Influenza Pandemic: Continued Focus on the Nation's Planning and Preparedness Efforts Remains Essential
Published: 2009-06-03T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: As the recent outbreak of the H1N1 (swine flu) virus underscores, an influenza pandemic remains a real threat to our nation and to the world. Over the past 3 years, GAO has conducted a body of work to help the nation better prepare for a possible pandemic. In a February 2009 report, GAO synthesized the results of this work, pointing out that while the previous administration had taken a number of actions to plan for a pandemic, including developing a national strategy and implementation plan, much more needs to be done, and many gaps in preparedness and planning still remain. This statement is based on the February 2009 report which synthesized the results of 11 reports and two testimonies covering six thematic areas: (1) leadership, authority, and coordination; (2) detecting threats and managing risks; (3) planning, training, and exercising, (4) capacity to respond and recover; (5) information sharing and communication; and (6) performance and accountability.
section_title: What GAO Found
paragraphs: (1) Leadership roles and responsibilities for an influenza pandemic need to be clarified, tested, and exercised, and existing coordination mechanisms, such as critical infrastructure coordinating councils, could be better utilized to address challenges in coordination between the federal, state, and local governments and the private sector in preparing for a pandemic. (2) Efforts are underway to improve the surveillance and detection of pandemic-related threats in humans and animals, but targeting assistance to countries at the greatest risk has been based on incomplete information, particularly from developing countries. (3) Pandemic planning and exercising has occurred at the federal, state, and local government levels, but important planning gaps remain at all levels of government. (4) Further actions are needed to address the capacity to respond to and recover from an influenza pandemic, which will require additional capacity in patient treatment space, and the acquisition and distribution of medical and other critical supplies, such as antivirals and vaccines. (5) Federal agencies have provided considerable guidance and pandemic-related information to state and local governments, but could augment their efforts with additional information on state border closures and other topics. (6) Performance monitoring and accountability for pandemic preparedness needs strengthening. For example, the May 2006 National Strategy for Pandemic Influenza Implementation Plan does not establish priorities among its 324 action items and does not provide information on the financial resources needed to implement them. The recent outbreak of the H1N1 influenza virus should serve as a powerful reminder that the threat of a pandemic influenza, which seemed to fade from public awareness in recent years, never really disappeared. While federal agencies have taken action on 13 of GAO's 23 recommendations, 10 of the recommendations that GAO has made over the past 3 years are still not fully implemented. With the possibility that the H1N1 virus could return in a more virulent form in a second wave in the fall or winter, the administration and federal agencies should turn their attention to filling in the planning and preparedness gaps GAO's work has pointed out.

section_title: Letter
paragraphs: I am pleased to be here today to discuss key themes from the body of  work GAO has developed over the past several years to help the nation  better prepare for, respond to, and recover from a possible influenza  pandemic. An influenza pandemic remains a real threat to our nation and  to the world, as we are witnessing during the current outbreak of the  H1N1 (swine flu) virus. The previous administration took a number of  actions to plan for a pandemic, including developing a national strategy  and implementation plan. However, much more needs to be done, and  many gaps in preparedness and planning still remain. At the same time,  national priorities have been shifting as a global pandemic has yet to  occur, and the nation’s financial crisis and other national issues have  become more immediate and pressing. Strengthening preparedness for  large-scale public health emergencies, such as an influenza pandemic, is  one of 13 urgent issues that we identified earlier this year as among those  needing the immediate attention of the new administration and Congress.
In the past 3 years, GAO has issued 11 reports and two testimonies on  influenza pandemic planning. We synthesized the results of this work in a  February 2009 report, which I will discuss in more detail today. We have  made 23 recommendations based on the findings from these reports and  testimonies, thirteen of which have been acted upon by the responsible  federal agencies. While the responsible federal agencies have generally  agreed with our recommendations and some actions are underway to  address them, 10 recommendations have not yet been fully implemented.  While our February 2009 report made no new recommendations, we  updated the status of recommendations that had not yet been  implemented as of February 2009. Many of the recommendations that  remain unimplemented have become even more pressing in light of the  very real possibility of a more serious return of the H1N1 virus later this  year. Lists of our open recommendations and related GAO products that  are referenced throughout this statement are located in attachments I and  II.
In summary, my statement will address the following issues which were  drawn from the key themes of GAO’s pandemic work:    Leadership roles and responsibilities for an influenza pandemic need  to be clarified, tested, and exercised, and existing coordination  mechanisms, such as critical infrastructure coordinating councils,  could be better utilized to address challenges in coordination between  the federal, state, and local governments and the private sector in  preparing for a pandemic.
Efforts are underway to improve the surveillance and detection of  pandemic-related threats in humans and animals, but targeting  assistance to countries at the greatest risk has been based on  incomplete information, particularly from developing countries.
