A flu pandemic is a worldwide epidemic of an influenza virus. As such, the United States' response to a flu pandemic would have both international and domestic components. Additionally, the domestic response effort would depend upon contributions from every governmental level (local, state, tribal, and federal), non-governmental organizations, and the private sector. This report will focus largely on the role of the Department of Defense (DOD) in supporting the nation's domestic response effort, although it will also touch on DOD's international role. The federal response to a flu pandemic would be broadly shaped by statute and executive branch plans and policies. Statutes such as the Robert T. Stafford Disaster Relief and Emergency Assistance Act (the Stafford Act), the Public Health Service Act, and other public health emergency authorities permit the federal government to provide various forms of assistance to eligible applicants, including state and local governments, non-profit organizations and individuals. While these statutes authorize the federal government to provide assistance, the manner in which the array of federal agencies provide that assistance in coordination with other levels of government, non-governmental organizations, and the private sector is guided by an executive branch planning document known as the National Response Framework (NRF). The NRF "is a guide to how the Nation conducts all-hazards response." Among other things, it establishes broad lines of authority for federal government agencies to prepare for and respond to any terrorist attack, major disaster, or other emergency (i.e., "all-hazards"). Under the NRF, the Secretary of State is responsible for "managing international preparedness, response and recovery activities relating to domestic incidents and the protection of U.S. citizens and U.S. interests overseas." The Secretary of Homeland Security is "the principal Federal official for domestic incident management...[and is] responsible for coordination of Federal resources utilized in the prevention of, preparation for, response to, and recovery from terrorist attacks, major disasters, and other emergencies." However, the Secretary of Health and Human Services (HHS) "leads all Federal public health and medical response to public health emergencies and incidents covered by the NRF." Given the centrality of public health and medical response during a flu pandemic, HHS would be the primary response agency for the domestic response, even while DHS coordinates the overall domestic response effort. The role of the Department of Defense (DoD) in supporting domestic response efforts under the NRF is potentially significant, while recognizing certain limits due to the Department's principal mission of national defense: The primary mission of the Department of Defense (DOD) and its components is national defense. Because of this critical role, resources are committed after approval by the Secretary of Defense or at the direction of the President. Many DOD components and agencies are authorized to respond to save lives, protect property and the environment, and mitigate human suffering under imminently serious conditions, as well as to provide support under their separate established authorities, as appropriate. The provision of defense support is evaluated by its legality, lethality, risk, cost, appropriateness, and impact on readiness. When Federal military and civilian personnel and resources are authorized to support civil authorities, command of those forces will remain with the Secretary of Defense. DOD elements in the incident area of operations and National Guard forces under the command of a Governor will coordinate closely with response organizations at all levels. A more thorough discussion of the types of support DoD might be called upon to provide to civil authorities, and the process whereby such support can be requested, occurs later in this report. While the NRF provides an "all-hazards" response framework, the federal government also has a strategic plan which specifies in more detail precisely how it will prepare for and respond to a flu pandemic within the context of the NRF. The National Strategy for Pandemic Influenza ( hereafter National Strategy) provides an overarching outline of how the federal government will prepare for, detect and respond to a such an event. It is based on three "pillars": preparedness and communications; surveillance and detection; and response and containment. A related document, the National Strategy for Pandemic Influenza Implementation Plan ( hereafter Implementation Plan) , details the specific actions and policy decisions which will be needed to execute this strategy and bring all the resources of the federal government to bear in a coordinated manner. Like the NRF, it affirms that the Secretary of State would be responsible for the coordination of the international response, the Secretary of Homeland Security would have overall responsibility for the federal government's response to a pandemic, and the Secretary of Health and Human Services would be responsible for the "overall coordination of the public health and medical emergency response during a pandemic...." It describes the role to the Secretary of Defense as follows: The Secretary of Defense will be responsible for protecting American interests at home and abroad. The Secretary of Defense may assist in the support of domestic infrastructure and essential government services or, at the direction of the President and in coordination with the Attorney General, the maintenance of civil order or law enforcement, in accordance with applicable law. The Secretary of Defense will retain command of military