The National Response Framework consists of a base document and two types of annexes—the Emergency Support Function Annex and the Support Annex. The 2014 Quadrennial Defense Review notes the importance of DOD’s role in protecting the homeland and supporting civil authorities in mitigating the effects of natural disasters such as pandemics. DOD works closely with other federal agencies to coordinate the federal response to address the threat of pandemics and other types of incidents. Under the National Response Framework, Emergency Support Function (ESF) #8, Public Health and Medical Services Annex, HHS, DHS, and DOD have specific roles and responsibilities to support civil authorities and coordinate response efforts with other federal agencies to address public health and medical disasters. Department of Health and Human Services. HHS, through its Assistant Secretary for Preparedness and Response, leads all federal public health and medical responses to public health emergencies and other incidents covered by the National Response Framework and coordinates with other departments and supporting agencies to accomplish this mission. Several of its key functions under ESF #8 include activating the National Disaster Medical System as necessary to ensuring the proper disposal of contaminated products and the decontamination of affected food facilities in order to protect the public health; coordinating public health and medical support, patient evacuation, and movement requirements with other primary and supporting departments, agencies, and government authorities throughout the incident; and coordinating with support agencies—such as DOD—when an incident requires federal assistance above and beyond its interagency mechanisms. Department of Homeland Security. DHS serves as the lead for interagency coordination and planning for emergency response. Several of its key functions under ESF #8 include assisting in providing information and liaison with emergency arranging transportation to evacuate patients who are too seriously ill or otherwise incapable of being evacuated in general evacuation conveyances; and arranging for the use of U.S. Coast Guard aircraft and other assets in providing urgent airlift and other transportation support. Department of Defense. DOD is responsible—subject to the availability of resources and the direction of the President or by approval of the Secretary of Defense—for providing support functions and supplementing civil authorities’ resources in response to public health and medical disasters. Several of its key functions under ESF #8 include providing military personnel for casualty clearing or staging and other providing support for the evacuation of patients to locations where hospital care or outpatient services are available; and providing military personnel to assist in the protection of public health by providing, for example, food, water, wastewater removal, solid waste disposal, hygiene, and vector control. (See appendix III for a more complete discussion of these federal agencies’ roles and responsibilities in support of the National Response Framework through ESF #8.) DOD typically provides support in response to a formal request for assistance (RFA) from other federal departments or agencies and—in cases where response is needed immediately—from state, local, or tribal and territorial governments. Support provided in response to such RFAs may help these civil authorities to prepare for, prevent, protect against, respond to, and recover from domestic incidents, including terrorist attacks and major disasters. DOD assets are usually requested if other federal, state, local, and tribal assets are not available. However, DOD resources are not typically required to respond every domestic incident. DOD resources can be made available to support disaster response through a presidential declaration. For example, according to the Robert T. Stafford Disaster Relief and Emergency Assistance Act (commonly referred to as the Stafford Act), when a state’s capabilities and resources are overwhelmed and the President declares an emergency or disaster, the state Governor can request assistance from the federal government. The Stafford Act gives the President the authority to establish a program of disaster preparedness and response support. Homeland Security Presidential Directive-5 designates the Secretary of Homeland Security as the principal federal official for domestic incident management. Defense resources are committed only after the primary agency submits a request for assistance, through proper channels, and the President or Secretary of Defense authorizes DOD to provide support. Such support may help civil authorities prepare for, prevent, protect against, respond to, or recover from domestic incidents—including pandemics and major disasters. Figure 1 illustrates how DOD’s support is obtained through the current RFA process following a presidential declaration of a major disaster or emergency. FEMA currently is developing guidance that will include a standardized mission assignment process, which will replace the current mission assignment process. According to FEMA officials, they have not yet determined when a final version of the guidance will be issued. Defense support of civil authorities also can be requested and provided when there has been no presidential declaration. DOD Directive 3025.18, Defense Support of Civil Authorities, authorizes immediate response authority for providing support. This can be invoked when DOD is requested to respond to an incident under imminently serious conditions when time does not permit approval from a higher authority. Upon request from a civil authority, DOD officials may employ resources under their control for up to 72 hours, subject to any supplemental direction provided by higher headquarters, to save lives, prevent human suffering, or mitigate great property damage within the United States. Immediate response authority does not permit actions that would subject civilians to the use of military power that is regulatory, prescriptive, proscriptive, or compulsory. In addition, the Economy Act permits one federal agency to request the support of another federal agency, provided that the requested services cannot be obtained more cheaply or conveniently by contract. Under this Act, a federal agency with lead (primary) responsibility may request the support of DOD without the presidential declaration of emergency required by the Stafford Act. Finally, DOD may provide health services—as a supporting agency to HHS—in accordance with the National Disaster Medical System, following HHS’s declaration of a public health emergency. According to DOD guidance, for the purpose of activating the National Disaster Medical System, a public health emergency may include a public health emergency declaration by the Secretary of Health and Human Services or a declaration of a disaster or emergency pursuant to the Stafford Act. DOD has developed guidance and plans at various levels to direct its efforts to provide assistance in support of civil authorities in the event of a domestic outbreak of a pandemic disease. The Department of Defense Global Campaign Plan