Pandemic planning and exercising has occurred at the federal, state,  and local government levels, but important planning gaps remain at all  levels of government.
Further actions are needed to address the capacity to respond to and  recover from an influenza pandemic, which will require additional  capacity in patient treatment space, and the acquisition and  distribution of medical and other critical supplies, such as antivirals  and vaccines.
Federal agencies have provided considerable guidance and pandemic- related information to state and local governments, but could augment  their efforts with additional information on state border closures and  other topics.
Performance monitoring and accountability for pandemic  preparedness needs strengthening. For example, the May 2006  National Strategy for Pandemic Influenza Implementation Plan  (National Pandemic Implementation Plan) does not establish priorities  among its 324 action items and does not provide information on the  financial resources needed to implement them.
This statement is largely based on our prior work, which was conducted in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
subsections: section_title: Background
paragraphs: Given the consequences of a severe influenza pandemic, in 2006 GAO  developed a strategy for our work that would help support Congress’s  decision making and oversight related to pandemic planning. Our strategy  was built on a large body of work spanning two decades, including reviews  of government responses to prior disasters such as Hurricanes Andrew  and Katrina, the devastation caused by the 9/11 terror attacks, efforts to  address the Year 2000 (Y2K) computer challenges, and assessments of  public health capacities in the face of bioterrorism and emerging  infectious diseases such as Severe Acute Respiratory Syndrome (SARS).  The strategy was built around six key themes, as shown in figure 1. While  all of these themes are interrelated, our earlier work underscored the  importance of leadership, authority, and coordination, a theme that  touches on all aspects of preparing for, responding to, and recovering from  an influenza pandemic.
Influenza pandemic—caused by a novel strain of influenza virus for which  there is little resistance and which therefore is highly transmissible among  humans—continues to be a real and significant threat facing the United  States and the world. Unlike incidents that are discretely bounded in space  or time (e.g., most natural or man-made disasters), an influenza pandemic  is not a singular event, but is likely to come in waves, each lasting weeks  or months, and pass through communities of all sizes across the nation  and the world simultaneously. While the current H1N1 outbreak seems to  have been relatively mild, the history of an influenza pandemic suggests it  could return in a second wave this fall or winter in a more virulent form.  While a pandemic will not directly damage physical infrastructure such as  power lines or computer systems, it threatens the operation of critical  systems by potentially removing the essential personnel needed to operate  them from the workplace for weeks or months. In a severe pandemic,  absences attributable to illnesses, the need to care for ill family members,  and fear of infection may, according to the Centers for Disease Control  and Prevention (CDC), reach a projected 40 percent during the peak  weeks of a community outbreak, with lower rates of absence during the  weeks before and after the peak. In addition, an influenza pandemic could  result in 200,000 to 2 million deaths in the United States, depending on its  severity.
The Homeland Security Council (HSC) took an active approach to this  potential disaster by, among other things, issuing the National Strategy  for Pandemic Influenza (National Pandemic Strategy) in November 2005,  and the National Pandemic Implementation Plan in May 2006. The  National Pandemic Strategy is intended to provide a high-level overview of  the approach that the federal government will take to prepare for and  respond to an influenza pandemic. It also provides expectations for  nonfederal entities—including state, local, and tribal governments; the  private sector; international partners; and individuals—to prepare  themselves and their communities. The National Pandemic  Implementation Plan is intended to lay out broad implementation  requirements and responsibilities among the appropriate federal agencies  and clearly define expectations for nonfederal entities. The plan contains  324 action items related to these requirements, responsibilities, and  expectations, most of which were to be completed before or by May 2009.  HSC publicly reported on the status of the action items that were to be  completed by 6 months, 1 year, and 2 years in December 2006, July 2007,  and October 2008, respectively. HSC indicated in its October 2008 progress  report that 75 percent of the action items have been completed. At the  request of the House Homeland Security Committee, we have ongoing  work assessing the status of implementing this plan.
section_title: Leadership Roles and Responsibilities Need to Be Clarified and Tested, and Coordination Mechanisms Could Be Better Utilized
paragraphs: Federal government leadership roles and responsibilities for pandemic  preparedness and response are evolving, and will require further testing  before the relationships among the many federal leadership positions are  well understood. Such clarity in leadership is even more crucial now, given  the change in administration and the associated transition of senior  federal officials. Most of these federal leadership roles involve shared  responsibilities between the Department of Health and Human Services  (HHS) and the Department of Homeland Security (DHS), and it is not clear  how these would work in practice. According to the National Pandemic  Strategy and Plan, the Secretary of HHS is to lead the federal medical  response to a pandemic, and the Secretary of Homeland Security will lead  the overall domestic incident management and federal coordination. In  addition, under the Post-Katrina Emergency Management Reform Act of  2006, the Administrator of the Federal Emergency Management Agency  (FEMA) was designated as the principal domestic emergency management  advisor to the President, the HSC, and the Secretary of Homeland Security,  adding further complexity to the leadership structure in the case of a  pandemic. To assist in planning and coordinating efforts to respond to a  pandemic, in December 2006 the Secretary of Homeland Security  predesignated a national Principal Federal Official (PFO) for influenza  pandemic and established five pandemic regions each with a regional PFO  and Federal Coordinating Officers (FCO) for influenza pandemic. PFOs  are responsible for facilitating federal domestic incident planning and  coordination, and FCOs are responsible for coordinating federal resources  support in a presidentially-declared major disaster or emergency.
