Influenza Pandemic
Federal Agencies Should Continue to Assist States to Address Gaps in Pandemic Planning Gao ID: GAO-08-539 June 19, 2008The Implementation Plan for the National Strategy for Pandemic Influenza states that in an influenza pandemic, the primary response will come from states and localities. To assist them with pandemic planning and exercising, Congress has provided $600 million to states and certain localities. The Department of Homeland Security (DHS) established five federal influenza pandemic regions to work with states to coordinate planning and response efforts. GAO was asked to (1) describe how selected states and localities are planning for an influenza pandemic and who they involved, (2) describe the extent to which selected states and localities conducted exercises to test their influenza pandemic planning and incorporated lessons learned as a result, and (3) identify how the federal government can facilitate or help improve state and local efforts to plan and exercise for an influenza pandemic. GAO conducted site visits to five states and 10 localities.
All of the five states and 10 localities reviewed by GAO had developed influenza pandemic plans. In fact, according to officials at the Centers for Disease Control and Prevention (CDC), which administers the federal pandemic funds, all 50 states have developed an influenza pandemic plan, in accordance with federal pandemic funding requirements. At the time of GAO's site visits, officials from the selected states and localities reviewed said that they involved the federal government, other state and local agencies, tribal nations, and nonprofit and private sector organizations in their influenza pandemic planning. Since GAO's site visits, the Department of Health and Human Services (HHS) has provided feedback to the states, territories, and the District of Columbia (hereafter referred to as states) on whether their plans addressed 22 priority areas, such as policy process for school closure and communication. On average the department found that states' plans had "many major gaps" in 16 of the 22 priority areas. In March 2008, HHS, DHS, and other federal agencies issued guidance to states to help them update their pandemic plans, which are due by July 2008, in preparation for another HHS-led review. According to CDC officials, all states and localities that received the federal pandemic funds have met the requirement to conduct an exercise to test their plans. Officials from all of the states and localities reviewed by GAO reported that they had incorporated lessons learned from influenza pandemic exercises into their influenza pandemic planning, such as buying additional medical equipment, providing training, and modifying influenza pandemic plans. For example, as a result of an exercise, officials at the Dallas County Department of Health and Human Services (Texas) reported that they developed an appendix to their influenza pandemic plan on school closures during a pandemic. The federal government has provided influenza pandemic guidance on a variety of topics including an influenza pandemic planning checklist for states and localities and draft guidance on allocating an influenza pandemic vaccine. However, officials of the states and localities reviewed by GAO told GAO that they would welcome additional guidance from the federal government in a number of areas to help them to better plan and exercise for an influenza pandemic, in areas such as community containment (community-level interventions designed to reduce the transmission of a pandemic virus). Three of these areas were also identified as having "many major gaps" in states' plans nationally in the HHS-led review. In January 2008, HHS and DHS, in coordination with other federal agencies, hosted a series of meetings of states in the five federal influenza pandemic regions to discuss the draft guidance on updating their pandemic plans. Although a senior DHS official reported that there are no plans to conduct further workshops, additional regional meetings could provide a forum for state and federal officials to address gaps in states' planning identified by the HHS-led review and to maintain the momentum of states' pandemic preparedness through this next governmental transition.
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Director: Team: Phone:GAO-08-539, Influenza Pandemic: Federal Agencies Should Continue to Assist States to Address Gaps in Pandemic Planning
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
June 2008:
Influenza Pandemic:
Federal Agencies Should Continue to Assist States to Address Gaps in
Pandemic Planning:
GAO-08-539:
GAO Highlights:
Highlights of GAO-08-539, a report to congressional requesters.
Why GAO Did This Study:
The Implementation Plan for the National Strategy for Pandemic
Influenza states that in an influenza pandemic, the primary response
will come from states and localities. To assist them with pandemic
planning and exercising, Congress has provided $600 million to states
and certain localities. The Department of Homeland Security (DHS)
established five federal influenza pandemic regions to work with states
to coordinate planning and response efforts.
GAO was asked to (1) describe how selected states and localities are
planning for an influenza pandemic and who they involved, (2) describe
the extent to which selected states and localities conducted exercises
to test their influenza pandemic planning and incorporated lessons
learned as a result, and (3) identify how the federal government can
facilitate or help improve state and local efforts to plan and exercise
for an influenza pandemic. GAO conducted site visits to five states and
10 localities.
What GAO Found:
All of the five states and 10 localities reviewed by GAO had developed
influenza pandemic plans. In fact, according to officials at the
Centers for Disease Control and Prevention (CDC), which administers the
federal pandemic funds, all 50 states have developed an influenza
pandemic plan, in accordance with federal pandemic funding
requirements. At the time of GAO‘s site visits, officials from the
selected states and localities reviewed said that they involved the
federal government, other state and local agencies, tribal nations, and
nonprofit and private sector organizations in their influenza pandemic
planning. Since GAO‘s site visits, the Department of Health and Human
Services (HHS) has provided feedback to the states, territories, and
the District of Columbia (hereafter referred to as states) on whether
their plans addressed 22 priority areas, such as policy process for
school closure and communication. On average the department found that
states‘ plans had ’many major gaps“ in 16 of the 22 priority areas. In
March 2008, HHS, DHS, and other federal agencies issued guidance to
states to help them update their pandemic plans, which are due by July
2008, in preparation for another HHS-led review.
According to CDC officials, all states and localities that received the
federal pandemic funds have met the requirement to conduct an exercise
to test their plans. Officials from all of the states and localities
reviewed by GAO reported that they had incorporated lessons learned
from influenza pandemic exercises into their influenza pandemic
planning, such as buying additional medical equipment, providing
training, and modifying influenza pandemic plans. For example, as a
result of an exercise, officials at the Dallas County Department of
Health and Human Services (Texas) reported that they developed an
appendix to their influenza pandemic plan on school closures during a
pandemic.
The federal government has provided influenza pandemic guidance on a
variety of topics including an influenza pandemic planning checklist
for states and localities and draft guidance on allocating an influenza
pandemic vaccine. However, officials of the states and localities
reviewed by GAO told GAO that they would welcome additional guidance
from the federal government in a number of areas to help them to better
plan and exercise for an influenza pandemic, in areas such as community
containment (community-level interventions designed to reduce the
transmission of a pandemic virus). Three of these areas were also
identified as having ’many major gaps“ in states‘ plans nationally in
the HHS-led review. In January 2008, HHS and DHS, in coordination with
other federal agencies, hosted a series of meetings of states in the
five federal influenza pandemic regions to discuss the draft guidance
on updating their pandemic plans. Although a senior DHS official
reported that there are no plans to conduct further workshops,
additional regional meetings could provide a forum for state and
federal officials to address gaps in states‘ planning identified by the
HHS-led review and to maintain the momentum of states‘ pandemic
preparedness through this next governmental transition.
What GAO Recommends:
GAO recommends that the Secretaries of Health and Human Services and
Homeland Security, 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 generally concurred with the recommendation and DHS
concurred.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-539]. For more
information, contact Bernice Steinhardt at (202) 512-6543 or
steinhardtb@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
States and Localities Have Planned for an Influenza Pandemic and Have
Involved Others in Their Planning, but HHS Has Found Major Gaps in
States' Plans:
All States and Localities Reviewed Have Conducted or Participated in at
Least One Exercise to Test Their Planning for an Influenza Pandemic and
Have Incorporated Lessons Learned:
HHS and DHS Could Further Assist States in Addressing Gaps Identified
in Pandemic Planning:
Conclusions:
Recommendation for Executive Action:
Agency Comments:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: Comments from the Department of Homeland Security:
Related GAO Products:
Table:
Table 1: National Average of Status of States' Pandemic Plans by
Priority Areas and Lead Federal Government Reviewer:
Figures:
Figure 1: Five Federal Influenza Pandemic Regions:
Figure 2: HHS Influenza Pandemic Supplemental Appropriations, Fiscal
Year 2006:
Abbreviations:
ASPR: Office of the Assistant Secretary for Preparedness and Response:
CDC: Centers for Disease Control and Prevention:
DHS: Department of Homeland Security:
FCO: Federal Coordinating Officer:
FEMA: Federal Emergency Management Agency:
HHS: Department of Health and Human Services:
HSEEP: Homeland Security Exercise and Evaluation Program:
LLIS: Lessons Learned Information Sharing System:
MOU: Memorandum of Understanding:
National Pandemic Implementation Plan: Implementation Plan for the
National Strategy for Pandemic Influenza:
National Pandemic Strategy: National Strategy for Pandemic Influenza:
NIMS: National Incident Management System:
NIPP: National Infrastructure Protection Plan:
NRF: National Response Framework:
PAHPA: Pandemic and All-Hazards Preparedness Act:
PFO: Principal Federal Official:
PHEP: Public Health Emergency Preparedness Program:
SFO: Senior Federal Official:
Stafford Act: Robert T. Stafford Disaster Relief and Emergency
Assistance Act:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
June 19, 2008:
Congressional Requesters:
The Implementation Plan for the National Strategy for Pandemic
Influenza (National Pandemic Implementation Plan) states that in the
event of an influenza pandemic the distributed nature and sheer burden
of 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. However, given the unique nature of an influenza pandemic,
all sectors of society, including the federal government, states and
local communities, the private sector, nonprofit organizations, tribal
nations, individual citizens, and global partners will need to be
involved in preparedness for and response to a pandemic.
An influenza pandemic is a real and significant threat facing the
United States and the world. There is widespread agreement that it is
not a question of if, but when, such an influenza pandemic will occur.
Some of the issues associated with the preparation for and responses to
an influenza pandemic are similar to those for any other type of
disaster or hazard. However, a pandemic poses some unique challenges.
During the peak weeks of an outbreak of a severe influenza pandemic in
the United States, an estimated 40 percent of the United States
workforce might not be at work due to illness, the need to care for
family members who are sick, or fear of becoming infected. Moreover, an
influenza pandemic is likely to occur in several waves, each lasting up
to 6 to 8 weeks, with outbreaks occurring simultaneously across the
country.