for Pandemic Influenza and Infectious Diseases 3551-13, issued in 2013, provides overarching guidance to DOD and the military services on how to plan and prepare for a pandemic outbreak. According to a DOD official, other DOD guidance—such as the Guidance for the Employment of the Force—directs U.S. Northern Command and U.S. Pacific Command to be prepared to provide defense support of civil authorities and the Joint Strategic Capabilities Plan specifies how this should be accomplished. According to the Global Campaign Plan, U.S. Northern Command is designated by DOD as the global synchronizer for influenza pandemic and infectious disease plans. In this role, U.S. Northern Command is responsible for providing strategic planning guidance for the department’s efforts to prepare for and respond to pandemic diseases. This guidance directs the geographic combatant commands and the military services to develop influenza pandemic and infectious disease plans and to coordinate and synchronize those plans with the Global Campaign Plan. As the lead synchronizer, U.S. Northern Command is responsible for ensuring that plans developed by the combatant commands and military services are aligned with the Global Campaign Plan in areas such as biosurveillance and disease monitoring and sharing best practices; among other responsibilities. U.S. Northern Command’s CONPLAN 3591-09 Response to Pandemic Influenza provides guidance to U.S. Northern Command decision makers on identifying the capabilities and forces needed to maintain the defense of the homeland while limiting the long-term effect of a pandemic on the security, health, and safety of the nation. This plan explains how U.S. Northern Command would respond to a pandemic outbreak by identifying capabilities—such as personal protective equipment and medical countermeasures—to prevent human- to-human transmission. The plan also includes key assumptions about how a pandemic could affect DOD’s ability to provide homeland defense. For example, the plan states that an absentee rate of 40 percent among DOD personnel, occurring at the height of a severe pandemic wave, could affect U.S. Northern Command’s ability to protect the homeland and result in fewer resources being available to support requests for support from civil authorities. The Homeland Defense mission can be performed only by DOD and thus is its first priority. The pandemic response ultimately is the responsibility of state, local, and tribal and territorial authorities, and with the support of other federal agencies. The plan states that an influenza pandemic would cause unprecedented illness, death, and disruption to normal patterns of life, resulting in emotional, psychological, spiritual, and physical pressures on U.S. Northern Command’s forces. The plan states that the combatant command will mitigate the risk of a pandemic by synchronizing planning within the department and with other elements of national power (i.e., diplomatic, informational, military, and economic) to support U.S. government strategies and objectives embodied in the National Strategy for Pandemic Influenza. In addition, the plan states that the combatant command will coordinate resources with federal departments and agencies to ensure that preparedness and response efforts are prioritized and resourced to respond to a pandemic. Other combatant commands also have developed plans for providing support in the event of a pandemic. According to an official from U.S. Northern Command, currently all six of the geographical combatant commands have pandemic influenza and infectious disease plans for their assigned areas of responsibility. The remaining three ‘functional” combatant commands, which include the U.S. Special Operations Command, have not developed pandemic influenza and infectious disease plans because they operate in support of and within the supported geographical combatant command’s area of responsibility. For example, U.S. Pacific Command’s CONPLAN 5003-13, Commander United States Pacific Command Concept Plan for Pandemic and Emerging Infectious Diseases, fulfils strategic guidance to prepare for and maintain response plans for pandemic and emerging infectious diseases for regional execution in support of U.S. Northern Command’s Global Campaign Plan. According to U.S. Pacific Command officials, CONPLAN 5003-13 serves as an operational framework for interagency and international collaboration, DOD coordination, and synchronization of a whole-of-government response to pandemics and infectious diseases. Specifically, U.S. Pacific Command’s CONPLAN 5003-13 states that the combatant command will adopt an active, layered defense with respect to a disease of operational significance. The plan for such a defense consists of the following six phases: Phase 0 (Prepare): security cooperation and partner activities aimed at building the capacity of partner nations and partner nation militaries in coordination with the host nation, the international health community, and federal agencies. Phase 1 (Protect): identification and characterization of a disease of operational significance. Phase 2 (Mitigate): more significant DOD actions to further protect the force and maintain mission assurance. Phase 3 (Respond): requests for defense support of civil authorities related to pandemics or emerging infectious diseases, or for foreign humanitarian assistance, have been received and authorized through the request for assistance process. Phase 4 (Stabilize): maintaining appropriate force protection and force health protection measures and finalizing defense support of civil authorities and force health protection requests related to pandemic emerging and infectious diseases. Phase 5 (Transition and Recovery): redeploying forces while maintaining vigilance for a potential second wave outbreak of a pandemic or emerging infectious disease. In addition, the plan assumes that certain challenges could affect military personnel’s ability to support civil authorities in responding to a pandemic. For example, the plan states that a disease of operational significance could, among other things, create a global pandemic with the potential of incapacitating upwards of 40 percent of the workforce worldwide. Beyond its primary negative effects, a disease of operational significance could have secondary and tertiary effects, which could significantly threaten the economic, political, and social stability of nations and regions. The military services have developed plans to contain and mitigate the effects of pandemic influenza and infectious diseases. For example, the Army’s Pandemic Influenza and Infectious Disease Plan states that the Army will support geographic combatant commands to contain or mitigate the effects of an influenza pandemic or infectious disease of operational significance. The plan also states that the Army will conduct theater and functional planning to protect the personnel and resources necessary to maintain readiness to sustain mission assurance and support, as directed, other U.S. government efforts to protect the nation’s welfare, to include assisting partner countries. According to an official in the Office of the Assistant Secretary of Defense for