An influenza pandemic is caused by a novel strain of influenza virus for which there is little resistance and which therefore is highly transmissible among humans. 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 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. On June 11, 2009, the World Health Organization (WHO) declared a pandemic based on the novel influenza A (H1N1) virus currently in wide circulation by raising the worldwide pandemic alert level to Phase 6—the highest level. Figure 1 shows the WHO phases of a pandemic, characterizing Phase 6 as community-level outbreaks in at least one country in a different WHO region in addition to the criteria defined in Phase 5. This action was a reflection of the spread of the new H1N1 virus, not the severity of illness caused by the virus. At that time, more than 70 countries had reported cases of 2009 H1N1 and there were ongoing community-level outbreaks in multiple parts of the world. As of November 8, 2009, WHO reported over 503,536 confirmed cases and at least 6,260 deaths, acknowledging, however, that the number of cases was actually understated since it is no longer requiring affected countries to count individual cases and confirm them through laboratory testing. Similar to the seasonal influenza, the 2009 H1N1 influenza can vary from mild to severe. Given ongoing H1N1 activity to date, the Centers for Disease Control and Prevention (CDC) stated that it anticipates that there will be more cases, more hospitalizations, and more deaths associated with this pandemic in the United States in the fall and winter. The novel H1N1 virus, in conjunction with regular seasonal influenza viruses, poses the potential to cause significant illness with associated hospitalizations and deaths during the U.S. influenza season. The United States continues to report the largest number of 2009 H1N1 cases of any country worldwide, although most people who have become ill have recovered without requiring medical treatment. The 2009 H1N1 influenza has been reported in all 50 states, the District of Columbia, Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands. As shown in figure 2, the Strategy lays out three high-level goals to prepare for and respond to an influenza: (1) stop, slow, or otherwise limit the spread of a pandemic to the United States; (2) limit the domestic spread of a pandemic and mitigate disease, suffering, and death; and (3) sustain infrastructure and mitigate impact on the economy and the functioning of society. These goals are underpinned by three pillars that are intended to guide the federal government’s approach to a pandemic threat, including: (1) preparedness and communication, (2) surveillance and detection, and (3) response and containment. Each pillar describes domestic and international efforts, animal and human health efforts, and efforts that would need to be undertaken at all levels of government and in communities. The Plan outlines steps for federal entities and 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. Of the 324 action items in the Plan, 144 are related to pillar 1 on preparedness and communication; 86 are related to pillar 2 on surveillance and detection; and the remaining 94 are related to pillar 3 on response and containment. Nearly all of the action items (307 of 324) have a measure of performance, and most (287 of 324) of the action items have a time frame identified either in the action item’s description, measure of performance, or both. Most of the action items in the Plan—those that were not tied to response—were expected to have been completed in 3 years, by May 2009. Since the issuance of the Plan in May 2006, the HSC publicly reported on the status of the action items at 6 months, 1 year, and 2 years in December 2006, July 2007, and October 2008, respectively. Although this administration has not yet publicly reported on the 3-year status of implementing the Plan’s action items, an NSS official stated that the 3-year progress report had been in development prior to the 2009 H1N1 pandemic, and may be released shortly. The HSC monitors the status of action items in the Plan tasked to federal agencies by convening regular interagency meetings and requesting summaries of progress from agencies. According to a former HSC official who was involved with monitoring the Plan in the prior administration and officials from all of the six agencies, following the development of the Plan, the HSC officials convened interagency meetings at the Sub-Policy Coordination Committee level (deputy assistant secretary or his or her representative) that included discussions on the implementation of action items. The former HSC official stated that these meetings are a forum for monitoring the status of the Plan’s action items. These meetings were held weekly after the release of the Plan and biweekly after the spring of 2008, according to the former HSC official. Officials from several of the selected agencies stated that the interagency meetings facilitate interagency cooperation and coordination on the action items in the Plan. Officials also said that these meetings provide a venue to raise and address concerns relating to how to implement particular action items, and enable them to build relationships with their colleagues in other agencies. In addition, the HSC requested that agencies provide the Council with periodic summaries of their progress on the action items in preparation for the HSC’s progress reports, according to officials from all of the selected agencies. Officials from the six selected agencies informed us that, in this administration, the NSS continues to lead the interagency process used to monitor progress of the Plan. Officials from several of the selected agencies stated that the NSS continues to hold meetings at the Sub- Interagency Policy Committee level to monitor efforts related to influenza pandemic, with a primary focus on the 2009 H1N1 response. According to an NSS official, the NSS has also requested periodic summaries of progress from agencies on the action items. For action items that involve multiple federal agencies, the six agencies monitor the action items assigned to them by designating one or two agencies to report one consolidated summary of progress for each action item to the HSC, according to agency officials. Some action items task additional federal agencies with a support role as well. According to agency officials, all agencies tasked with responsibility for an action item have to approve its summary of progress before it is provided to the HSC. The HSC’s 6-month, 1-year, and 2-year progress reports state that the action items’ summaries in the reports were prepared by relevant agencies and departments. Officials from all six agencies said that the HSC does not always require them to submit supporting documentation along with their summary of progress to determine if an action item is complete. For instance, officials at three of the agencies said that the HSC does not require them to submit supporting documentation, while officials from two other agencies said that additional information is required by the HSC if it is not convinced about the completeness of an action item, or if it is unclear that the respective measure of performance was met based on the summary of progress. For the 112 action items in the Plan that include both federal agencies and nonfederal entities, the responsible federal agencies determined how they would work with and monitor the nonfederal entities. According to the former HSC official, the responsible agencies determined how these action items would be implemented, including deciding which nonfederal entities they would work with and in what manner they would work with them. Among the six agencies we reviewed, five said that they worked with nonfederal entities to implement some of the action items in the Plan. For example, DOT officials stated that they worked with professional associations to develop guidelines and recommendations for Emergency Medical Services (EMS) and 9-1-1 call centers, and HHS officials told us that they worked with medical experts to develop guidance on mass casualty care. We interviewed representatives of nine of these nonfederal entities and all of them confirmed that the status of the action items with which they were associated had been accurately reported. However, they also told us that they had not been asked for input into the summaries of progress for the action items with which they were associated and had therefore been unable to check the accuracy of the summaries before they were reported. The HSC makes the final determination as to whether the Plan’s action items are completed, according to the former HSC official and officials from the selected agencies. The HSC bases its determination on information from federal agencies, and uses the measure of performance associated with the action items as criteria for completion, as stated in the HSC’s 6-month, 1-year, and 2-year progress reports. Officials from three of the selected agencies stated that their agencies advise the HSC as to whether they believe an action item is complete when they provide summaries of progress to the HSC, while officials from two selected agencies stated that they provide summaries of progress to the HSC, and the HSC ultimately determines if an action item is complete. An interagency group led by the HSC reviews the agencies’ summaries of progress to help determine if action items are complete. The former HSC official told us that the HSC’s method of assessing whether an action item was complete depends on the specific action item.