The National Strategy for Pandemic Influenza (National Pandemic
Strategy), which was issued in November 2005 by the President and his
Homeland Security Council, 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. The National Pandemic
Implementation Plan, which was issued in May 2006 by the President and
his Homeland Security Council, lays out the broad implementation
requirements and responsibilities among the appropriate federal
agencies and defines expectations of nonfederal entities for the
National Pandemic Strategy. The National Pandemic Implementation Plan
lays out the expectation that states and communities should have
influenza pandemic preparedness plans and conduct pandemic exercises.
Exercises are crucial in testing and planning. Our work has shown the
importance of ensuring that lessons learned from exercises are
incorporated into planning to address any gaps or challenges
identified.[Footnote 1] To assist in planning and coordinating efforts
to respond to an influenza pandemic, in December 2006, the Secretary of
Homeland Security established five federal influenza pandemic regions
across the United States to work with states to coordinate planning and
response efforts. In addition, cooperative agreements and grants from
the Department of Health and Human Services (HHS) and the Department of
Homeland Security (DHS) provide funds that state and local governments
can use to support planning and exercising for an influenza pandemic.
During fiscal year 2006, Congress provided HHS $600 million in
supplemental funding for state and local influenza pandemic planning
and exercising, which has been administered by the Centers for Disease
Control and Prevention (CDC), the last portion is to be distributed in
2008. The federal government has communicated the importance of
remaining vigilant and sustaining pandemic preparedness. Continuing and
maintaining these efforts is particularly crucial now, given the
upcoming federal governmental transition in January 2009.
This report responds to your request that we (1) describe how selected
states and localities are planning for an influenza pandemic and how
their efforts are involving the federal government, other state and
local agencies, tribal nations, nonprofit organizations, and the
private sector, (2) describe the extent to which selected states and
localities have conducted exercises to test their influenza pandemic
planning and incorporated lessons learned into their planning, and (3)
identify how the federal government can facilitate or help improve
state and local efforts to plan and exercise for an influenza pandemic.
To address these objectives, from June 2007 through September 2007, we
conducted site visits to the five most populous states: California,
Florida, Illinois, New York, and Texas. Recognizing that we would be
limited in our ability to report on all states in detail, we selected
these five states for a number of reasons, including that these states:
* comprised over one-third of the United States population;
* received over one-third of the total funding from HHS and DHS that
could be used for planning or exercising for an influenza pandemic,
[Footnote 2] and each state received the highest amount of total HHS
and DHS funding that could be used for planning and exercising for an
influenza pandemic respectively within each of the five regions
established by DHS for influenza pandemic preparedness and emergency
response, and;
* were likely entry points for individuals coming from another country
given that the states bordered either Mexico or Canada or contained
major ports, or both, and accounted for over one-third of the total
number of passengers traveling within the United States, and over half
of both inbound and outbound international air passenger traffic to and
from the United States.
In each state, we interviewed officials responsible for health,
emergency management, and homeland security. We also interviewed
officials at 10 localities in these same states, which consisted of
five urban areas and five rural counties. We interviewed officials
responsible for health and emergency management at an urban area and a
rural county in each of the five states. The urban areas included Los
Angeles County (California), Miami (Florida), Chicago (Illinois), New
York City (New York), and Dallas (Texas). These urban areas were
selected based on having the highest population totals of all urban
areas in the respective states and high levels of international airport
passenger traffic. Three of these urban areas also received federal
pandemic funds: Los Angeles County, Chicago, and New York City. The
rural counties we selected--Stanislaus County (California), Taylor
County (Florida), Peoria County (Illinois), Washington County (New
York), and Angelina County (Texas)--were each nominated by state
officials based on the following criteria: these counties had conducted
some planning or exercising for an influenza pandemic and they were
representative of challenges and needs that surrounding counties might
also be facing. In total we interviewed officials with 34 different
agencies. We also reviewed documentation from the selected state and
local governments.
While the states and localities selected provided a broad perspective,
we cannot generalize or extrapolate the information gleaned from the
site visits to the nation. In addition, since the states that we
selected were large, the most populous states, and likely entry points
for people coming into the United States, the information we collected
may not be as relevant to smaller, less populated states that are not
likely entry points for people coming into the United States.
We also interviewed HHS, CDC, and DHS officials about how they are
working with states and localities in planning and exercising for an
influenza pandemic and reviewed documentation that they provided,
including information on the HHS-led review of states', five
territories',[Footnote 3] and the District of Columbia's[Footnote 4]
influenza pandemic plans and the guidance to assist them in updating
their influenza plans for the next assessment of their plans. In
January 2008, we observed two of five influenza pandemic regional
workshops led by HHS and DHS, in coordination with other federal
agencies. The purpose of the workshops was to obtain state leaders'
input on guidance to assist their governments in updating their
pandemic plans in preparation for a second HHS-led review of these
plans. In addition, we interviewed officials from the National
Governors Association, Association of State and Territorial Health
Officials, National Association of County and City Health Officials,
and the National Emergency Management Association who are working on
issues related to state and local influenza pandemic activities. We
also reviewed relevant literature and prior GAO work.
We conducted this performance audit from March 2007 to June 2008 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. Detailed information on our
scope and methodology appears in appendix I. In addition, a list of
related GAO products is included at the end of this report.
Results in Brief:
All of the five states and 10 localities we reviewed, both urban and
rural, had developed influenza pandemic plans. In addition, all 50
states have developed an influenza pandemic plan in accordance with
federal pandemic funding requirements according to CDC officials. At
the time of our site visits, officials from three of the five states
and two of the three localities that received direct federal pandemic
funds reported conferring with HHS and CDC for technical assistance in
planning for an influenza pandemic. Officials from the selected states
and localities reviewed said that they involved other state and local
agencies, tribal nations, and nonprofit and private sector
organizations in their influenza pandemic planning in accordance with
federal pandemic funding requirements. For example, state public health
agencies in all the states reported assisting their local counterparts
with their influenza pandemic plans. Since we visited these states and
localities, HHS has provided feedback to the states on whether their
plans addressed 22 priority areas, such as policy process for school
closures and communication. On average, the department found that
states had "many major gaps" in their influenza pandemic plans in 16 of
the 22 priority areas. In March 2008, HHS, DHS, and other federal
agencies issued guidance to states to help them to update their
pandemic plans, which are due by July 2008.
According to CDC officials, all states and localities that received
federal pandemic funds have met the requirement to conduct an exercise
to test their influenza pandemic plans. These states and localities
could have met this requirement by conducting a discussions-based
exercise or an operations-based exercise, which is used to validate the
plans, policies, agreements, and procedures assessed in discussions-
based exercises. One state and two localities conducted at least one
discussions-based and an operations-based exercise, one state and one
locality conducted at least one operations-based exercise, and the
remaining three states and seven localities conducted or participated
in at least one discussions-based influenza pandemic exercise.
Officials from all of the states and localities we reviewed reported
that they had incorporated lessons learned from influenza pandemic
exercises into their influenza pandemic planning, such as buying
additional medical equipment, providing training, and modifying
policies or influenza pandemic plans. For example, as a result of an
exercise, officials at the Dallas County Department of Health and Human
Services (Texas) reported that they developed an appendix to their
influenza pandemic plan on school closures during a pandemic that
included factors for schools to consider in deciding when to close
schools and for how long.
The federal government has provided influenza pandemic information and
guidance through Web sites and state and regional meetings on a variety
of topics including an influenza pandemic planning checklist for states
and localities, draft guidance on allocating and targeting an influenza
pandemic vaccine, and discussions-based exercises for influenza
pandemic preparedness for local public health agencies. However,
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 to help them to better plan and exercise for an
influenza pandemic. Three of these areas--including community
containment, which is community-level interventions, such as closing
schools, designed to reduce the transmission of a pandemic virus--were
also identified as having "many major gaps" in states' plans nationwide
in the HHS-led review. In January 2008, HHS and DHS, in coordination
with other federal agencies, hosted a series of meetings of states in
the five federal influenza pandemic regions to discuss draft guidance
on updating their pandemic plans. Although a senior DHS official in the
Office of Health Affairs reported that there are no plans to conduct
further regional state workshops on influenza pandemic, additional
meetings could provide a forum for state and federal officials to
address gaps in states' planning identified by the HHS-led review. The
meetings could also help maintain the momentum that has already been
started by HHS and DHS to continue to work with the states on pandemic
preparedness through this next federal government transition.
Although HHS completes distribution of the federal pandemic funds in
2008, the federal government can continue to provide support to states
in other ways. To help maintain a continuity of focus on state pandemic
planning efforts and to further assist states in their pandemic
planning, we recommend that the Secretaries of Health and Human
Services and Homeland Security, 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.
We provided a draft of the report to the Secretaries of Health and
Human Services and Homeland Security for their review and comment. HHS
generally concurred with our recommendation in an e-mail. The
department stated that although additional workshops would be
impractical in the short-term in light of the ongoing update of the
state pandemic plans, the workshops had been successful, and HHS was
prepared to arrange for similar sessions in the future if states would
find them useful. The department also provided us with technical
comments, which we incorporated as appropriate. DHS generally agreed
with the contents of the report and concurred with our recommendation.
DHS's comments are reprinted in appendix II. We also provided draft
portions of the report to the state and local officials from the five
states and 10 localities we reviewed to ensure technical accuracy. We
received no comments from these states and localities.
Background:
Federal Emergency Response Framework:
In the event of a disaster, such as an influenza pandemic, states may
request federal assistance to maintain essential services pursuant to
the Robert T. Stafford Disaster Relief and Emergency Assistance Act
(Stafford Act) of 1974.[Footnote 5] The Stafford Act primarily
establishes the programs and processes for the federal government to
provide disaster assistance to state and local governments and tribal
nations, individuals, and qualified private nonprofit organizations.
Federal assistance may include technical assistance, the provision of
goods and services, and financial assistance. The Federal Emergency
Management Agency (FEMA), which is part of DHS, is responsible for
carrying out the functions and authorities of the Stafford Act. For
Stafford Act incidents, upon the recommendation of the Secretary of
Homeland Security and the FEMA Administrator, the President may appoint
a Federal Coordinating Officer (FCO) to manage and coordinate federal
resource support activities provided pursuant to the Stafford Act.