However, the relationship of these roles to each other as well as with other  leadership roles in a pandemic is unclear. Moreover, as we testified in July  2007, state and local first responders were still uncertain about the need  for both FCOs and PFOs and how they would work together in disaster  response. Accordingly, we recommended in our August 2007 report on  federal leadership roles and the National Pandemic Strategy that DHS and  HHS develop rigorous testing, training, and exercises for influenza  pandemic to ensure that federal leadership roles and responsibilities for a  pandemic are clearly defined and understood and that leaders are able to  effectively execute shared responsibilities to address emerging  challenges. In response to our recommendation, HHS and DHS officials  stated in January 2009 that several influenza pandemic exercises had been  conducted since November 2007 that involved both agencies and other  federal officials, but it is unclear whether these exercises rigorously tested  federal leadership roles in a pandemic.
In addition to concerns about clarifying federal roles and responsibilities  for a pandemic and how shared leadership roles would work in practice,  private sector officials told us that they are unclear about the respective  roles and responsibilities of the federal and state governments during a  pandemic emergency. The National Pandemic Implementation Plan states  that in the event of an influenza pandemic, the distributed nature and  sheer burden of the disease across the nation would mean that the federal  government’s support to any particular community is likely to be limited,  with the primary response to a pandemic coming from states and local  communities. Further, federal and private sector representatives we  interviewed at the time of our October 2007 report identified several key  challenges they face in coordinating federal and private sector efforts to  protect the nation’s critical infrastructure in the event of an influenza  pandemic. One of these was a lack of clarity about the roles and  responsibilities of federal and state governments on issues such as state  border closures and influenza pandemic vaccine distribution.
Coordination Mechanisms  Mechanisms and networks for collaboration and coordination on  pandemic preparedness between federal and state governments and the  private sector exist, but they could be better utilized. In some instances,  the federal and private sectors are working together through a set of  coordinating councils, including sector-specific and cross-sector councils.  To help protect the nation’s critical infrastructure, DHS created these  coordinating councils as the primary means of coordinating government  and private sector efforts for industry sectors such as energy, food and  agriculture, telecommunications, transportation, and water. Our October  2007 report found that DHS has used these critical infrastructure  coordinating councils primarily to share pandemic information across  sectors and government levels rather than to address many of the  challenges identified by sector representatives, such as clarifying the roles  and responsibilities between federal and state governments. We  recommended in the October 2007 report that DHS encourage the councils  to consider and address the range of coordination challenges in a potential  influenza pandemic between the public and private sectors for critical  infrastructure. DHS concurred with our recommendation and DHS  officials informed us at the time of our February 2009 report that the  department was working on initiatives to address it, such as developing  pandemic contingency plan guidance tailored to each of the critical  infrastructure sectors, and holding a series of “webinars” with a number of  the sectors.
Federal executive boards (FEB) bring together federal agency and  community leaders in major metropolitan areas outside of Washington,  D.C., to discuss issues of common interest, including an influenza  pandemic. The Office of Personnel Management (OPM), which provides  direction to the FEBs, and the FEBs have designated emergency  preparedness, security, and safety as an FEB core function. The FEBs’  emergency support role with its regional focus may make the boards a  valuable asset in pandemic preparedness and response. As a natural  outgrowth of their general civic activities and through activities such as  hosting emergency preparedness training, some of the boards have  established relationships with, for example, federal, state, and local  governments; emergency management officials; first responders; and  health officials in their communities. In a May 2007 report on the FEBs’  ability to contribute to emergency operations, we found that many of the  selected FEBs included in our review were building capacity for influenza  pandemic response within their member agencies and community  organizations by hosting influenza pandemic training and exercises. We  recommended that, since FEBs are well positioned within local  communities to bring together federal agency and community leaders, the  Director of OPM work with FEMA to formally define the FEBs’ role in  emergency planning and response. As a result of our recommendation,  FEBs were included in the National Response Framework (NRF) in  January 2008 as one of the regional support structures that have the  potential to contribute to development of situational awareness during an  emergency. OPM and FEMA also signed a memorandum of understanding  in August 2008 in which FEBs and FEMA agreed to work collaboratively in  carrying out their respective roles in the promotion of the national  emergency response system.
