cases of H5N1 avian  influenza in South Korea and the large number of U.S. military personnel  stationed in U.S. Forces Korea’s area of responsibility. Furthermore, to  better understand how the COCOMs’ planning and preparedness efforts  relate to DOD’s departmentwide planning efforts, we met in the  Washington, D.C., area with officials from the Office of the Assistant  Secretary of Defense for Homeland Defense and Americas’ Security  Affairs, Office of the Assistant Secretary of Defense for Health Affairs, and  Joint Staff. We also met with officials from the Department of State to  better understand their pandemic influenza planning and preparedness  efforts, as they relate to the COCOMs’ efforts. We did not assess the efforts  of the individual installations to prepare for an influenza pandemic or  whether installations’ implementation plans supported the COCOM or  military services’ plans because many installations had not yet completed  their implementation plans and because our focus for this report was on  the COCOM-level planning and preparedness efforts.
To determine management challenges that COCOMs face as they continue  their planning efforts, we compared the COCOMs’ actions to date to best  practices that we have identified in our prior work. Specifically, we  reviewed our previous work on risk management, influenza pandemics,  emergency preparedness, and overall management to determine whether  other issues or lessons learned addressed in these reports were applicable  to the COCOMs’ pandemic influenza planning and preparedness efforts.  This work is referenced in the list of Related GAO Products at the end of  this report.
We conducted our review from September 2006 through April 2007 in  accordance with generally accepted government auditing standards.
section_title: Appendix III: Comments from the Department of Defense
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: Mark A. Pross, Assistant Director; Susan Ditto; Nicole Gore; Simon  Hirschfeld; Aaron Johnson; and Hilary Murrish made key contributions to  this report.
section_title: Related GAO Products
paragraphs: 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-07-835T. Washington,  D.C.: May 15, 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.
Homeland Security: Applying Risk Management Principles to Guide  Federal Investments. GAO-07-386T. Washington, D.C.: February 7, 2007.
Influenza Pandemic: DOD Has Taken Important Actions to Prepare, but  Accountability, Funding, and Communications Need to be Clearer and  Focused Departmentwide. GAO-06-1042. Washington, D.C.: September 21,  2006.
Hurricane Katrina: Better Plans and Exercises Need to Guide the  Military’s Response to Catastrophic Natural Disasters. GAO-06-808T.  Washington, D.C.: May 25, 2006.
Hurricane Katrina: Better Plans and Exercises Needed to Guide the  Military’s Response to Catastrophic Natural Disasters. GAO-06-643.  Washington, D.C.: May 15, 2006.
Continuity of Operations: Agencies Could Improve Planning for  Telework during Disruptions. GAO-06-740T. Washington, D.C.: May 11,  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.
Influenza Pandemic: Challenges Remain in Preparedness. GAO-05-760T.  Washington, D.C.: May 26, 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.
Emerging Infectious Diseases: Asian SARS Outbreak Challenged  International and National Responses. GAO-04-564. Washington, D.C.:  April 28, 2004.
Public Health Preparedness: Response Capacity Improving but Much  Remains to Be Accomplished. GAO-04-458T. Washington, D.C.: February  12, 2004.
HHS Bioterrorism Preparedness Programs: States Reported Progress but  Fell Short of Program Goals for 2002. GAO-04-360R. Washington, D.C.:  February 10, 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.
Severe Acute Respiratory Syndrome: Established Infectious Disease  Control Measures Helped Contain Spread, But a Large-Scale Resurgence  May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003.
SARS Outbreak: Improvements to Public Health Capacity Are Needed for  Responding to Bioterrorism and Emerging Infectious Diseases.   GAO-03-769T. Washington, D.C.: May 7, 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.
Flu Vaccine: Steps Are Needed to Better Prepare for Possible Future  Shortages. GAO-01-786T. Washington, D.C.: May 30, 2001.
Flu Vaccine: Supply Problems Heighten Need to Ensure Access for High- Risk People. GAO-01-624. Washington, D.C.: May 15, 2001.
Influenza Pandemic: Plan Needed for Federal and State Response.   GAO-01-4. Washington, D.C.: October 27, 2000.
Global Health: Framework for Infectious Disease Surveillance.  GAO/NSIAD-00-205R. Washington, D.C.: July 20, 2000.