DHS has recently updated the National Response Plan, now called the
National Response Framework (NRF).[Footnote 6] To assist in planning
and coordinating efforts to respond to an influenza pandemic, in
December 2006, the Secretary of Homeland Security predesignated a
national Principal Federal Official (PFO) and FCO for influenza
pandemic, and established five federal influenza pandemic regions each
with a regional PFO and FCO. This structure was formalized in the NRF.
The PFO facilitates federal support to establish incident management
and assistance activities for prevention, preparedness, response, and
recovery efforts while the FCO manages and coordinates federal resource
support activities provided pursuant to the Stafford Act. The PFO is to
provide a primary point of contact and situational awareness for the
Secretary of Homeland Security. In addition, according to an official
in HHS' Office of the Assistant Secretary for Preparedness and Response
(ASPR), HHS has also predesignated a national Senior Federal Official
(SFO) and a regional SFO for influenza pandemic in each of the five
federal influenza pandemic regions who serve as ambassadors for public
health to states, territories, and the District of Columbia, which
aligns with the PFO and FCO structure. The federal influenza pandemic
regions, each of which consists of two standard federal regions, are
shown below.
Figure 1: Five Federal Influenza Pandemic Regions:
[See PDF for image]
This figure is a listing of the Five Federal Influenza Pandemic
Regions, as follows:
Region: A;
Standard federal regions: 1 + 2 (Boston/New York);
By state:
* Connecticut;
* Maine;
* Massachusetts;
* New Hampshire;
* New Jersey;
* New York;
* Puerto Rico;
* Rhode Island;
* Vermont;
* Virgin Islands.
Region: B;
Standard federal regions: 3 + 4 (Philadelphia/Atlanta);
By state:
* Alabama;
* Delaware;
* District of Columbia;
* Florida;
* Georgia;
* Kentucky;
* Maryland;
* Mississippi;
* North Carolina;
* Pennsylvania;
* South Carolina;
* Tennessee;
* Virginia;
* West Virginia.
Region: C;
Standard federal regions: 5 + 8 (Chicago/Denver);
By state:
* Colorado;
* Illinois;
* Indiana;
* Michigan;
* Minnesota;
* Montana;
* North Dakota;
* Ohio;
* South Dakota;
* Utah;
* Wisconsin;
* Wyoming.
Region: D;
Standard federal regions: 6 + 7 (Denton/Kansas City);
By state:
* Arkansas;
* Iowa;
* Kansas;
* Louisiana;
* Missouri;
* Nebraska;
* New Mexico;
* Oklahoma;
* Texas.
Region: E;
Standard federal regions: 9 + 10 (Oakland/Bothell);
By state:
* Alaska;
* Arizona;
* California;
* Hawaii;
* Idaho;
* Nevada;
* Oregon;
* Washington.
Source: DHS.
[End of figure]
In addition, under the Public Health Service Act, the Secretary of
Health and Human Services has the authority to declare a public health
emergency and to take actions necessary to respond to that emergency
consistent with his/her authorities.[Footnote 7] These actions may
include making grants, entering into contracts, and conducting and
supporting investigations into the cause, treatment, or prevention of
the disease or disorder that caused the emergency. According to the
National Pandemic Implementation Plan, as the lead agency responsible
for public health and medical care, HHS would lead efforts during an
influenza pandemic while DHS would be responsible for overall
nonmedical support such as domestic incident management and federal
coordination.
In December 2006, Congress passed the Pandemic and All-Hazards
Preparedness Act (PAHPA)[Footnote 8] which codifies preparedness and
response federal leadership roles and responsibilities for public
health and medical emergencies by designating the Secretary of Health
and Human Services as the lead federal official for public health and
medical preparedness and response.[Footnote 9] The act also prescribes
several new preparedness responsibilities for HHS. Among these, the
Secretary must develop and disseminate criteria for an effective state
plan for responding to an influenza pandemic. Additionally, the
Secretary is required to develop and require the application of
evidence-based benchmarks and objective standards that measure the
levels of preparedness for public health emergencies in consultation
with state, local, and tribal officials and private entities, as
appropriate. Application of these benchmarks and standards is required
of entities receiving funds under HHS public health emergency
preparedness grant and cooperative agreement programs.[Footnote 10]
Beginning in fiscal year 2009, the Secretary of Health and Human
Services is to withhold certain amounts of funding under these grant
and cooperative agreement programs where a state has failed to develop
an influenza pandemic plan that is consistent with the criteria
established by HHS or where an entity has failed to meet the benchmarks
or standards established.[Footnote 11]
Various Federal Funds Are Available to States and Localities for
Influenza Pandemic Planning and Exercising:
In addition to the federal pandemic funds provided for states and
localities by Congress in fiscal year 2006, HHS and DHS receive funds
for public health and emergency management grant programs that can be
used by states and localities to continue to support influenza pandemic
efforts. In fiscal year 2006, Congress appropriated $5.62 billion in
supplemental funding to HHS for, among other things, (1) monitoring
disease spread to support rapid response, (2) developing vaccines and
vaccine production capacity, (3) stockpiling antivirals[Footnote 12]
and other countermeasures, (4) upgrading state and local capacity, and
(5) upgrading laboratories and research at CDC.[Footnote 13]
As shown in figure 2, a total of $770 million, or about 14 percent, of
this supplemental funding went to states and localities for
preparedness activities. Of the $770 million, $600 million was
specifically provided by Congress for state and local planning and
exercising while the remaining $170 million was allocated for state
antiviral purchases. According to HHS, as of May 2008, states had
purchased $21.9 million of treatment courses of influenza antivirals
for their state stockpiles. In addition to these state stockpiles of
antivirals, HHS has also acquired antivirals that are in the HHS-
managed Strategic National Stockpile, which is a national repository of
medical supplies that is designed to supplement and resupply local
public health agencies in the event of a public health emergency.
Figure 2: HHS Influenza Pandemic Supplemental Appropriations, Fiscal
Year 2006:
[See PDF for image]
This figure is a pie-chart depicting the following data:
HHS Influenza Pandemic Supplemental Appropriations, Fiscal Year 2006
(Dollars in million):
Risk communications: $51 (1%);
Medical supplies (personal protective equipment, ventilators, etc.);
$170 (3%);
International activities[A]: $179 (3%);
Other domestic[B]: $276 (5%);
State and local preparedness[C]: $770 (14%);
Antivirals[C]: $911 (16%);
Vaccine: $3,233 (58%);
Total: $5,590[D].
Source: GAO, HHS.
Notes: Data are from HHS, Pandemic Planning Update III: A Report from
Secretary Michael O. Leavitt (Washington, D.C.: Nov. 13, 2006).
[A] International activities includes: international preparedness,
surveillance, response, and research.
[B] Other domestic includes: surveillance, quarantine, lab capacity,
rapid tests.
[C] State and local preparedness includes funding for state subsidies
of antiviral drugs.
[D] This chart does not include $30 million in supplemental funding
that was transferred to the United States Agency for International
Development.
[End of figure]
In addition to the federal pandemic funds specifically provided by
Congress, which are administered for HHS by CDC, HHS officials said
that states and localities could use funds provided under two other HHS
public health emergency preparedness cooperative agreement programs to
continue to support their influenza pandemic activities.[Footnote 14]
* The Public Health Emergency Preparedness Program (PHEP), which is a
cooperative agreement administered by CDC, is intended to improve state
and local public health security capabilities. Specifically, the Cities
Readiness Initiative, a component of PHEP, is intended to ensure that
major cities and metropolitan areas are prepared to distribute medicine
and medical supplies during a large-scale public health emergency.
* The Hospital Preparedness Program, which is administered by HHS ASPR,
is intended to improve surge capacity and enhance community and
hospital preparedness for public health emergencies.
DHS officials also said that states and localities could use funds
provided under three of the Homeland Security Grant Program grants,
which are administered by DHS's Office of Grants and Training, to
continue to support influenza pandemic activities.
* The State Homeland Security Grant Program's purpose includes
supporting, building, and sustaining capabilities at the state and
local levels through planning, equipment, training, and exercise
activities.
* The Metropolitan Medical Response System Program is intended to
support an integrated, systematic mass casualty incident preparedness
program that enables an effective response during the first crucial
hours of an incident such as an epidemic outbreak, natural disaster,
and a large-scale hazardous materials incident.
* The Urban Area Security Initiative Grant Program is intended to
address the unique planning, equipment, training, and exercise needs of
high-threat, high-density urban areas.
States and Localities Have Planned for an Influenza Pandemic and Have
Involved Others in Their Planning, but HHS Has Found Major Gaps in
States' Plans:
All of the five states and 10 localities we reviewed, both urban and
rural, had developed influenza pandemic plans. As directed by the
federal pandemic funding guidance, all 50 states and localities that
received direct funding through the PHEP and Hospital Preparedness
Program were required to plan and exercise for an influenza pandemic.
According to CDC officials, all 50 states have developed an influenza
pandemic plan. Of the $600 million designated by Congress for states
and localities for planning and exercising, CDC divided the funding
into three phases. Recipients included 50 states, five territories,
[Footnote 15] three Freely Associated States of the Pacific,[Footnote
16] three localities,[Footnote 17] and the District of Columbia. CDC
awarded $100 million for Phase I in March 2006, $250 million for Phase
II in two disbursements--July 2006 and March 2008 [Footnote 18]--and
$250 million for Phase III in two disbursements--September 2007 and
October 2007.[Footnote 19] Phase III is to be completed in 2008 and
will be the final phase for dedicated federal pandemic funds to states
and localities that received direct federal funding.