section_title: Efforts Are Underway to Improve the Surveillance and Detection of Pandemic-Related Threats in Humans and Animals, but Targeting Assistance to Countries at the Greatest Risk Has Been Based on Incomplete Information
paragraphs: International disease surveillance and detection efforts serve as an early  warning system that could prevent the spread of an influenza pandemic  outbreak. The United States and its international partners are involved in  efforts to improve pandemic surveillance, including diagnostic  capabilities, so that outbreaks can be quickly detected. Yet, as reported in  2007, international capacity for surveillance has many weaknesses,  particularly in developing countries. As a result, assessments of the risks  of the emergence of an influenza pandemic by U.S. agencies and  international organizations, which were used to target assistance to  countries at risk, were based on insufficiently detailed or incomplete  information, limiting their value for comprehensive comparisons of risk  levels by country.
section_title: Pandemic Planning and Exercising Has Occurred, but Planning Gaps Remain
paragraphs: While the National Pandemic Strategy and National Pandemic  Implementation Plan are important first steps in guiding national  preparedness, important gaps exist that could hinder the ability of key  stakeholders to effectively execute their responsibilities. In our August  2007 report on the National Pandemic Strategy and Implementation Plan,  we found that while these documents are an important first step in guiding  national preparedness, they do not fully address all six characteristics of  an effective national strategy, as identified in our work. The documents  fully address only one of the six characteristics, by reflecting a clear  description and understanding of problems to be addressed. Further, the  National Pandemic Strategy and Implementation Plan do not address one  characteristic at all; they contain no discussion of what it will cost, where  resources will be targeted to achieve the maximum benefits, and how  benefits, risks, and costs will be balanced. Moreover, the documents do  not provide a picture of priorities or how adjustments might be made in  view of resource constraints. Although the remaining four characteristics  are partially addressed, important gaps exist that could hinder the ability  of key stakeholders to effectively execute their responsibilities. For  example, state and local jurisdictions that will play crucial roles in  preparing for and responding to a pandemic were not directly involved in  developing the National Pandemic Implementation Plan, even though it  relies on these stakeholders’ efforts. Stakeholder involvement during the  planning process is important to ensure that the federal government’s and  nonfederal entities’ responsibilities are clearly understood and agreed  upon. Further, relationships and priorities among actions were not clearly  described, performance measures were not always linked to results, and  insufficient information was provided about how the documents are  integrated with other response-related plans, such as the NRF. We  recommended that HSC establish a process for updating the National  Pandemic Implementation Plan and that the updated plan should address  these and other gaps. HSC did not comment on our recommendation and  has not indicated if it plans to implement it.
subsections: section_title: State and Local Pandemic Planning
paragraphs: We reported in June 2008 that, according to CDC, all 50 states and the  three localities that received federal pandemic funds have developed  influenza pandemic plans and conducted pandemic exercises in  accordance with federal funding guidance. A portion of the $5.62 billion  that Congress appropriated in supplemental funding to HHS for pandemic  preparedness in 2006—$600 million—was allocated for state and local  planning and exercising. All of the 10 localities that we reviewed in depth  had also developed plans and conducted exercises, and had incorporated  lessons learned from pandemic exercises into their planning. However,  an HHS-led interagency assessment of states’ plans found on average that  states had “many major gaps” in their influenza pandemic plans in 16 of 22  priority areas, such as school closure policies and community  containment, which are community-level interventions designed to reduce  the transmission of a pandemic virus. The remaining six priority areas  were rated as having “a few major gaps.” Subsequently, HHS led another  interagency assessment of state influenza pandemic plans and reported in  January 2009 that although they had made important progress, most states  still had major gaps in their pandemic plans.
As we had reported in June 2008, HHS, in coordination with DHS and  other federal agencies, had convened a series of regional workshops for  states in five influenza pandemic regions across the country. Because  these workshops could be a useful model for sharing information and  building relationships, we recommended that HHS and DHS, in  coordination with other federal agencies, convene additional meetings  with states to address the gaps in the states’ pandemic plans. As reported  in February 2009, HHS and DHS generally concurred with our  recommendation, but have not yet held these additional meetings. HHS  and DHS indicated at the time of our February 2009 report that while no  additional meetings had been planned, states will have to continuously  update their pandemic plans and submit them for review.