Homeland Defense Integration and Defense Support of Civil Authorities, the Army, the Navy, and the Air Force have provided installations with guidance necessary to develop installation-level disease containment plans to ensure force health protection and continuity of operations in response to pandemics, and direct coordination with state and local authorities. According to the Strategy for Homeland Defense and Support to Civil Authorities, DOD often is expected to play a prominent supporting role to primary federal agencies in their response efforts. According to officials in the Office of the Deputy Assistant Secretary of Defense for Homeland Defense Integration and Defense Support of Civil Authorities, in the event of a pandemic, DOD’s support would be most useful in providing unique military capabilities, such as logistics and transportation, to distribute medical supplies and other assets to an affected site. Moreover, in anticipation of requests for this type of assistance, these officials said that because DOD has this role, it is critical that those primary agencies be aware of DOD’s capabilities in a given scenario. Furthermore, the strategy states that DOD historically has supported civil authorities in a wide variety of domestic contingencies, often in response to natural disasters. However, the 21st century security environment, the concentration of population in major urban areas, and the interconnected nature of critical infrastructures have all combined to fundamentally alter the scope and scale of “worst case” incidents for which DOD might be called upon to provide support. This environment creates the potential for complex catastrophes, with effects that would qualitatively and quantitatively exceed those experienced to date. In such events, the demand for defense support of civil authorities would be unprecedented. Meeting this demand would be especially challenging if, for example, a cyber attack, or other electrical power grid disruption creating cascading failures of critical infrastructure, or DOD’s capabilities being limited if a pandemic were to threaten lives and greatly complicate DOD response operations. According to Joint Publication 5-0, Joint Operation Planning, an important consideration in effective planning is to anticipate certain events. This publication also states that the body of knowledge and understanding created during DOD’s planning allows commanders to monitor, assess, and adapt to uncertain and changing environments and to anticipate and act proactively in crisis situations. According to officials in the Office of the Deputy Assistant Secretary of Defense for Homeland Defense Integration and Defense Support of Civil Authorities, there may be expectation gaps between DOD and primary agencies regarding DOD’s capabilities to provide support. Primary agencies coordinate with support agencies—such as DOD—when an incident requires more capabilities than those primary agencies can provide, such as materiel movement during a pandemic. These officials said that while HHS and FEMA can usually rely on DOD during natural disasters, including a pandemic, should support capabilities from primary sources (e.g., other local, regional, state, and federal agencies, non- governmental organizations, and the private sector) become overwhelmed, DOD might not always be in a position to provide requested assistance because its capabilities may be limited. HHS and DHS have plans to guide their responses to a pandemic, but their plans do not explain how they would respond in a resource- constrained environment where state and local capabilities are overwhelmed or unavailable, and other federal capabilities, like DOD’s, are limited. In addition, DOD, as well as HHS and DHS, through FEMA, use existing mechanisms to coordinate their pandemic preparedness and response. These three departments also have conducted joint training exercises to test plans, improve proficiency, and assess capabilities and readiness to plan, prepare for, and respond to pandemic outbreaks. HHS’s Pandemic Influenza Plan is its blueprint for influenza pandemic preparedness and response. The plan assigns lead roles and responsibilities for response actions to specific HHS agencies and offices. HHS’s plan also outlines planning assumptions for its influenza pandemic response, but it is not intended to address what actions other agencies are to take during a pandemic. For example, it outlines assumptions that must be considered in strategic planning, including the ability of an influenza virus to spread rapidly worldwide. In addition, the plan assumes that there would be large demands on the health care system and potential national and community disruption as a result of the widespread illness. The Secretary of Health and Human Services serves as the lead for all federal public health and medical response to public health emergencies, as previously noted, under ESF #8 and incidents covered by the National Response Plan or its update. In addition, the National Response Framework, which is DHS’s guidance for coordinating national support to respond to an emergency—such as a pandemic—recognizes HHS as the primary federal agency to respond to public health emergencies and incidents. The National Response Framework also designates primary agencies—such as HHS—to oversee preparedness activities through ESF #8, monitor progress in meeting core capabilities, and coordinate with both primary and support agencies through training exercises and other activities. Under ESF #8, DOD may be expected to provide support capabilities, such as logistical support, to public health and medical response operations, evacuation of patients to locations where hospital care is available, medical supplies for distribution to mass care centers, and assistance in managing human remains—including victim identification and mortuary affairs. (Appendix III lists DOD’s roles and responsibilities to support the National Response Framework.) ESF #8 serves as a key mechanism to assist HHS in its pandemic preparedness and response because, according to the National Response Framework, emergency support functions bring together the capabilities of federal departments and agencies and other national-level assets. In addition, according to the National Response Framework, the Secretary of Homeland Security is responsible for coordinating preparedness activities within the United States to respond to and recover from major disasters and emergencies. The Secretary’s responsibilities also include managing FEMA’s emergency management and response authorities. According to DHS’s Response Federal Interagency Operational Plan, primary and support agencies involved in implementing federal emergency support functions conduct contingency and operational planning in conjunction with federal, state, local, tribal, and territorial authorities and the private sector. According to officials with HHS’s Office of the Assistant Secretary for Preparedness and Response, mechanisms such as interagency dialogue and coordination among federal, state, and local entities are often used to determine what resources would be needed during a pandemic. For example, HHS officials said that surge