For Phase I, recipients were expected to comply with the following
requirements, among others:
* establish a committee or consortium at the state and local levels
with which the recipient is engaged that represents all relevant
stakeholders in the jurisdiction, such as public health, emergency
response, business, community-based, and faith-based sectors;
* implement a planning framework for influenza pandemic preparedness
and response activities to support public health and medical efforts;
* collaborate among public health and medical preparedness, influenza,
infectious disease, and immunization programs and state and local
emergency management to maximize the effect of funds and efforts;
* coordinate activities between state and local jurisdictions, tribes,
and military installations; among local agencies; with hospitals and
major health care facilities; and with adjacent states;
* conduct exercises to test the plans of states or localities that
receive the funding directly and prepare an after-action report, which
is a summary of lessons learned highlighting necessary corrective
actions;
* assess gaps in pandemic preparedness using CDC's self-assessment tool
to evaluate the jurisdiction's current state of preparedness;
* submit a proposed approach to filling the identified gaps; and:
* provide an associated budget for the critical tasks necessary to
address those gaps.
According to CDC officials, all entities that received direct federal
funding have met the requirements for Phase I of the federal pandemic
funds.
For Phase II, recipients were expected to comply with the following
four priority activities, among others:
* development of a jurisdictional work plan to address gaps identified
by the CDC self-assessment process in Phase I;
* development of and exercise an antiviral drug distribution plan;
* development of a pandemic exercise program that includes medical
surge, mass prophylaxis,[Footnote 20] and nonpharmacological public
health interventions[Footnote 21] and a community containment plan
[Footnote 22] with emphasis on closing schools and discouragement of
large public gatherings at a minimum; and:
* submission of an influenza pandemic operational plan to CDC.
According to HHS, CDC has reviewed whether recipients met the
requirements identified in the Phase II guidance.[Footnote 23]
In addition, recipients were asked to document the process used to
engage Indian tribal governments in Phases I and II and to develop and
implement an influenza pandemic preparedness exercise program involving
community partners to exercise their capabilities and prepare an after-
action report highlighting necessary corrective actions. Unlike Phase I
in which there is no mention of DHS's Homeland Security Exercise and
Evaluation Program (HSEEP),[Footnote 24] in Phase II CDC encouraged,
but did not require, recipients to use HSEEP for disaster planning and
exercising efforts. HSEEP guidance defines seven different types of
exercises, each of which is either discussions-based or operations-
based. Discussions-based exercises are a starting point in the building
block approach of escalating exercise complexity. These types of
exercises typically highlight existing plans, policies, interagency and
interjurisdictional agreements, and procedures and focus on strategic,
policy-oriented issues. An example of a discussions-based exercise is a
tabletop exercise that can be used to assess plans, policies, and
procedures or to assess the systems needed to guide the prevention of,
response to, and recovery from a defined incident. Operations-based
exercises are characterized by an actual reaction to simulated
intelligence; response to emergency conditions; mobilization of
apparatus, resources, and networks; and commitment of personnel,
usually over an extended period. These exercises are used to validate
the plans, policies, agreements, and procedures assessed in discussions-
based exercises. An example of an operations-based exercise is a full-
scale exercise, which is a multiagency, multijurisdictional,
multiorganizational exercise that validates many facets of
preparedness. CDC's federal pandemic funding guidance for Phase I and
II did not explicitly specify the type of exercises to be conducted;
the exception was the mass prophylaxis exercise for Phase II, which was
required to be an operations-based exercise. In order to be compliant
with HSEEP protocols, there are four distinct performance requirements.
They include (1) conducting an annual training and exercise plan
workshop and developing and maintaining a multiyear training and
exercise plan, (2) planning and conducting exercises in accordance with
the guidelines set forth by HSEEP, (3) developing and submitting an
after-action report, and (4) tracking and implementing corrective
actions identified in the after-action report.
For Phase II, the National Governors Association conducted a series of
nine influenza pandemic regional workshops for states between April
2007 and January 2008 to enhance intergovernmental and interstate
coordination. In a February 2008 issue brief, the National Governors
Association reported its results from five regional influenza pandemic
preparedness workshops involving 27 states and territories conducted
between April and August 2007. The workshops were designed to identify
gaps in state influenza pandemic preparedness--specifically in non-
health-related areas such as continuity of government, maintenance of
essential services, and coordination with the private sector, and to
examine strengths and weaknesses of coordination activities among
various levels of government. The workshops also included a discussions-
based exercise focused on regional issues.[Footnote 25]
For Phase III, recipients were asked to describe ongoing influenza
pandemic-related priority projects that would improve exercising and
response capabilities specifically for an influenza pandemic. Phase III
required recipients to fill planning gaps identified in Phase I and II.
In addition, recipients were expected to comply with the following
requirements, among others:
* submit workplans that included specific influenza pandemic planning,
implementation, and evaluation of activities;
* update the existing influenza pandemic operational plan based on
CDC's assessment on six priority thematic areas,[Footnote 26] by
January 2008;
* create an exercise strategy and schedule; and:
* utilize the tools developed by DHS's HSEEP to create planning,
training, and exercise evaluation programs, which includes an after-
action report, improvement plan, and corrective action program for each
seminar, tabletop, functional, or full-scale exercise conducted.
States Have Made Progress in Developing Their Influenza Pandemic Plans:
Over the past several years, states have made progress in developing
pandemic plans. In 2006, CDC reported that most states did not have
complete influenza pandemic plans addressing areas such as enhancing
surveillance and laboratory capacity, managing vaccines and antivirals,
and implementing community containment measures to reduce influenza
transmission.[Footnote 27] However, all 50 states, territories, and the
District of Columbia now have influenza pandemic plans according to CDC
officials. Trust for America's Health, a health advocacy nonprofit
organization, reported that the type of publicly available influenza
pandemic plan varied from a comprehensive influenza pandemic plan to
free-standing annexes to emergency management plans, to mere summaries
of a state's influenza pandemic plan.[Footnote 28]
At the time of our review, all five states we reviewed had influenza
pandemic plans that focused on leadership, surveillance and laboratory
testing, vaccine and antiviral distribution, and communications. Some
state plans included sections on education and training, and infection
control. Two of the three localities that received the federal pandemic
funds in our study addressed similar types of topics, such as disease
surveillance and laboratory testing, health care planning, vaccine and
antiviral distribution, mental health response, and communications in
their influenza pandemic plans. Most of the remaining urban and rural
localities also primarily addressed similar topics.
States and Localities We Reviewed That Received Federal Pandemic Funds
Involved HHS and CDC in Planning:
In planning for an influenza pandemic, officials from three of the five
states and two of the three localities that received the federal
pandemic funds told us that they interacted with HHS and CDC in
planning for a pandemic. However, federal officials did not reach out
to states and localities when the National Pandemic Implementation Plan
was being developed and the PFOs for influenza pandemic had limited
interaction with the selected states and localities.
At the time of our site visits, officials from three of the five states
and two of the three localities that received direct federal funding
reported interacting with HHS and CDC in planning for an influenza
pandemic to clarify funding requirements and expectations. CDC
officials in the Coordinating Office for Terrorism Preparedness and
Emergency Response also told us that they reviewed reports from the
states and local government recipients on how they had met the federal
pandemic funding requirements. CDC then provided feedback to the states
and localities on how well they were meeting the requirements. In
addition, CDC officials told us that they provided technical assistance
when requested.
While the federal government has provided some support to states in
their planning efforts, states and localities have had little
involvement in national planning for an influenza pandemic. The
National Pandemic Implementation Plan lays out a series of actions and
defines responsibilities for those actions. The National Pandemic
Implementation Plan includes 324 action items, 17 of which call for
states and local governments to lead national and subnational efforts,
and 64 in which their involvement is needed. In our August 2007 report,
we highlighted that key stakeholders such as state and local
governments were not directly involved in developing the action items
in the National Pandemic Implementation Plan and the performance
measures that are to assess progress, even though the National Pandemic
Implementation Plan relies on these stakeholders' efforts.[Footnote 29]
Stakeholder involvement during the planning process is important to
ensure that the federal government's and nonfederal entities'
responsibilities and resource requirements are clearly understood and
agreed upon. Moreover, HHS ASPR officials confirmed that the National
Pandemic Implementation Plan was developed by the federal government
without any state input. Officials from all of the states and
localities reviewed told us that they were not directly involved in
developing the National Pandemic Implementation Plan. Officials from
all five of the states and seven of the localities were aware of the
National Pandemic Implementation Plan. Officials from Taylor County
(Florida), Peoria County (Illinois) and Washington County (New York)
had not seen the National Pandemic Implementation Plan. State officials
from Florida, New York, and Texas, and officials from two localities in
California and one locality in New York reported that they used its
action items for their own planning efforts.
In addition, states and localities reported limited interaction with
the predesignated federal PFOs and FCOs in coordinating influenza
pandemic efforts. According to the national PFO for influenza pandemic,
the PFOs for influenza pandemic had limited interaction with state
governments for influenza pandemic efforts because it was unclear
whether the PFO structure for an influenza pandemic would remain in the
National Response Framework until it was issued in January 2008, and
finalized in March 2008. The Secretary of Homeland Security sent
letters in December 2006 and in March 2008 to state Governors on the
PFO structure, and the PFO structure was discussed at the HHS-and DHS-
led workshops in the five federal pandemic regions. At the time of our
site visits, we found that only state officials in California and New
York were aware of these federally predesignated officials. In
addition, in its issue brief on the five state influenza pandemic
workshops, the National Governors Association reported that the
presence of the PFOs for influenza pandemic at two of their workshops
was the first opportunity for most states to interact with these
officials.
States and Localities We Reviewed Involved Other State and Local
Agencies, Tribal Nations, Nonprofit Organizations, and the Private
Sector in Pandemic Planning:
In every state and locality reviewed, officials told us that they
involved other state and local agencies within their jurisdiction in
accordance with federal pandemic funding requirements. Health and
emergency management officials at some of the states and localities
reviewed said they collaborated with each other to develop the
influenza pandemic plan for public health response as required by the
federal pandemic funds and the influenza pandemic annex for emergency
response where applicable. For example, the Miami-Dade County Health
Department (Florida) collaborated with the Miami-Dade County Pandemic
Influenza Workgroup, which included stakeholders such as the Miami-Dade
County Department of Emergency Management and Homeland Security, CDC
Miami Quarantine Station, Medical Examiner Department, and the Miami-
Dade Corrections and Rehabilitation Department to develop its influenza
plan. This plan is also used as an annex to the Miami-Dade County
Department of Emergency Management and Homeland Security's
Comprehensive Emergency Management Plan. In some cases, both the health
and emergency management departments at the state and local levels
developed separate influenza pandemic plans to address health and
emergency response efforts respectively, while in other cases the
emergency management departments used the health department's influenza
pandemic plan as an annex to their emergency operations plans.