We have also reported on the need for more guidance from the federal  government to help states and localities in their planning. In June 2008, we  reported that although the federal government has provided a variety of  guidance, officials of the states and localities we reviewed told us that they  would welcome additional guidance from the federal government in a  number of areas, such as community containment, to help them to better  plan and exercise for an influenza pandemic. Other state and local officials  have identified similar concerns. According to the National Governors  Association’s (NGA) September 2008 issue brief on states’ pandemic  preparedness, states are concerned about a wide range of school-related  issues, including when to close schools or dismiss students, how to  maintain curriculum continuity during closures, and how to identify the  appropriate time at which classes could resume. NGA also reported that  states generally have very little awareness of the status of disease  outbreaks, either in real time or in near real time, to allow them to know  precisely when to recommend a school closure or reopening in a  particular area. NGA reported that states wanted more guidance in the  following areas: (1) workforce policies for the health care, public safety,  and private sectors; (2) schools; (3) situational awareness such as  information on the arrival or departure of a disease in a particular state,  county, or community; (4) public involvement; and (5) public-private  sector engagement.
section_title: Private Sector Pandemic Planning
paragraphs: The private sector has also been planning for an influenza pandemic, but  many challenges remain. To better protect critical infrastructure, federal  agencies and the private sector have worked together across a number of  sectors to plan for a pandemic, including developing general pandemic  preparedness guidance, such as checklists for continuity of business  operations during a pandemic. However, federal and private sector  representatives have acknowledged that sustaining preparedness and  readiness efforts for an influenza pandemic is a major challenge, primarily  because of the uncertainty associated with a pandemic, limited financial  and human resources, and the need to balance pandemic preparedness  with other, more immediate, priorities, such as responding to outbreaks of  foodborne illnesses in the food sector and, now, the effects of the financial  crisis.
In our March 2007 report on preparedness for an influenza pandemic in  one of these critical infrastructure sectors—financial markets—we found  that despite significant progress in preparing markets to withstand  potential disease pandemics, securities and banking regulators could take  additional steps to improve the readiness of the securities markets. The  seven organizations that we reviewed—which included exchanges,  clearing organizations, and payment-system processors—were working on  planning and preparation efforts to reduce the likelihood that a worldwide  influenza pandemic would disrupt their critical operations. However, only  one of the seven had completed a formal plan. To increase the likelihood  that the securities markets will be able to function during a pandemic, we  recommended that the Chairman, Federal Reserve; the Comptroller of the  Currency; and the Chairman, Securities and Exchange Commission (SEC);  consider taking additional actions to ensure that market participants  adequately prepare for a pandemic outbreak. In response to our  recommendation, the Federal Reserve and the Office of the Comptroller of  the Currency, in conjunction with the Federal Financial Institutions  Examination Council and the SEC, directed all banking organizations  under their supervision to ensure that the pandemic plans the financial  institutions have in place are adequate to maintain critical operations  during a severe outbreak. SEC issued similar requirements to the major  securities industry market organizations.
section_title: Further Actions Are Needed to Address the Capacity to Respond to and Recover from an Influenza Pandemic
paragraphs: Improving the nation’s response capability to catastrophic disasters, such  as an influenza pandemic, is essential. Following a mass casualty event,  health care systems would need the ability to adequately care for a large  number of patients or patients with unusual or highly specialized medical  needs. The ability of local or regional health care systems to deliver  services could be compromised, at least in the short term, because the  volume of patients would far exceed the available hospital beds, medical  personnel, pharmaceuticals, equipment, and supplies. Further, in natural  and man-made disasters, assistance from other states may be used to  increase capacity, but in a pandemic, states would likely be reluctant to  provide assistance to each other due to scarce resources and fears of  infection.
The $5.62 billion that Congress provided in supplemental funding to HHS  in 2006 was for, among other things, (1) monitoring disease spread to  support rapid response, (2) developing vaccines and vaccine production  capacity, (3) stockpiling antivirals and other countermeasures, (4)  upgrading state and local capacity, and (5) upgrading laboratories and  research at CDC. Figure 2 shows that the majority of this supplemental  funding—about 77 percent—was allocated for developing antivirals and  vaccines for a pandemic, and purchasing medical supplies. Also, a portion  of the funding for state and local preparedness—$170 million—was  allocated for state antiviral purchases for their state stockpiles.
An outbreak will require additional capacity in many areas, including the  procurement of additional patient treatment space and the acquisition and  distribution of medical and other critical supplies, such as antivirals and  vaccines for an influenza pandemic. In a severe pandemic, the demand  would exceed the available hospital bed capacity, which would be further  challenged by the existing shortages of health care providers and their  potential high rates of absenteeism. In addition, the availability of  antivirals and vaccines could be inadequate to meet demand due to limited  production, distribution, and administration capacity.