capabilities, such as capabilities developed through the local Hospital Preparedness Program, could be used to support the local response effort prior to requesting state or federal assistance. HHS officials stated that there are other existing mechanisms, such as the Public Health Emergency Medical Countermeasures Enterprise and Enterprise Executive Committee, which consists of senior program managers across the partner agencies who address issues such as influenza pandemic preparedness and response capabilities, among other issues. Influenza Risk Management Meetings are another existing mechanism that provides partner agencies with a venue to discuss their influenza pandemic response. HHS and DHS plans also do not specifically address what resources would be needed to support a response to a pandemic in an environment where federal resources, including DOD, are exceeded by demands. HHS officials stated that there would be no way of knowing in advance what unique facts, circumstances, or conditions might occur to determine what resources would be needed. The National Response Framework notes the importance of planning as a core capability to manage the life cycle of a potential crisis, determine capability requirements, and help stakeholders learn their roles. Planning includes the analysis and dissemination of risk assessment data, and the development of plans, procedures, mutual aid and assistance agreements, strategies, and other arrangements to perform specific missions and tasks to improve incident preparedness and response. When planning for an incident, such as a pandemic, governments at all levels have a responsibility to develop continuity plans that identify essential functions, succession and delegation of authority, continuity facilities, communication capabilities, and human resource issues. HHS and DHS are in the process of updating their pandemic plans, which presents an opportunity for them to coordinate with each other and with DOD to determine the appropriate actions to take—training exercises, pre-scripted mission assignments, or other coordination activities—should DOD’s support be limited during a pandemic. Finally, according to the Global Campaign Plan, large-scale, sustained military conflicts in multiple theaters of operation could severely degrade DOD’s capabilities and capacities to support civil authorities in responding to a pandemic. Although DOD may have personnel and equipment available to some degree to support civil authorities, it may not have the appropriate number or type of personnel, equipment, or training available to provide adequate support. According to an official in the Office of the Deputy Assistant Secretary of Defense for Homeland Defense Integration and Defense Support of Civil Authorities, DOD is not funded for defense support of civil authority missions and must adapt funded military capabilities to conduct such missions. DOD uses various mechanisms, including planning activities, interagency work groups, liaison officers, and training exercises both to coordinate within the department and its support with HHS and with DHS through FEMA. For example, according to DOD officials, DOD coordinates among its own organizations, such as the combatant commands and military services, to develop pandemic response plans. Specifically, Joint Staff officials stated they collaborate with the Office of the Secretary of Defense, the combatant commands, and the military services to establish guidance for providing support to civil authorities. We previously reported that U.S. Northern Command faced challenges involving coordination with interagency partners and the states in planning, conducting, and assessing exercises. We recommended that DOD coordinate with DHS and FEMA to develop guidance and consistently involve state officials in planning, executing, and assessing exercises that incorporate relevant state-specific information. In response, DOD stated that it continues to expand its efforts to ensure that states are able to benefit from participation in DOD-sponsored exercises. According to officials from the Office of the Assistant Secretary of Defense for Homeland Defense Integration and Defense Support of Civil Authorities, the Joint Staff and the U.S. Pacific Command, DOD coordinates formally and informally with HHS and DHS to identify capability requirements for supporting civil authorities in the event of a pandemic outbreak. For example, officials from the Office of the Assistant Secretary of Defense for Homeland Defense Integration and Defense Support of Civil Authorities and FEMA stated DOD actively is participating in interagency planning efforts to develop FEMA’s Biological Incident Annex. FEMA currently is updating the Biological Incident Annex that, according to FEMA officials, will include for the first time information on influenza pandemic and infectious disease guidance. As a member of the Public Health Emergency Medical Countermeasures Enterprise, DOD coordinates with HHS through formal working groups and interagency agreements to develop medical countermeasures for pandemic outbreaks. According to HHS officials, this interagency collaboration helped to develop and distribute diagnostics and vaccines for the 2009 H1N1 influenza pandemic and the antibody therapeutics for the 2014-15 Ebola epidemic (see figure 2). In addition, officials in the Office of the Assistant Secretary of Defense for Health Affairs stated the DOD officials sit on the National Security Council’s Sub-Integrated Policy Committee on Pandemic Preparedness, which oversaw interagency implementation of the National Strategy for Pandemic Influenza. According to DOD, HHS, and DHS officials, the three agencies each have liaison officers located in the others to collaborate on federal response plans and facilitate and coordinate requests for DOD assistance. FEMA officials stated that DOD’s primary mechanism for coordination with state and local entities is through the Defense Coordinating Officer and FEMA staff. According to officials with U.S. Northern Command, Defense Coordinating Officers assist in regional integrated disaster planning and coordination activities and help identify specific capabilities that DOD is likely to be asked to provide in support of specific civil authorities’ disaster responses. During an incident response, the Defense Coordinating Officer would integrate with the federal coordinating officer and, upon receiving a request for DOD assistance, would help tailor the request to leverage key DOD capabilities and then submit the request to U.S. Northern Command to begin the Secretary of Defense approval process. FEMA officials stated that Defense Coordinating Officers are integrated with their assigned FEMA regions, and therefore they know what capabilities are being requested and what capabilities DOD has available to respond to these requests. Further, officials from DOD, HHS, and FEMA stated that DOD has conducted or participated in training exercises with HHS and DHS to assess its capabilities for responding to a pandemic outbreak. To prepare for a pandemic outbreak, DOD, HHS, and FEMA conducted joint training exercises from 2011 through 2015, the most recent fiscal