In addition to developing their own influenza pandemic plans, state
public health agencies in all the states reviewed assisted their local
counterparts with their influenza pandemic plans. For example,
officials from the Florida Department of Health said they used a
standardized assessment tool to assess county influenza pandemic plans
on 36 elements such as surveillance, response and containment, and
community-based control and mitigation interventions. The tool also
included a section on strengths and areas for improvement for each
element. Further, New York State Department of Health officials said
that they reviewed all of the county-level influenza pandemic plans and
provided feedback. We also found that in some cases, localities
consulted other localities' influenza pandemic plans to help them to
develop their own plans. For example, officials from Stanislaus County
Health Services Agency (California), Miami-Dade County Health
Department (Florida), and Dallas County Health and Human Services
(Texas) said they reviewed King County's (Washington) influenza
pandemic plan to help them develop their own plans.
Officials at all 15 of the states and localities reviewed also said
they assisted other state and local agencies within their jurisdiction
in their influenza pandemic efforts by reviewing each other's plans or
sharing information. For example, New York State Department of Health
officials said that as the lead agency responsible for influenza
pandemic planning efforts, they participated in and coordinated
meetings with other state agencies such as the Unified Court System and
Department of Correctional Services to discuss areas such as infection
control and community containment, visitation policies during an
influenza pandemic, management of sick inmates, emergency staffing
plans, and employee education and training.
Officials from 6 of the 15 states and localities we reviewed reported
that they had tribal nations within their jurisdictions. Of these 6,
only officials from California, Florida, New York state, and Miami told
us that they had included tribal nations in their influenza planning
efforts, as required by the federal pandemic funds. For example,
officials from the New York State Department of Health said they
provided guidance to the Mohawk and Seneca tribes in developing
influenza pandemic plans. Tribal nation representatives also had access
to the state's health provider network and were invited to influenza
pandemic training sessions and monthly influenza pandemic conference
calls. Officials from Texas and Taylor County (Florida) reported that
they did not include tribal nations in their influenza planning
efforts. Texas Department of State Health Services officials reported
that there are three tribes within the state with which the respective
counties are coordinating. In Taylor County (Florida), officials
reported that they had not yet involved their local tribe, the
Miccosukee tribe, in their influenza pandemic planning efforts.
Officials from all five states and four localities also reported that
they provided guidance or technical assistance for continuity planning
efforts to nonprofit organizations, and officials from all five states
and seven localities told us that they provided the same assistance to
the private sector. States and localities that received direct federal
pandemic funding are required to involve nonprofit organizations and
the private sector in planning for an influenza pandemic. For example,
Peoria City/County Health Department (Illinois) officials told us that
in addition to contracting with the Red Cross in providing bulk food
distribution services during an influenza pandemic, they had initial
discussions on how to implement isolation and quarantine. Officials
from the New York City Department of Health and Mental Hygiene (New
York) stated that they partnered with the New York City Department of
Small Business Services and conducted six focus groups with
approximately 60 participants from nonprofit and for-profit
organizations to provide general information related to influenza
pandemic, and to discuss the continuity strategies from CDC's Business
Pandemic Influenza Planning Checklist and feasibility in adopting them.
While all five selected states and seven localities have coordinated
with the private sector for influenza pandemic planning, several
officials from state agencies in Florida and Illinois, and local
agencies in Los Angeles County (California), Chicago (Illinois), and
Dallas County (Texas) have focused specifically on critical
infrastructure sectors, such as transportation (highway and motor
carriers), food and agriculture, water, energy (electricity), and
telecommunications (communications). Officials from the Dallas County
Department of Health and Human Services (Texas) said that they assisted
a local power company and a grocery chain on continuity of operations
planning for an influenza pandemic. The National Governors Association
reported in its February 2008 issue brief that few states from its five
regional workshops had defined the roles and responsibilities of
private sector entities.[Footnote 30] Moreover, potential shortages of
critical goods and services--specifically, food, electricity, and
transportation capacity--were cited as key areas of concern across all
five National Governors Association-led workshops. While Idaho,
Minnesota, Montana, North Dakota, South Dakota, and Utah were less
concerned about the food supply due to longstanding practices of
stockpiling against severe weather and other threats, other
participating states were concerned that they did not have agreements
in place with the private sector food distribution and retail systems.
HHS Has Found Major Gaps in States' Influenza Pandemic Plans:
Since we visited these states and localities, HHS provided feedback to
the states in November 2007 on whether their influenza pandemic plans
addressed certain priority areas, such as fatality management, and
found that there were major gaps nationally in the plans in these
priority areas. In response to an action item in the National Pandemic
Implementation Plan, HHS led a multidepartment effort to review
pertinent parts of states' influenza pandemic plans in 22 priority
areas[Footnote 31] along with other federal agencies such as the
Departments of Agriculture, Commerce, Education, Homeland Security,
Justice, Labor, and State under the auspices of the Homeland Security
Council.[Footnote 32] For example, DHS was responsible for reviewing
the priority area of how states worked with the private sector to
ensure critical essential services. States were required to submit
parts of their plans that addressed the priority areas to CDC by March
2007. The participating departments reviewed the pertinent parts of the
plans and HHS compiled the results into individual draft interim
assessments, which included the status of planning for each entity and
how they measured against the national average for the priority areas,
and provided this feedback to the states.[Footnote 33]
As shown in table 1, on average, states had major gaps in all areas,
with a ranking of "many major gaps" in 16 of the 22 priority areas and
"a few major gaps" in the remaining 6 priority areas, as defined by
HHS.[Footnote 34] An official in HHS ASPR told us that generally, the
states fared better in the public health priority areas such as mass
vaccination and antiviral drug distribution plans than in other areas
such as school closures and sustaining critical infrastructure. As we
will discuss in more detail later in the report, we found that the
areas in which state and local officials were looking for additional
federal guidance were often the same areas that were rated by HHS as
having "many major gaps" in planning.
Table 1: National Average of Status of States' Pandemic Plans by
Priority Areas and Lead Federal Government Reviewer:
Priority areas: Mass Vaccination;
National average: on status of planning: A Few Major Gaps;
Lead reviewer for the federal government: HHS/CDC.
Priority areas: Public Health Continuity of Operation Plan;
National average: on status of planning: A Few Major Gaps;
Lead reviewer for the federal government: HHS/CDC.
Priority areas: Surveillance and Laboratory;
National average: on status of planning: A Few Major Gaps;
Lead reviewer for the federal government: HHS/CDC.
Priority areas: Communication;
National average: on status of planning: A Few Major Gaps;
Lead reviewer for the federal government: HHS/CDC.
Priority areas: Community-Wide Healthcare Coalitions;
National average: on status of planning: A Few Major Gaps;
Lead reviewer for the federal government: HHS/ASPR/Health Resources and
Services Administration.
Priority areas: Facilitating Medical Surge;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: HHS/ASPR/Health Resources and
Services Administration.
Priority areas: Fatality Management;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: HHS/ASPR/Health Resources and
Services Administration.
Priority areas: Antiviral Drug Distribution Plan;
National average: on status of planning: A Few Major Gaps;
Lead reviewer for the federal government: HHS/CDC.
Priority areas: Community Containment Plan;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: HHS/CDC.
Priority areas: Policy Process for School Closure and Communication;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: Department of Education.
Priority areas: Education and Social Services in the Face of School
Closures;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: Department of Education.
Priority areas: Sustain/Support 17 Critical Infrastructure Sectors and
Key Assets[A];
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: DHS.
Priority areas: Working with the Private Sector to Ensure Critical
Essential Services;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: DHS.
Priority areas: State Plans Must Conform to All National Response Plan/
National Incident Management System Requirements;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: DHS.
Priority areas: Mitigate the Impact of an Influenza Pandemic on Workers
in the State;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: Department of Commerce.
Priority areas: Assisting Employers in the State;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: Department of Commerce.
Priority areas: Employment Policies during an Influenza Pandemic;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: Department of Labor.
Priority areas: Human Resource Policies for State Employees;
National average: on status of planning: Combined with Previous
Priority;
Lead reviewer for the federal government: Department of Labor.
Priority areas: Coordination of Law Enforcement;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: Department of Justice.
Priority areas: Critical Essential Function for Food Safety[B];
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: Department of Agriculture,
HHS/Food and Drug Administration.
Priority areas: Operational Status of State-Inspected Slaughter and
Food Processing Establishments;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: Department of Agriculture,
HHS/Food and Drug Administration.
Priority areas: Communication Strategy for USDA FSIS and FDA's Federal
State Relationships;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: Department of Agriculture,
HHS/Food and Drug Administration.
Priority areas: Ensure Adequate Reporting System Regarding Food Safety;
National average: on status of planning: Many Major Gaps;
Lead reviewer for the federal government: Department of Agriculture,
HHS/Food and Drug Administration.
Priority areas: State Advisories Regarding Diplomatic Missions;
National average: on status of planning: Not Reviewed;
Lead reviewer for the federal government: Department of State.
Source: GAO analysis of HHS data.
Notes: The analysis is based on data from HHS Guidance to States on
Pandemic Plans, January 2007, and HHS Feedback to States on Pandemic
Plans, November 2007.
[A] Since the HHS-led review of the first round of state influenza
pandemic plans, on April 30, 2008, DHS designated critical
manufacturing as an additional critical infrastructure sector under the
National Infrastructure Protection Plan (NIPP), which brings the
current number of critical infrastructure and key resources sectors
from 17 to 18.
[B] Only 28 states were required to address this priority area.