The federal government has provided some guidance and funding to help  states plan for additional capacity. For example, the federal government  provided guidance for states to use when preparing for medical surge and  on prioritizing target groups for an influenza pandemic vaccine. Some  state officials reported, however, that they had not begun work on altered  standards of care guidelines, that is, for providing care while allocating  scarce equipment, supplies, and personnel in a way that saves the largest  number of lives in mass casualty event, or had not completed drafting  guidelines, because of the difficulty of addressing the medical, ethical, and  legal issues involved. We recommended that HHS serve as a clearinghouse  for sharing among the states altered standards of care guidelines  developed by individual states or medical experts. HHS did not comment  on the recommendation, and it has not indicated if it plans to implement  it. Further, in our June 2008 report on state and local planning and  exercising efforts for an influenza pandemic, we found that state and local  officials reported that they wanted federal influenza pandemic guidance  on facilitating medical surge, which was also one of the areas that the  HHS-led assessment rated as having “many major gaps” nationally among  states’ influenza pandemic plans.
section_title: Federal Agencies Have Provided Considerable Guidance and Pandemic-Related Information, but Could Augment Their Efforts
paragraphs: The National Pandemic Implementation Plan emphasizes that government  and public health officials must communicate clearly and continuously  with the public throughout a pandemic. Accordingly, HHS, DHS, and other  federal agencies have shared pandemic-related information in a number of  ways, such as through Web sites, guidance, and state summits and  meetings, and are using established networks, including coordinating  councils for critical infrastructure protection, to share information about  pandemic preparedness, response, and recovery. Federal agencies have  established an influenza pandemic Web site (www.pandemicflu.gov) and  disseminated pandemic preparedness checklists for workplaces,  individuals and families, schools, health care and community  organizations, and state and local governments.
However, state and local officials from all of the states and localities we  interviewed wanted additional federal influenza pandemic guidance from  the federal government on specific topics, such as implementing  community interventions, fatality management, and facilitating medical  surge. Although the federal government has issued some guidance, it may  not have reached state and local officials or may not have addressed the  particular concerns or circumstances of the state and local officials we  interviewed. In addition, private sector officials have told us that they  would like clarification about the respective roles and responsibilities of  the federal and state governments during an influenza pandemic  emergency, such as for state border closures and influenza pandemic  vaccine distribution.
section_title: Performance Monitoring and Accountability For Pandemic Preparedness Needs Strengthening
paragraphs: While the National Pandemic Strategy and Implementation Plan identify  overarching goals and objectives for pandemic planning, the documents  are not altogether clear on the roles, responsibilities, and requirements to  carry out the plan. Some of the action items in the National Pandemic  Implementation Plan, particularly those that are to be completed by state,  local, and tribal governments or the private sector, do not identify an  entity responsible for carrying out the action. Most of the plan’s  performance measures consist of actions to be completed, such as  disseminating guidance, but the measures are not always clearly linked  with intended results. This lack of clear linkages makes it difficult to  ascertain whether progress has in fact been made toward achieving the  national goals and objectives described in the National Pandemic Strategy  and Implementation Plan. Without a clear linkage to anticipated results,  these measures of activities do not give an indication of whether the  purpose of the activity is achieved.
In addition, as discussed earlier, the National Pandemic Implementation  Plan does not establish priorities among its 324 action items, which  becomes especially important as agencies and other parties strive to  effectively manage scarce resources and ensure that the most important  steps are accomplished. Moreover, the National Pandemic Strategy and  Implementation Plan do not provide information on the financial  resources needed to implement them, which is one of six characteristics of  an effective national strategy that we have identified. As a result, the  documents do not provide a picture of priorities or how adjustments might  be made in view of resource constraints.
section_title: Concluding Observations
paragraphs: The recent outbreak of H1N1 influenza virus should serve as a powerful  reminder that the threat of a pandemic influenza, which seemed to fade  from public awareness in recent years, never really disappeared. While  federal agencies have taken action on many of our recommendations,  almost half the recommendations that we have made over the past 3 years  are still not fully implemented. For one thing, it is essential, given the  change in administration and the associated transition of senior federal  officials, that the shared leadership roles that have been established  between HHS and DHS along with other responsible federal officials, are  tested in rigorous tests and exercises. Likewise, DHS should continue to  work with other federal agencies and private sector members of the  critical infrastructure coordinating councils to help address the challenges  of coordination and clarify roles and responsibilities of federal and state  governments. DHS and HHS should also, in coordination with other  federal agencies, continue to work with states and local governments to  help them address identified gaps in their pandemic planning. Moreover,  the 3-year period covered by the National Pandemic Implementation Plan  is now over and it will be important for HSC to establish a process for  updating the National Pandemic Implementation Plan so that the updated  plan can address the gaps we have identified, as well as lessons learned  from the current H1N1 outbreak.
Pandemic influenzas, as I noted earlier, differ from other types of disasters  in that they are not necessarily discrete events. While the current H1N1  outbreak seems to have been relatively mild, it could return in a second  wave this fall or winter in a more virulent form. Given this risk, the  administration and federal agencies should turn their attention to filling in  some of the gaps our work has pointed out, while time is still on our side.