years for which there is complete information available on training exercises. Exercises play an instrumental role in preparing these agencies to respond to an incident by providing opportunities to test plans, improve proficiency, and assess capabilities and readiness. Short of performance in actual operations, exercises provide the best means to assess the effectiveness of organizations in achieving mission preparedness. Exercises also provide an ideal opportunity to enhance preparedness by collecting, developing, implementing, and disseminating lessons learned and verifying that corrective action has been taken to resolve previously identified issues. These exercises have included state and local agencies and private sector organizations. For example, according to documentation obtained from U.S. Northern Command, in July 2015, U.S. Northern Command conducted Vista Express, an infectious disease training exercise that included a weaponized anthrax scenario. Over 80 individuals from 29 organizations participated, including individuals from DHS, FEMA, other federal agencies, and private organizations. According to HHS officials, in 2011 HHS hosted exercises to test public health plans, processes, and procedures to respond to an anthrax outbreak. Participants included representatives from state, local, tribal, territorial and federal agencies. In September 2013, the National Security Staff sponsored an exercise for senior-level federal government executives to discuss interagency plans for response to pandemics, including agency roles and responsibilities. While HHS and DHS have conducted joint training exercises with DOD, they have not exercised a pandemic outbreak scenario in which DOD capabilities are limited. In addition, DOD has not exercised a pandemic outbreak scenario with HHS and DHS. DOD officials believe that an exercise in which DOD participates—but for which it provides limited capabilities or none at all—would be useful in preparing for a pandemic response. However, U.S. Northern Command has not participated in such an exercise. DOD, HHS, and DHS have issued after-action reports and have documented lessons learned information from the training exercises they have conducted, and they have shared these documents with each other. Specifically, U.S. Northern Command provides external partners with access to its website to provide lessons-learned information. In addition, our analysis of U.S. Northern Command and U.S. Pacific Command after- action reports and other exercise information related to pandemic response for fiscal years 2011 through 2015 indicated that lessons resulting from training exercises, or from a real-world event such as the Ebola outbreak, are summarized in after-action reports or other documentation. According to U.S. Pacific Command officials, federal, state, and local entities can access DOD’s Joint Lessons Learned Information System, through a registered account, to retrieve after-action reports and other information, consistent with DOD’s security requirements. Otherwise, these entities would need to request after- action reports and other information either from the organization that conducted the training exercise or from the Joint Staff. According to HHS officials, HHS prepares an after-action report or a summary of conclusions for each pandemic-related training exercise. They stated that after-action reports or other documentation are disseminated through electronic mail to all participants in a training exercise. Agencies that do not participate in the training exercises but are involved in pandemic response efforts also are provided this documentation. While this documentation is not shared with a broad audience, HHS officials said that it is available to DOD stakeholders upon request, and as soon as it is approved for broad release, it is shared with all participants. Further, HHS has access to DOD’s Joint Lessons Learned Information System, and thus can access the reports posted on it. Similarly, our analysis of FEMA documentation from fiscal years 2013 through 2015 indicated that FEMA also documented lessons learned resulting from pandemic-related training exercises. FEMA managed its Lessons Learned Information System as an independent system through 2015; however, FEMA has since consolidated this system with the Naval Postgraduate School’s Homeland Security Digital Library. According to FEMA officials, federal agencies can access FEMA’s published lessons- learned information through DOD’s Joint Lessons Learned Information System or by requesting such information from FEMA. Federal agencies without access to DOD’s Joint Lessons Learned Information System can obtain historical lessons-learned information through the Homeland Security Digital Library or directly from FEMA. According to a FEMA official, FEMA also encourages exercise sponsors to publish their reports on the Homeland Security Information Network. In addition, FEMA, DOD, and several other federal agencies coordinate and share lessons- learned information through monthly interagency planners’ teleconferences, exercise planning workshops, and an annual DOD conference. DOD has developed plans for how it could, if requested, provide support to civil authorities in the event of a pandemic. HHS and FEMA plans contain guidance to respond to a pandemic, but they do not address a scenario in which DOD’s capabilities are limited. DOD, HHS, and DHS also have coordination mechanisms to respond to a pandemic, but they may have an expectation gap regarding the capabilities DOD can provide. Unless DOD, HHS, and DHS explore opportunities to enhance their existing coordination mechanisms—such as working groups, Defense Coordinating Officers, and training exercises—to identify approaches for responding to a pandemic in the event that DOD’s capabilities are limited, HHS and FEMA risk being unprepared to respond. Given that a severe pandemic is a unique type of disaster and could affect a significant portion of the U.S. population, including both civilian and military personnel, further planning would help HHS and DHS, as well as DOD, to improve their planning and preparation in response to a pandemic. HHS and DHS are in the process of updating their plans, which presents an opportunity for them to coordinate with each other and with DOD to determine the appropriate actions to take should DOD’s support be limited during a pandemic. Doing so could further position the federal government to be better prepared to respond to a severe pandemic outbreak should one occur. We are making three recommendations, one each to DOD, HHS, and FEMA, to use existing coordination mechanisms to improve their preparedness and response to a pandemic if DOD’s capabilities are limited. As DOD plans to respond to a pandemic, we recommend that the Secretary of Defense direct the Under Secretary of Defense for Policy and other DOD officials, as appropriate, to use DOD’s existing coordination mechanisms with HHS and FEMA to explore opportunities to improve their preparedness and response to a pandemic if DOD’s capabilities are limited. As HHS plans to respond to a pandemic, we recommend that the Secretary of Health and Human Services direct the Assistant