[End of table]
Every state received individual comments from CDC on the strengths and
weaknesses of their influenza pandemic plans in six priority areas.
[Footnote 35] According to HHS officials in ASPR, states also received
feedback in some of the remaining priority areas. In addition, states
received general comments from the Departments of Agriculture,
Commerce, Labor, Homeland Security, and Justice. The Departments of
Commerce, Labor, and Homeland Security noted that many state influenza
pandemic plans did not address the effect of social distancing in
private workplaces or state agencies. Nor did they address issues
related to loss of jobs and income for workers, particularly for those
needing to stay home to care for children dismissed from school or to
care for themselves or ill relatives. Further, they concluded that many
states needed to develop occupational safety and health plans that
dealt with infection control and other influenza pandemic issues such
as worker behavioral and mental health concerns.
HHS, DHS, and other federal agencies issued guidance to states in March
2008 to assist them in updating their current influenza pandemic plans.
These updated plans are due in July 2008. HHS will provide feedback to
them on the strengths and weaknesses of their plans as they did for the
previous review of plans.
All States and Localities Reviewed Have Conducted or Participated in at
Least One Exercise to Test Their Planning for an Influenza Pandemic and
Have Incorporated Lessons Learned:
Disaster planning, including for an influenza pandemic, needs to be
tested and refined with a rigorous and robust exercise program to
expose weaknesses in planning and allow planners to address the
weaknesses. Exercises--particularly for the type and magnitude of
emergency incidents such as a severe influenza pandemic for which there
is little actual experience--are essential for developing skills and
identifying what works well and what needs further improvement.
The first phase of the federal pandemic funds required states and
localities that received this funding to test their influenza pandemic
plan. CDC officials stated that their expectation was that the
recipients would conduct a gap analysis using CDC's self-assessment
tool to identify objectives to exercise to improve their plans and then
exercise the identified vulnerabilities of their plans, rather than
testing their entire plan. According to CDC officials, all states and
localities that received this funding have met the requirement to
conduct a discussions-based or operations-based exercise to test their
influenza pandemic plans and to prepare an after-action report. The
second phase of funding required states and localities that receive the
funding directly to conduct an exercise that would test an antiviral
drug distribution plan and to develop an influenza pandemic exercise
schedule that included medical surge, mass prophylaxis, and
nonpharmaceutical public health interventions such as closing schools
and discouragement of large public gatherings. As noted earlier, HHS
stated that CDC has reviewed whether recipients met the requirements
identified in the Phase II guidance.
All of the states and localities except for two of the localities in
our review had conducted at least one influenza pandemic exercise to
test their influenza pandemic planning. The two localities that had not
conducted their own exercise had participated in discussions-based
exercises in other jurisdictions. Among the states and localities that
had conducted an exercise, one state and two localities conducted at
least one discussions-based and an operations-based exercise, one state
and one locality conducted at least one operations-based exercise, and
the remaining three states and five localities conducted at least one
discussions-based influenza pandemic exercise. For example, the
Stanislaus County Health Services Agency (California) conducted an
influenza pandemic discussions-based exercise and the New York City
Department of Health and Mental Hygiene (New York) conducted both
influenza pandemic discussions-based exercises and operations-based
exercises. In addition, state agencies in New York, Texas, and Illinois
conducted or funded regional influenza pandemic exercises that included
multiple jurisdictions within each state. For example, the Peoria City/
County Health Department (Illinois) participated in an influenza
pandemic discussions-based exercise with nine other counties. According
to the National Governors Association, the states' influenza pandemic
exercises have been almost exclusively discussions-based exercises and
few have held regional or multistate exercises. In addition, health
departments conducted influenza pandemic exercises at all but one of
the states and localities that had conducted at least one influenza
pandemic exercise. In all but one of the states and localities
reviewed, emergency management officials had either conducted or
participated in an influenza pandemic exercise.
Officials from All States and Localities Reviewed Reported That Lessons
Learned from Exercises Were Incorporated into Influenza Pandemic
Planning:
Officials of all states and localities reviewed reported they had
incorporated lessons learned from exercises into their influenza
pandemic planning. Officials told us that the changes made as a result
of an exercise included buying additional medical equipment and
providing training. For example, officials at the New York City
Department of Health and Mental Hygiene (New York) informed us that an
influenza pandemic exercise resulted in identifying a potential
shortage of ventilators. In response, they purchased 70 ventilators
that were relatively easy to train staff to use, which were being used
by selected hospitals. Other influenza pandemic exercises resulted in
providing additional training. For example, Stanislaus County Health
Services Agency (California) officials identified the need for their
staff to be trained in the National Incident Management System (NIMS),
which is a consistent nationwide approach to enable all government,
private-sector, and nongovernmental organizations to work together to
prepare for, respond to, and recover from domestic incidents. All
county staff have been subsequently trained in NIMS.
Furthermore, state and local officials stated that influenza pandemic
exercises led to modifying policies or influenza pandemic plans.
Officials at the Illinois Department of Public Health realized during
an exercise that a judge's ruling would be needed to quarantine an
individual with a suspected contagious disease. As a result, the
department sought and obtained amendments to its department's authority
that if voluntary compliance cannot be obtained, then the department
can quarantine an individual with a suspected contagious disease for 2
days before a judge's ruling is necessary. In addition, officials at
the Dallas County Department of Health and Human Services (Texas)
reported that they identified the need for, and subsequently developed,
an appendix to their influenza pandemic plan on school closures during
a pandemic that included factors for schools to consider in deciding
when to close schools and for how long.
HHS and DHS Could Further Assist States in Addressing Gaps Identified
in Pandemic Planning:
HHS (including CDC), DHS and other federal agencies have provided a
variety of influenza pandemic information and guidance for states and
local governments through Web sites and state and regional meetings.
HHS and CDC have disseminated pandemic preparedness checklists for
workplaces, individuals and families, schools, health care, and
community organizations, with one geared for state and local
governments.[Footnote 36] HHS and CDC have also provided additional
influenza pandemic guidance including Interim Pre-pandemic Planning
Guidance: Community Strategy for Pandemic Influenza Mitigation in the
United States (February 2007). CDC and other federal agencies are
currently considering the Interim Guidance for the Use of Intervals,
Triggers, and Actions in Pandemic Influenza Planning that was developed
by HHS and CDC and provides a framework and thresholds for implementing
student dismissal and school closure. HHS also issued Interim Public
Health Guidance for the Use of Facemasks and Respirators in Non-
Occupational Community Settings during an Influenza Pandemic, and
funded Providing Mass Medical Care with Scarce Resources: A Community
Planning Guide (November 2006). CDC officials stated that the journal
CHEST published four papers on providing mass critical care with scarce
resources for all-hazards in May 2008. In addition, HHS funded guidance
on exercising for an influenza pandemic, including discussions-based
exercises for influenza pandemic preparedness for local public health
agencies.[Footnote 37] Furthermore, the federal planning guidance for
states to update their influenza pandemic plans provided by HHS, DHS,
and other federal agencies includes references to federal guidance that
pertains to the topics on which the states' plans will be assessed. The
guidance includes preparedness and planning advice and information on
specific tasks and capabilities that the states' plans should contain
for each of the priority areas for which the states will be assessed.
The guidance contains information on several of the priority areas that
state and local officials were looking for additional guidance on and
that were rated as having "many major gaps" in planning in the first
assessment, such as fatality management and community containment.
However, while the guidance document states what the states' plans
should contain for each of the topics, it does not include how to
implement these tasks and capabilities.
HHS and DHS, in coordination with other federal agencies, have also
developed draft guidance on how to allocate limited supplies of
vaccines, including target groups for individuals, and are working on
similar guidance for antivirals. They are also working on guidance on
the prophylactic use of antivirals (administering antivirals to
individuals who had not shown symptoms).[Footnote 38] However, HHS and
DHS officials acknowledged that the federal government has not provided
guidance on some of the influenza pandemic-specific topics that state
and local officials had told us that they would like guidance on from
the federal government, such as ethical decision making and liability
and legal issues.
There are also two federal Web sites that contain influenza pandemic
information. The purpose of the Web site [hyperlink,
http://www.pandemicflu.gov] is to be one-stop access to U.S. government
avian and pandemic flu information. The site includes guidance and
information on state and local planning and response activities, such
as all state influenza pandemic plans. The Web site [hyperlink,
http://www.llis.dhs.gov] is a national network of lessons learned and
best practices for emergency response providers and homeland security
officials and contains information on many different topic areas, such
as cyber security and wildland fires. Lessons Learned Information
Sharing System (LLIS) officials stated that the best practices are
vetted by working groups of subject matter experts. LLIS has an
influenza pandemic topic area that includes news, upcoming events,
plans and guidance, after-action reports, and best practices. An LLIS
representative also informed us that there is an influenza pandemic
forum that acts as a message board for LLIS users to discuss topics,
which have included how to implement teleworking during an influenza
pandemic. In addition, there is an influenza pandemic channel on the
Web site that has a document and resource library and a message board,
including topics such as antiviral and vaccine planning. HHS officials
stated that CDC and LLIS have created a secure channel for state and
local health departments to post and share influenza pandemic exercise
information. According to an LLIS representative, the secure channel
contains the influenza pandemic exercise schedules for states and
localities that receive the funding directly and there are plans to
include after-action reports from the exercises on the Web site.
There are also several nonfederal Web sites that contain influenza
pandemic practices on particular topics. The Center for Infectious
Disease Research and Policy at the University of Minnesota has
collected and peer-reviewed influenza pandemic "promising practices"
that can be adapted or adopted by public health stakeholders. Their Web
site [hyperlink,
http://www.pandemicpractices.org/practices/list.do?topic-id=13] has
practices on three themes: models for care (surge capacity, standards
of care, triage strategies, out-of-hospital care, collaborations),
communications (risk communications, community engagement, and
resiliency), and mitigation (nonpharmaceutical interventions). In
addition, National Public Health Information Coalition officials said
that they are planning to post influenza pandemic communications on
their Web site. CDC officials also stated that CDC has a cooperative
agreement with the Association of State and Territorial Health
Officials and the National Association of County and City Health
Officials to provide influenza pandemic best practices and tools that
states and localities can download from their respective Web sites.