Chairman Pryor, Senator Ensign, and Members of the Subcommittee, this  concludes my prepared statement. I would be happy to respond to any  questions you may have.
section_title: Contacts and Staff Acknowledgements
paragraphs: For further information regarding this statement, please contact Bernice  Steinhardt, Director, Strategic Issues, at (202) 512-6543 or  steinhardtb@gao.gov. Contact points for our Offices of Congressional  Relations and Public Affairs may be found on the last page of this  statement. Individuals making key contributions to this testimony include  Sarah Veale, Assistant Director; Maya Chakko; Melissa Kornblau; Susan  Sato; Ellen Grady; Karin Fangman; and members of GAO’s Pandemic  Working Group.
section_title: Attachment I: Open Recommendations from GAO’s Work on an Influenza Pandemic as of February 2009
subsections: section_title: Influenza Pandemic: HHS Needs to Continue Its Actions and Finalize Guidance for Pharmaceutical Interventions, GAO-08-671, September 30, 2008
paragraphs: The Secretary of HHS should expeditiously  finalize guidance to assist state and local  jurisdictions to determine how to effectively  use limited supplies of antivirals and pre- pandemic vaccine in a pandemic, including  prioritizing target groups for pre-pandemic  vaccine.
In December 2008, HHS released final  guidance on antiviral drug use during an  influenza pandemic. HHS officials informed  us that they are drafting the guidance on  pre-pandemic influenza vaccination.
The Secretaries of HHS and Homeland  Security should, in coordination with other  federal agencies, convene additional  meetings of the states in the five federal  influenza pandemic regions to help them  address identified gaps in their planning.
HHS and DHS officials indicated that while  no additional meetings are planned at this  time, states will have to continuously  update their pandemic plans and submit  them for review.
The Secretary of Homeland Security should  work with sector-specific agencies and lead  efforts to encourage the government and  private sector members of the councils to  consider and help address the challenges  that will require coordination between the  federal and private sectors involved with  critical infrastructure and within the various  sectors, in advance of, as well as during, a  pandemic.
DHS officials informed us that the  department is working on initiatives, such  as developing pandemic contingency plan  guidance tailored to each of the critical  infrastructure sectors, and holding a series  of webinars with a number of the sectors.
Influenza Pandemic: Further Efforts Are  Needed to Ensure Clearer Federal  Leadership Roles and an Effective National  Strategy, GAO-07-781, August 14, 2007  (1) HHS and DHS officials stated that  several influenza pandemic exercises had  been conducted since November 2007 that  involved both agencies and other federal  officials, but it is unclear whether these  exercises rigorously tested federal  leadership roles in a pandemic.
Influenza Pandemic: Opportunities Exist to  Clarify Federal Leadership Roles and  Improve Pandemic Planning,   GAO-07-1257T, September 26, 2007  (1) The Secretaries of Homeland Security  and HHS should work together to develop  and conduct rigorous testing, training, and  exercises for an influenza pandemic to  ensure that the federal leadership roles are  clearly defined and understood and that  leaders are able to effectively execute  shared responsibilities to address emerging  challenges. Once the leadership roles have  been clarified through testing, training, and  exercising, the Secretaries of Homeland  Security and HHS should ensure that these  roles are clearly understood by state, local,  and tribal governments; the private and  nonprofit sectors; and the international  community.  (2) The Homeland Security Council (HSC)  should establish a specific process and  time frame for updating the National  Pandemic Implementation Plan. The  process should involve key nonfederal  stakeholders and incorporate lessons  learned from exercises and other sources.  The National Pandemic Implementation  Plan should also be improved by including  the following information in the next update:  (a) resources and investments needed to  complete the action items and where they  should be targeted, (b) a process and  schedule for monitoring and publicly  reporting on progress made on completing  the action items, (c) clearer linkages with  other strategies and plans, and (d) clearer  descriptions of relationships or priorities  among action items and greater use of  outcome-focused performance measures. (2) HSC did not comment on the  recommendation and has not indicated if it  plans to implement it.