Secretary for Preparedness and Response to use HHS’s existing coordination mechanisms with DOD and FEMA to explore opportunities to improve their preparedness and response to a pandemic if DOD’s capabilities are limited. As DHS, through FEMA, plans to respond to a pandemic, we recommend that the Secretary of Homeland Security direct the Administrator of FEMA to use FEMA’s existing coordination mechanisms with DOD and HHS to explore opportunities to improve their preparedness and response to a pandemic if DOD’s capabilities are limited. In written comments on a draft of this report, DOD, HHS, and DHS agreed with all three of our recommendations and discussed steps they plan to take to address these recommendations. The full text of DOD’s, HHS’s, and DHS’s written comments are reprinted in their entirety in appendixes IV, V, and VI, respectively. DOD and HHS also provided us with technical comments, which we incorporated in the report as appropriate. DOD concurred with our recommendation to use its existing coordinating mechanisms with HHS and FEMA to explore opportunities to improve their preparedness and response to a pandemic if DOD’s capabilities are limited. DOD stated that it would work with HHS—the primary agency for public health and medical services and the lead for pandemic planning— and DHS to explore opportunities that leverage existing coordination mechanisms in identifying the full spectrum of resources from federal, state, local, and private sector entities for pandemic preparedness and response. We believe these actions, if fully implemented, will address our recommendation. HHS concurred with our recommendation with comments explaining how it will use its existing coordination mechanisms with DOD and FEMA to explore opportunities to improve their preparedness and response to a pandemic if DOD’s capabilities are limited. HHS stated that it would ensure that the issue of limited support from DOD during a pandemic is included in its analysis and rewrite during its next review of its Pandemic Annex to the All-Hazards plan. We believe these actions, if fully implemented, will address our recommendation. DHS concurred with our recommendation to use FEMA’s existing coordination mechanisms with DOD and HHS to explore opportunities to improve their preparedness and response to a pandemic if DOD’s capabilities are limited. In its written response, FEMA agreed that strengthening established relationships with its DOD and HHS partners, including conducting planning events and live exercises, are cornerstones to increased preparedness for all interagency partners tasked with emergency response. FEMA stated that its Office of Response and Recovery planners will continue to explore opportunities to improve and update pandemic preparedness plans by incorporating key planning assumptions, restraints, constraints, post-exercise lessons learned, and other relevant factors related to scenarios in which DOD support is limited. FEMA noted that its planning efforts would be completed by March 13, 2017. We believe these efforts will enhance FEMA’s ability to improve its preparedness and response to a pandemic should DOD support be limited and, if fully implemented, will address our recommendation. We are sending copies of this report to the appropriate congressional committees; Secretaries of Defense, Health and Human Services, and Homeland Security; the Under Secretary of Defense for Policy; the Assistant Secretary of Defense for Homeland Defense and Global Security; the Assistant Secretary of Defense for Health Affairs; the Deputy Assistant Secretary of Defense for Homeland Defense Integration and Defense Support of Civil Authorities; the Chairman of the Joint Chiefs of Staff; the Department of Defense Inspector General, the Commanders, U.S. Northern Command, U.S. Pacific Command, and U.S. Southern Command; the Secretaries of the Army, the Navy, and the Air Force; the Commandant of the Marine Corps; the Chief, National Guard Bureau; the Director of the Defense Intelligence Agency; the Commanders, U.S. Army Medical Command and U.S. Army Medical Research and Materiel Command; the Chief of the Armed Forces Health Surveillance Branch; and the Directors, Centers for Disease Control and Prevention, Food and Drug Administration, National Institutes of Health, Federal Emergency Management Agency, and Office of Management and Budget. If you or your staff have any questions concerning this report, please contact Joseph Kirschbaum at (202) 512-9971 or KirschbaumJ@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 key contributions to this report are listed in appendix VII. The Department of Defense (DOD) also assists federal agencies in combating other non-pandemic viruses that have occurred, such as the recent Zika virus. DOD has taken steps to establish preparedness, detection, and response measures to deal with the Zika virus. In February and March 2016, DOD issued guidance on surveillance, control, and testing to DOD medical and force health protection personnel, military services, and installations, and the combatant commands regarding, among other things, prevention, diagnosis, and treatment of the virus. DOD has no dedicated budget for Zika virus preparedness, detection, and response, but it recently provided about $2 million to military laboratories to expand Zika virus surveillance worldwide and assess the virus’s effect on deployed service members’ health and readiness. In addition, funds from DOD’s Humanitarian Assistance Program have been used to purchase equipment and supplies in support of U.S. Southern Command’s Zika prevention projects in several Latin American countries. Further, National Guard units have received funding from the National Guard Bureau’s State Partnership Program to provide vector (i.e., mosquito) control and provide personal protective training to partner nations. The Zika virus is transmitted to humans predominantly through the bite of an infected Aedes aegypti or Aedes albopictus mosquito. Infected individuals may experience fever, rash, and muscle and joint pain for a short period. Human-to-human transmission is also possible through sexual contact, blood transfusions, and from mother to child. Recently, the Centers for Disease Control and Prevention concluded that Zika virus infection during pregnancy is a cause of microcephaly and other severe fetal brain defects; thus, pregnant women are at particular risk. In addition, the Zika virus is possibly associated with the Guillain-Barré syndrome, a rare disorder in which the body’s immune system attacks part of the nervous system in infected adults; however, this association has not been firmly established. There currently is no vaccine available to prevent infection by the Zika virus. Because of the risk to pregnant women, DOD has issued guidance to the military departments and combatant commands to determine if they should allow relocation and temporary assignment for pregnant service members, DOD employees, and their dependents in areas outside the United States where the Zika virus is being actively transmitted. U.S. Northern Command, U.S. Pacific Command, and U.S. Southern Command each have issued guidance on health protection