In addition to providing guidance, HHS has also convened state
influenza pandemic planning summits and funded regional state influenza
pandemic workshops. To help coordinate influenza pandemic planning, HHS
and other federal agencies, including DHS, held "State Pandemic
Planning Summits" with the public health and emergency response
community in all states in 2005 and 2006. As part of the summits, the
Secretary of Health and Human Services signed memorandums of
understanding (MOU) with each state that identified shared common goals
and shared and independent responsibilities between HHS and the
individual state for influenza pandemic planning and preparedness. For
example, the MOU between HHS and the state of California noted that
states and local communities are responsible under their own
authorities for responding to an influenza pandemic outbreak within
their jurisdictions and having comprehensive influenza pandemic
preparedness plans and measures in place to protect their citizens. In
addition, to further assist states and localities with their influenza
pandemic preparedness efforts, HHS funded the National Governors
Association to conduct a series of influenza pandemic regional
workshops for states, the first five of which are discussed earlier. A
National Governors Association official stated the association held
nine workshops between April 2007 and January 2008 and that it is not
planning to conduct additional influenza pandemic workshops for states.
In addition, in May 2008, FEMA hosted an influenza pandemic exercise
and seminar for senior executives. The purpose of the exercise, which
involved FEMA officials, the Pandemic Region A PFO team, and a number
of states in Pandemic Region A, was to determine best practices for
communication and coordination during an influenza pandemic response.
The senior executive seminar, which included officials from CDC, HHS,
DHS, and a number of states in Pandemic Region C, was intended to
address pandemic risk, challenges, and issues, both regionally and
nationally. FEMA is also planning to host another influenza pandemic
seminar in May 2008 for the other states in Pandemic Region C that did
not participate in the previous seminar.
State and Local Officials Reported That They Wanted Additional Federal
Influenza Pandemic Guidance:
Despite these efforts, state and local officials from all of the states
and localities we interviewed told us that they would like additional
federal influenza pandemic guidance from the federal government on
specific topics to help them to better plan and exercise for an
influenza pandemic. Although, as discussed earlier, there is federal
guidance for some of these topics, the existing guidance may not have
reached state and local officials or may not address the particular
concerns or circumstances of the state and local officials we
interviewed.
Three of the areas on which state and local officials reported that
they wanted federal influenza pandemic guidance were rated as having
"many major gaps" nationally among states' influenza pandemic plans in
the first HHS-led review of their influenza pandemic plans. These areas
were (1) implementing the community interventions, such as closing
schools, discussed in the Interim Pre-pandemic Planning Guidance:
Community Strategy for Pandemic Influenza Mitigation in the United
States (which is called community containment in the federal priority
topics), (2) fatality management, and (3) facilitating medical surge.
[Footnote 39] Two other areas that state and local officials told us
that they would like additional federal influenza pandemic guidance on,
mass vaccination and antiviral drug distribution, were also rated as
having "a few major gaps" nationally. State and local officials also
told us that they would like the federal government to provide guidance
on additional topics: ethical decision making, prophylactic use of
antivirals, Strategic National Stockpile utilization, liability and
legal issues, and personal protective equipment.
While officials from some state and local governments were looking for
guidance from the federal government, others were developing the
information on their own. For example, while California Department of
Health officials stated that they were developing standards and
guidelines for health care professionals to use in any medical surge
(including an influenza pandemic), which has since been released,
Peoria City/County Health Department (Illinois) officials told us that
they wanted guidance on how to deal with medical surge. In addition,
the Texas Department of State Health Services developed an antiviral
prioritization plan, while Illinois Department of Public Health
officials said they would like the federal government to provide
guidance on antiviral prioritization.
Two recent reports found similar concerns among state and local
officials. In its February 2008 issue brief, the National Governors
Association reported that states were grappling with many of the same
issues that we found: community containment (school closures),
antiviral prioritization, prophylactic use of antivirals, and legal
issues.[Footnote 40] Similarly, an October 2007 Kansas City Auditor's
Office report on influenza pandemic preparedness in the city noted that
Kansas City Health Department officials would like the federal
government to provide additional guidance on some of the same issues we
found: clarifying community interventions such as school closings and
the criteria that will trigger these measures, antiviral and vaccine
prioritization, and the type of personal protective equipment to use
(e.g., type of face mask).[Footnote 41]
Additional HHS and DHS State Influenza Pandemic Meetings Could Be Held
to Assist States in Addressing Gaps in States' Influenza Pandemic
Plans:
According to the National Pandemic Implementation Plan, it is essential
for states and localities to have plans in place that support the full
spectrum of societal needs over the course of an influenza pandemic and
for the federal government to provide clear guidance on the manner in
which these needs can be met. As discussed earlier, the HHS-led
assessment of the states' pandemic plans was in response to an action
item in the National Pandemic Implementation Plan that states that HHS,
in coordination with DHS, shall review and approve states' influenza
pandemic plans. The assessment found "many major gaps" in 16 of the 22
priority areas in the states' pandemic plans.
HHS and DHS, in coordination with the Homeland Security Council, Office
of Personnel Management, and the Departments of Agriculture, Commerce,
Defense, Education, Homeland Security, Justice, Labor, State,
Transportation, the Treasury, and Veteran Affairs, led a series of five
workshops for states in the five influenza pandemic regions shown in
figure 1 in January 2008. Prior to the meetings, HHS ASPR officials
told us that the workshops would be an opportunity for states to
request additional influenza pandemic guidance from the federal
government. We observed two of the five workshops, and received
summaries from HHS of all five workshops. The discussions at the
workshops mainly focused on the draft guidance and evaluation criteria
for the second round of assessing the state pandemic plans, but the
participants also raised concerns and requested guidance.[Footnote 42]
Some of the common high-level themes discussed at some of these
workshops included a need for more involvement from federal agencies in
communicating with state counterparts. The March 2008 planning guidance
included a list of contacts and phone numbers in federal agencies for
the state officials to help them to communicate with their federal
counterparts as they update their pandemic plans. Participants also
requested guidance on various topics. Among the five workshops
conducted, state officials in three of the workshops sought guidance on
how to handle school closures and ports of entry issues while state
officials in two of the workshops wanted to know how to plan with CDC
quarantine stations. In addition, in three of the workshops, state
officials discussed wanting more critical infrastructure information or
guidance. For example, state officials discussed that there are
challenges for state health departments to work with the critical
infrastructure sectors because they have no authority to influence
their participation in influenza pandemic planning. However, there was
not an opportunity to explore these issues in greater depth during the
meetings. A senior DHS official in the Office of Health Affairs
reported that there are no plans to conduct further regional state
workshops on influenza pandemic.
HHS, DHS, and the Department of Labor hosted three Web seminars that
provided an overview of the March 2008 planning guidance and included
time for discussion. In addition, according to HHS, state-specific
assistance has been provided through conference calls.
Additional meetings of states by federal influenza pandemic region, led
by HHS and DHS, and in coordination with other relevant federal
agencies, could be held and their purpose broadened to provide a forum
for state and federal officials to address the identified gaps in
states' planning. The federal agencies that were the lead departments
for rating priority areas in the states' influenza pandemic plans could
provide additional corresponding information and guidance on their
respective priority areas to the states on their common challenges.
Federal agencies could provide assistance to the states on the priority
areas that they rated as having "many major gaps" in planning
nationally. For example, the Department of Justice could provide
assistance on the coordination of law enforcement, the Department of
Agriculture could provide assistance on the operational status of state-
inspected slaughter and food processing establishments, and the
Department of Education on the policy process for school closures and
communication. With plans due in July 2008 for a second round of
review, states' plans may still have major gaps that could be addressed
by federal and state governments working together to address these
challenges.
The meetings could also provide a forum for states to build networks
with one another and federal officials. In our October 2007 report
related to critical infrastructure protection challenges that require
federal and private sector coordination for an influenza pandemic, we
found that for influenza pandemic efforts, DHS has used critical
infrastructure coordinating councils primarily to share influenza
pandemic information across sectors and government levels rather than
to address many of the identified challenges. Thus, we recommended that
DHS lead efforts to encourage the councils to consider and address the
range of identified challenges, such as clarifying roles and
responsibilities between federal and state governments, for a potential
influenza pandemic.[Footnote 43] DHS concurred with our recommendation
and is planning initiatives--with some underway--to address our
recommendation, such as the development of pandemic contingency plan
guidance tailored to each critical infrastructure sector. Similarly,
during the National Governors Association's workshops, state officials
reported that they would be interested in the influenza pandemic
response activities initiated in neighboring states, but few, if any
mechanisms, exist for states to gain regional situational awareness.
According to the National Governors Association's report, the networks
that do exist are informal communications among peers, which are built
on personal relationships and are not integrated into any formal
communications capacity or system. The National Governors Association
also reported that states must coordinate their plans among state,
local, and federal agencies and that this coordination should be tested
through exercises with neighboring states and with relevant federal
officials. In addition, the March 2008 planning guidance to help states
update their plans notes that among the keys for successful preparation
for an influenza pandemic are collaborating with other states to share
promising practices and lessons learned and to collaborate with
regional PFOs. Both of these collaborative relationships with other
states and with the federal government could be facilitated by
additional meetings and discussions within the framework of the federal
pandemic regional structure.
Conclusions:
HHS is to complete distribution in 2008 of all the federal pandemic
funds provided by Congress for states and localities, but HHS, DHS, and
other federal agencies can continue to provide other types of support
to states. Although all states have developed influenza pandemic plans,
the HHS-led review of states' influenza pandemic plans in coordination
with other federal agencies found "many major gaps" in planning
nationally in 16 out of 22 priority areas. While the federal government
has provided influenza pandemic guidance on a variety of topics, state
and local officials told us they would welcome additional guidance.