Avian Influenza: USDA Has Taken  Important Steps to Prepare for Outbreaks,  but Better Planning Could Improve  Response, GAO-07-652, June 11, 2007  (1) The Secretaries of Agriculture and  Homeland Security should develop a  memorandum of understanding that  describes how the U.S. Department of  Agriculture (USDA) and DHS will work  together in the event of a declared  presidential emergency or major disaster,  or an Incident of National Significance, and  test the effectiveness of this coordination  during exercises. (1) Both USDA and DHS officials told us  that they have taken preliminary steps to  develop additional clarity and better define  their coordination roles. For example the  two agencies meet regularly to discuss  such coordination. (2) The Secretary of Agriculture should, in  consultation with other federal agencies,  states, and the poultry industry, identify the  capabilities necessary to respond to a  probable scenario or scenarios for an  outbreak of highly pathogenic avian  influenza. The Secretary of Agriculture  should also use this information to develop  a response plan that identifies the critical  tasks for responding to the selected  outbreak scenario and, for each task,  identifies the responsible entities, the  location of resources needed, time frames,  and completion status. Finally, the  Secretary of Agriculture should test these  capabilities in ongoing exercises to identify  gaps and ways to overcome those gaps. (2) USDA officials told us that it has created  a draft preparedness and response plan  that identifies federal, state, and local  actions, timelines, and responsibilities for  responding to highly pathogenic avian  influenza, but the plan has not been issued  yet. (3) The Secretary of Agriculture should  develop standard criteria for the  components of state response plans for  highly pathogenic avian influenza, enabling  states to develop more complete plans and  enabling USDA officials to more effectively  review them. (3) USDA told us that it has drafted large  volumes of guidance documents that are  available on a secure Web site. However,  the guidance is still under review and it is  not clear what standard criteria from these  documents USDA officials and states  should apply when developing and  reviewing plans. (4) The Secretary of Agriculture should  focus additional work with states on how to  overcome potential problems associated  with unresolved issues, such as the  difficulty in locating backyard birds and  disposing of carcasses and materials  (4) USDA officials have told us that the  agency has developed online tools to help  states make effective decisions about  carcass disposal. In addition, USDA has  created a secure Internet site that contains  draft guidance for disease response,  including highly pathogenic avian influenza,  and it includes a discussion about many of  the unresolved issues. (5) The Secretary of Agriculture should  determine the amount of antiviral  medication that USDA would need in order  to protect animal health responders, given  various highly pathogenic avian influenza  scenarios. The Secretary of Agriculture  should also determine how to obtain and  provide supplies within 24 hours of an  outbreak. (5) USDA officials told us that the National  Veterinary Stockpile now contains enough  antiviral medication to protect 3,000 animal  health responders for 40 days.  However,  USDA has yet to determine the number of  individuals that would need medicine based  on a calculation of those exposed to the  virus under a specific scenario.  Further,  USDA officials told us that a contract for  additional medication for the stockpile has  not yet been secured, which would better  ensure that medications are available in the  event of an outbreak of highly pathogenic  avian influenza.
section_title: Attachment II: Related GAO Products
paragraphs: Influenza Pandemic: HHS Needs to Continue Its Actions and Finalize  Guidance for Pharmaceutical Interventions. GAO-08-671. Washington,  D.C.: September 30, 2008.
Influenza Pandemic: Federal Agencies Should Continue to Assist States  to Address Gaps in Pandemic Planning. GAO-08-539. Washington, D.C.:  June 19, 2008.
Emergency Preparedness: States Are Planning for Medical Surge, but  Could Benefit from Shared Guidance for Allocating Scarce Medical  Resources. GAO-08-668. Washington, D.C.: June 13, 2008.
Influenza Pandemic: Efforts Under Way to Address Constraints on  Using Antivirals and Vaccines to Forestall a Pandemic. GAO-08-92.  Washington, D.C.: December 21, 2007.
Influenza Pandemic: Opportunities Exist to Address Critical  Infrastructure Protection Challenges That Require Federal and Private  Sector Coordination. GAO-08-36. Washington, D.C.: October 31, 2007.
Influenza Pandemic: Federal Executive Boards’ Ability to Contribute to  Pandemic Preparedness. GAO-07-1259T. Washington, D.C.: September 28,  2007.
Influenza Pandemic: Opportunities Exist to Clarify Federal Leadership  Roles and Improve Pandemic Planning. GAO-07-1257T. Washington, D.C.:  September 26, 2007.
Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer  Federal Leadership Roles and an Effective National Strategy.  GAO-07-781. Washington, D.C.: August 14, 2007.
Emergency Management Assistance Compact: Enhancing EMAC’s  Collaborative and Administrative Capacity Should Improve National  Disaster Response. GAO-07-854. Washington, D.C.: June 29, 2007.
Influenza Pandemic: DOD Combatant Commands’ Preparedness Efforts  Could Benefit from More Clearly Defined Roles, Resources, and Risk  Mitigation. GAO-07-696. Washington, D.C.: June 20, 2007.
Influenza Pandemic: Efforts to Forestall Onset Are Under Way;  Identifying Countries at Greatest Risk Entails Challenges. GAO-07-604.  Washington, D.C.: June 20, 2007.
Avian Influenza: USDA Has Taken Important Steps to Prepare for  Outbreaks, but Better Planning Could Improve Response. GAO-07-652.  Washington, D.C.: June 11, 2007.
The Federal Workforce: Additional Steps Needed to Take Advantage of  Federal Executive Boards’ Ability to Contribute to Emergency  Operations. GAO-07-515. Washington, D.C.: May 4, 2007.
Financial Market Preparedness: Significant Progress Has Been Made,  but Pandemic Planning and Other Challenges Remain. GAO-07-399.  Washington, D.C.: March 29, 2007.
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.
Catastrophic Disasters: Enhanced Leadership, Capabilities, and  Accountability Controls Will Improve the Effectiveness of the Nation’s  Preparedness, Response, and Recovery System.  GAO-06-618. Washington,  D.C.: September 6, 2006.
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