measures to control the spread of the virus and guidance to pregnant service members, DOD personnel, and dependents to consult their health care providers on the risk of the Zika virus before they travel. The guidance also states service members, DOD personnel, and dependents who suspect they have been infected with the virus should consult their health care provider. Figure 3 shows a close-up photograph of the Aedes aegypti mosquito, the species primarily responsible for the spread of the Zika virus. According to Armed Forces Health Surveillance Branch (AFHSB) officials, the AFHSB tracks the Zika virus among military service members, DOD civilians, and their dependents and provides weekly surveillance reports to DOD on how the virus is spreading. AFHSB also has issued guidance giving direction to military treatment facilities and laboratories. DOD medical facilities have been notified of the concerns surrounding Zika virus infections and are prepared to test patients who may have been infected. As of August 3, 2016, DOD had reported that 41 active duty, reserve, and National Guard members had been diagnosed with Zika, including one service member who is pregnant. An additional seven family members have been diagnosed with Zika. According to DOD officials, at least 13 DOD laboratories currently are equipped to test human specimen samples for the Zika virus. DOD officials stated that researchers at the Uniformed Services University of the Health Sciences, Walter Reed Army Institute of Research, and Naval Medical Research are developing vaccines, diagnostic tests, and treatments for Zika and related viruses. Recently, DOD researchers indicated that the results of vaccine tests in non-human primates have proven effective and DOD has advanced efforts to proceed with conducting human trials. DOD officials stated that the department also is collaborating with the Department of Health and Human Services, Assistant Secretary for Preparedness and Response/Biomedical Advanced Research and Development Authority, and National Institutes of Health/National Institute of Allergy and Infectious Diseases, and the Centers for Disease Control and Prevention to develop, manufacture, and test a Zika vaccine. According to U.S. Pacific Command officials, the first documented outbreaks of the Zika virus occurred in 2007 in the South Pacific, on Yap Island, in the Federated States of Micronesia. Between 2013 and 2015, outbreaks occurred on a number of Pacific islands, including French Polynesia and the Cook Islands. U.S. Pacific Command recently issued guidance to service members and DOD civilians to take precautions when traveling to areas affected by the Zika virus. According to U.S. Southern Command officials, two Army National Guard units were dispatched earlier this year to Guyana and Suriname to provide subject matter expertise in combatting the spread of the Zika virus. In addition, officials said that the command is testing for the Zika virus at the Navy Research Medical Unit in Peru. Further, U.S. Pacific Command officials stated the command is collaborating closely with the Pan American Health Organization and other U.S. federal agencies, such as the U.S. Agency for International Development, to conduct needs assessments for regional ministries to mitigate the effects of the mosquito that carries the Zika virus. House Report 114-102, accompanying a bill for the National Defense Authorization Act for Fiscal Year 2016, included a provision that we assess the extent of the Department of Defense (DOD) planning to support civil authorities in the event of a domestic outbreak of a pandemic disease. This report assesses the extent to which (1) DOD has guidance and plans for supporting civil authorities in the event of a domestic outbreak of a pandemic disease, and (2) HHS and DHS have plans to respond to a pandemic if DOD’s support capabilities are limited, and they have mechanisms to coordinate their pandemic preparedness and response with DOD. To determine the extent to which DOD has guidance and plans for supporting civil authorities in the event of a domestic outbreak of a pandemic disease, we obtained and analyzed DOD guidance (e.g., DOD Directive 3025.18, Defense Support of Civil Authorities), policies (e.g., Department of Defense Global Campaign Plan for Pandemic Influenza and Infectious Disease), and directives, among other guidance, to determine DOD’s roles and responsibilities. We also obtained federal guidance such as DHS’s National Response Framework to determine which primary agencies would rely on DOD’s efforts to support civil authorities in the event of a domestic outbreak of a pandemic disease, and DHS’s Response Federal Interagency Operational Plan, which provides guidance to federal agencies on planning and coordinating federal response efforts. We compared DOD pandemic planning guidance with the National Response Framework to identify DOD’s role in support of primary federal agencies in their response to incidents such as pandemics. We also reviewed GAO’s prior work on influenza pandemic planning within DOD and other federal agencies. A list of related GAO products on influenza pandemics is included at the end of this report. To determine the extent to which HHS and DHS have plans to respond to a pandemic if DOD’s support capabilities are limited, and they have mechanisms to coordinate their pandemic preparedness and response with DOD, we obtained and analyzed pandemic planning guidance, such as HHS’s Pandemic Influenza Plan, DHS’s National Response Framework, and Federal Interagency Operational Plans to identify these primary agencies’ roles and responsibilities in support of civil authorities and in the event of a severe disease pandemic. We also identified— through interviews with agency officials and a review of guidance documents and plans—the mechanisms HHS and DHS use to coordinate with DOD and other federal, state, local, tribal, and territorial authorities and the private sector to prepare for a domestic outbreak of a pandemic disease and determined how coordination occurs among these entities. We compared HHS and DHS pandemic and response planning guidance with DOD pandemic planning guidance to determine the unity of effort among DOD and primary federal agencies to provide capabilities in support of civil authorities. In addition, we obtained and analyzed policy and guidance from DOD, HHS, and DHS to identify their roles and responsibilities for coordinating with governmental and private sector entities. To determine the extent to which DOD conducts or participates in training exercises with civil authorities in preparation for a domestic outbreak of a pandemic disease, we obtained and analyzed DOD and primary federal agency training exercise guidance to identify joint training exercises, documentation, and sharing requirements in preparation for a pandemic disease response. We conducted interviews with DOD, HHS, DHS, and FEMA to identify the pandemic-related training exercises they conducted during fiscal years 2011 through 2015. From DOD and FEMA, we also obtained after-action reports and lessons learned to identify the training exercise participants and the type of training exercises conducted. We