forces providing support. Subsequently, the Implementation Plan assigns some 300 tasks to various federal agencies. For each of these tasks, a lead federal agency is identified and, if need be, supporting agencies as well. A DoD analysis of the Implementation Plan identified 31 tasks which were assigned primarily to DoD and 83 which were assigned to other agencies with DoD in a supporting role. Of the tasks assigned primarily to DoD, most were related to one of these four objectives: Assisting in disease surveillance Assisting partner nations, particularly through military-to-military assistance Protecting and treating US forces and dependents Providing support to civil authorities in the United States Each of these general objectives is discussed in more detail below. The Department of Defense plays an important role in detecting and tracking diseases. Given the wide dispersal of U.S. military forces around the globe, the Department of Defense has long maintained a system for detecting infectious diseases in order to maintain intelligence on possible threats to force readiness. DoD conducts continuous worldwide influenza surveillance at domestic laboratories as well as at military installations around the world. More than a dozen different DOD entities cooperate with each other, foreign militaries, and some nonmilitary organizations in a complex arrangement that allows global surveillance of emerging infections. International cooperation is important due to the rapid transmission of disease made possible by high levels of global travel. DOD policy is designed to provide for detection capabilities at the lowest possible organizational level. The Institute of Medicine reviewed DOD's global influenza surveillance network in 2007 and issued a mainly favorable assessment, although the Implementation P lan required the Department of Defense to improve its capacity to detect and monitor new influenza strains, and to enhance its ability to share information with international organizations and agencies. DOD's influenza surveillance programs actively coordinate with the Centers for Disease Control and Prevention, Food and Drug Administration, and World Health Organization. Under the Implementation Plan , the Secretary of State is responsible for the coordination of the international response, including ensuring that other nations join us in our efforts to contain or slow the spread of a pandemic virus, helping to limit the adverse impacts on trade and commerce, and coordinating our efforts to assist other nations that are impacted by the pandemic. However, DoD has well-developed relationships with key leaders in many nations -- particularly with respect to foreign military officers and defense officials – and it also has expertise and capabilities that could be useful to the efforts of foreign governments to detect and contain a pandemic. As such, the Implementation Plan directed DoD to conduct a number of actions, in coordination with the Department of State and other appropriate agencies, to assist partner nation militaries in preparing for a pandemic. Examples of this type of assistance include assessing the preparedness and response plans of foreign militaries, validating these response plans with military-to-military exercises, conducting training programs to improve military infection control and case management, and assessing the capacity of foreign military labs and response teams. The Implementation Plan also directed DoD to support the Department of State in providing U.S. response capabilities to international response efforts. Examples of this type of support would include participating in investigative or technical assistance teams, or delivering countermeasures to affected countries. Additionally, if the Secretary of Defense approves a request from another federal agency for such support or if the President so directs, DoD may support containment operations or stability operations in another nation. In responding to an influenza pandemic, the Department of Defense would place a very high priority on protecting DoD personnel, including uniformed military servicemembers, DoD civilian employees, and contractors performing critical roles. The rationale for this is based on the national security implications of a virus disabling a sizable proportion of the DoD workforce. For example, an influenza pandemic could conceivably render naval ships unable to perform missions, shut down training and support activities on major bases, seriously degrade security at critical sites, and break the supply chain that sustains forward deployed forces. The Implementation Plan states: The primary responsibility of DOD is to preserve national security by protecting American forces, maintaining operational readiness, and sustaining critical military missions. DOD's first priority with respect to protecting human health will be to ensure sufficient capability to provide medical care to DOD forces and beneficiaries. DOD can provide medical, public health, transportation, logistical, communications, and other support [to non-DOD beneficiaries] consistent with existing legal authorities and to the extent that DOD's National Security preparedness is not compromised. In addition to conducting world-wide surveillance of potential disease threats (discussed previously), DoD protects its workforce through preparedness, communication, and medical response. Preparedness includes acquisition and prepositioning of vaccines, medicines, and other supplies. For example, DOD reports having 8.2 million treatment courses of Tamiflu on hand. With respect to the current H1N1 flu outbreak, testing to date shows the virus is susceptible to the antivirals Tamiflu and Relenza.