determined that the interviews, after-action reports, and lessons-learned documentation were sufficiently reliable for the purposes of determining the extent to which DOD and FEMA conducted or participated in pandemic-related training exercises from fiscal years 2011 through 2015, the most current, complete fiscal years available. To address our objectives, we interviewed cognizant officials at various DOD offices, including the Office of the Under Secretary of Defense for Policy, Office of the Assistant Secretary of Defense for Homeland Defense and Global Security, Office of the Assistant Secretary of Defense for Health Affairs, Office of the Deputy Assistant Secretary of Defense for Homeland Defense Integration and Defense Support of Civil Authorities, the Joint Staff, U.S. Northern Command, U.S. Pacific Command, U.S. Southern Command, the National Guard Bureau, the Defense Intelligence Agency, U.S. Army Medical Command, U.S. Army Medical Research and Materiel Command, and the Armed Forces Health Surveillance Branch. We also conducted interviews with cognizant officials at HHS (including the Assistant Secretary for Preparedness and Response, Centers for Disease Control and Prevention, Food and Drug Administration, and National Institutes of Health) and DHS, including the Federal Emergency Management Agency. We interviewed these officials to determine their agency roles and responsibilities in support of civil authorities during a pandemic response; the mechanisms DOD and primary federal agencies, which have the lead in managing the federal response to a domestic incident, use to coordinate planning and response efforts for a pandemic; and the joint training exercises to identify potential capability gaps in their pandemic response plans. We conducted this performance audit from September 2015 to February 2017 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. Under the National Response Framework, Emergency Support Function (ESF) #8, Public Health and Medical Services provides the mechanism for coordinated federal government assistance to supplement state, tribal, and local resources in response to a public health and medical disaster, potential or actual incidents requiring a coordinated federal response, or during a developing potential health and medical emergency. Table 1 below summarizes the roles and responsibilities of the Department of Health and Human Services, as the primary federal agency, and the Departments of Defense and Homeland Security and Federal Emergency Management Agency, as supporting agencies, in response to the National Response Framework. In addition to the contacts named above, GAO staff who made key contributions on this report include Elizabeth Curda, Acting Director; Mark A. Pross, Assistant Director; Tracy Barnes, Steve Boyles; Margaret Holihan; Joanne Landesman; Latrealle Lee; Amie Lesser; and Amber Sinclair. Emerging Infectious Diseases: Preliminary Observations on the Zika Virus Outbreak, GAO-16-470T. Washington, D.C.: March 2, 2016. Influenza Pandemic: Lessons from the H1N1 Pandemic Should Be Incorporated into Future Planning, GAO-11-632. Washington, D.C.: June 27, 2011. Influenza Pandemic: Monitoring and Assessing the Status of the National Pandemic Implementation Plan Needs Improvement, GAO-10-73. Washington, D.C.: November 24, 2009. Influenza Pandemic: Sustaining Focus on the Nation’s Planning and Preparedness Efforts, GAO-09-334. Washington, D.C.: February 26, 2009. Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer Federal Leadership Roles and an Effective National Strategy, GAO-07-781. Washington, D.C.: August 14, 2007. Influenza Pandemic: 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: DOD Has Taken Important Actions to Prepare, but Accountability, Funding, and Communications Needed to be Clearer and Focused Departmentwide, GAO-06-1042. Washington, D.C.: September 21, 2006.

Summary: The U.S. Army estimates that if a severe infectious disease pandemic were to occur today, the number of U.S. fatalities could be almost twice the total number of battlefield fatalities in all of America's wars since the American Revolution in 1776. A pandemic occurs when an infectious agent emerges that can be efficiently transmitted between humans and has crossed international borders. DOD's day-to-day functioning and the military's readiness and operations abroad could be impaired if a large percentage of its personnel are sick or absent, and DOD's assistance to civil authorities might be limited. House Report 114-102 included a provision for GAO to assess DOD's planning and coordination to support civil authorities during a pandemic. This report assesses the extent to which (1) DOD has guidance and plans for supporting civil authorities in the event of a domestic outbreak of a pandemic disease and (2) HHS and DHS have plans to respond to a pandemic if DOD support capabilities are limited, and they have mechanisms to coordinate their pandemic preparedness and response. GAO reviewed agency pandemic guidance and plans, interagency coordination mechanisms, and pandemic-related exercises and after-action reports. Strategy for Homeland Defense and Support to Civil Authorities states that DOD often is expected to play a prominent supporting role to primary federal agencies. DOD also assists those agencies in the preparedness, detection, and response to other non-pandemic viruses, such as the recent outbreak of the Zika virus. HHS and DHS have plans to guide their response to a pandemic, but their plans do not explain how they would respond in a resource-constrained environment in which capabilities like those provided by DOD are limited. DOD coordinates with the agencies, but existing coordination mechanisms among HHS, DHS, and DOD could be used to improve preparedness. HHS's Pandemic Influenza Plan is the departmental blueprint for its preparedness and response to an influenza pandemic. DHS's National Response Framework is a national guide on how federal, state, and local governments are to respond to such incidents. DOD, HHS, and DHS have mechanisms—such as interagency working groups, liaison officers, and training exercises—to coordinate their response to a pandemic. For example, training exercises are critical in preparing these agencies to respond to an incident by providing opportunities to test plans, improve proficiency, and assess capabilities and readiness. These existing mechanisms provide the agencies opportunities to improve their preparedness and response to a pandemic. HHS and DHS plans do not specifically identify what resources would be needed to support a response to a pandemic in which demands exceeded federal resources. These officials stated that there would be no way of knowing in advance what resources would be required. HHS and DHS are in the process of updating their plans and thus have an opportunity to coordinate with each other and with DOD to determine the appropriate actions to take should DOD's support be limited. GAO recommends that DOD, HHS, and DHS use existing coordination mechanisms to explore opportunities to improve preparedness and response to a pandemic if DOD's capabilities are limited. DOD, HHS, and DHS concurred with GAO's recommendations.