These requests highlight some of the areas where federal guidance does
not exist and other areas where guidance may exist, but may not have
reached state and local officials or may not have addressed their
particular concerns. In addition, three of the topics that state and
local officials told us that they wanted federal influenza pandemic
guidance on--community containment, fatality management, and
facilitating medical surge--were rated as having "many major gaps"
nationally among states' influenza pandemic plans in the first HHS-led
review of states' influenza pandemic plans. Moreover, the National
Governors Association's workshops and the March 2008 planning guidance
underscore the value of states collaborating with each other and the
federal government for pandemic planning. With plans due in July 2008
for a second round of review, states' plans may still have major gaps
that can only be addressed by federal and state governments working
together to address these challenges.
Although a senior DHS official in the Office of Health Affairs reported
that there are no plans to hold additional workshops in the five
pandemic regions, these workshops could be a useful model both for
sharing information across states and building relationships within
regions and to address the identified gaps in states' planning, and to
maintain the momentum that has already been started by HHS and DHS to
continue to work with the states on pandemic preparedness given the
upcoming governmental transition.
Recommendation for Executive Action:
To help maintain a continuity of focus on state pandemic planning
efforts and to further assist states in their pandemic planning, we
recommend that the Secretaries of Health and Human Services and
Homeland Security, 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.
Agency Comments:
We provided a draft of the report of the Secretaries of Health and
Human Services and Homeland Security for their review and comment. HHS
generally concurred with our recommendation in an e-mail. The
department stated that additional regional workshops would be
impractical in the short-term because of HHS' current involvement in
the update of the states' pandemic plans. However, the department
believes that the regional workshops already held were uniformly
successful and is prepared to arrange for similar sessions in the
future if states would find such sessions useful. HHS also provided us
with technical comments, which we incorporated as appropriate. DHS
generally agreed with the contents of the report and concurred with our
recommendation. DHS's comments are reprinted in appendix II. We also
provided draft portions of the report to the state and local officials
from the five states and 10 localities we reviewed to ensure technical
accuracy. We received no comments from these states and localities.
As agreed with your offices, we plan no further distribution of this
report until 30 days from its date, unless you publicly announce its
contents earlier. At that time, we will send copies of this report to
the Secretary of Health and Human Services and the Secretary of
Homeland Security; and other interested parties. We will also make
copies available to others upon request. In addition, this report is
available at no charge on the GAO Web site at [hyperlink,
http://www.gao.gov].
If you or your staff have any further questions about this report,
please contact me 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 report. Major contributors to
this report include Sarah Veale, Assistant Director; Maya Chakko,
Analyst-in-Charge; Susan Sato; Susan Ragland; Karin Fangman; David
Dornisch; and members of GAO's Pandemic Working Group.
Signed by:
Bernice Steinhardt:
Director, Strategic Issues:
List of Requesters:
The Honorable Judd Gregg:
Ranking Member:
Committee on the Budget:
United States Senate:
The Honorable Daniel K. Akaka:
Chairman:
Subcommittee on Oversight of Government Management, the Federal
Workforce, and the District of Columbia:
Committee on Homeland Security and Governmental Affairs:
United States Senate:
The Honorable Henry A. Waxman:
Chairman:
The Honorable Tom Davis:
Ranking Member:
Committee on Oversight and Government Reform:
House of Representatives:
The Honorable Bennie G. Thompson:
Chairman:
Committee on Homeland Security:
House of Representatives:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
The objectives of this study were to (1) describe how selected states
and localities are planning for an influenza pandemic and how their
efforts are involving the federal government, other state and local
agencies, tribal nations, nonprofit organizations, and the private
sector, (2) describe the extent to which selected states and localities
have conducted exercises to test their influenza pandemic planning and
incorporated lessons learned into their planning, and (3) identify how
the federal government can facilitate or help improve state and local
efforts to plan and exercise for an influenza pandemic.
To identify how selected states and localities are planning and
exercising for an influenza pandemic and how the federal government can
assist their efforts, from June 2007 to September 2007, we conducted
site visits to the five most populous states: California, Florida,
Illinois, New York, and Texas. Recognizing that we would be limited in
our ability to report on all states in detail, we selected these five
states for a number of reasons, including that these states:
* comprised over one-third of the United States population;
* received over one-third of the total funding from the Department of
Health and Human Services (HHS) and the Department of Homeland Security
(DHS) that could be used for planning or exercising for an influenza
pandemic, and each state received the highest amount of total HHS and
DHS funding that could be used for planning and exercising for an
influenza pandemic respectively within each of the five regions
established by DHS for influenza pandemic preparedness and emergency
response; and:
* were likely entry points for individuals coming from another country
given that the states bordered either Mexico or Canada or contained
major ports, or both, and accounted for over one-third of the total
number of passengers traveling within the United States, and over half
of both inbound and outbound international air passenger traffic to and
from the United States.
At each state, we interviewed officials responsible for health,
emergency management, and homeland security. We also interviewed
officials at 10 localities in these same states, which consisted of
five urban areas and five rural counties. We interviewed officials
responsible for health and emergency management at an urban area in
each of the five states, which included Los Angeles County
(California), Miami (Florida), Chicago (Illinois), New York City (New
York), and Dallas (Texas). These urban areas were selected based on
having the highest population totals of all urban areas in the
respective states as of July 2006 and high levels of international
airport passenger traffic as of 2005. Three of these urban areas, Los
Angeles County, Chicago, and New York City, also received federal
pandemic funds.
In addition, we asked the state officials to nominate a rural county
for us to interview in their states based on the following criteria:
(1) has conducted some planning or exercising for an influenza
pandemic; and (2) is representative of challenges and needs that other
surrounding rural counties might also be facing. The state officials in
each state nominated only one rural county. We interviewed officials
responsible for health and emergency management in the nominated
counties of Stanislaus County (California), Taylor County (Florida),
Peoria County (Illinois), Washington County (New York), and Angelina
County (Texas). In total we interviewed officials with 34 different
agencies, which included for each state the health, emergency
management, and homeland security agencies, except for Texas which had
a combined emergency management and homeland security agency, and
officials responsible for health and emergency management for each
urban area and rural county in the five states. In both states and
localities we also typically interviewed several officials from each of
the agencies. In addition, in four states and four localities reviewed,
we interviewed the state or local government agencies individually, and
for the remainder we interviewed the state or local government agencies
together. We interviewed both urban and rural counties in order to
obtain the perspectives of officials at both densely populated urban
areas and rural areas. We report the results of our interviewing as
counts at the level of the 15 states and localities. In general, if any
one of the officials we interviewed in a particular state or locality
stated a factor or issue, such as lessons learned from exercises being
applied to pandemic planning, then we considered that statement to
apply to the state or locality as a whole. However, a limitation of our
interview methodology is that we did not comprehensively or
systematically survey all interviewees across the range of interview
questions.
We did not interview tribal nations, and except in two cases when urban
areas included private and nonprofit officials in our interviews with
their agency, we did not interview private sector entities or nonprofit
organizations. We focused on state and local government officials and
asked these officials about their interaction with tribal nations,
private sector entities, and nonprofit organizations. Finally, we
interviewed the selected state and urban area's auditors on any current
or planned related audits. While the states and localities selected
provided a broad perspective, we cannot generalize or extrapolate the
information gleaned from the site visits to the nation. In addition,
since the states that we selected were large, the most populous states,
and likely entry points for people coming into the United States, the
information we collected may not be as relevant to smaller, less
populated states that are not likely entry points for people coming
into the United States.
We also reviewed the influenza pandemic planning and exercise documents
from the selected states and localities. We reviewed the state and
local influenza pandemic plans for common topics, however we did not
analyze the quality of the documents systematically amongst those
states and localities. Instead, we relied on the HHS-led assessment of
whether state's influenza pandemic plans contained 22 priority areas.
We reviewed the reliability of the data reported from that assessment
and determined that the data were sufficiently reliable for the
purposes of this engagement. We also reviewed the states' and
localities' exercise documents for commonalities across jurisdictions.
We also interviewed HHS, Centers for Disease Control and Prevention
(CDC), and DHS officials about how they are working with states and
localities in planning and exercising for an influenza pandemic and
reviewed documentation that they provided, including the HHS-led
feedback to states on their influenza pandemic plans and the March 2008
planning guidance to assist them in updating their influenza pandemic
plans. Within HHS, we met with or received information from the Deputy
Director of the Office of Policy and Strategic Planning within the
Office of Assistant Secretary for Preparedness and Response; the Senior
Advisor to the Director, Coordinating Office for Terrorism Preparedness
and Emergency Response at CDC; the Regional Inspector General, Office
of Inspector General; and their staff. Within DHS, we met with and or
received information from the Director and Associate Chief Medical
Officer for Medical Readiness, Office of Health Affairs; the Branch
Chief, National Integration Center, Federal Emergency Management
Agency; the National Principal Federal Official for influenza pandemic,
United States Coast Guard; the Program Director, Lessons Learned
Information System; and the Deputy Inspector General, the Office of the
Inspector General; and their staff. In January 2008, we observed two of
the five influenza pandemic regional workshops led by HHS and DHS, in
coordination with other federal agencies. The purpose of the workshops
was to obtain state leaders' input on guidance to assist their
governments in updating their pandemic plans in preparation for a
second HHS-led review of these plans.
In addition, we reviewed prior GAO work and other relevant literature.
We also interviewed officials from the National Governors Association,
Association of State and Territorial Health Officials, National
Association of County and City Health Officials, and the National
Emergency Management Association who are working on issues related to
state and local influenza pandemic activities. We obtained information
on state and local activities from the state and local auditors in
Kansas City, Missouri; Portland, Oregon; and New York state, who as
members of the GAO Comptroller General's Domestic Working Group, all
participated in a collaborative effort to assess influenza pandemic
planning in their jurisdictions.[Footnote 44]
We conducted this performance audit from March 2007 to June 2008, 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.
[End of section]
Appendix II: Comments from the Department of Homeland Security:
U.S. Department of Homeland Security:
Washington, DC 20528:
May 27, 2008:
Ms. Bernice Steinhardt:
Director, Strategic Issues:
U.S. Government Accountability Office:
441 G St. NW:
Washington, D.C. 20548:
Dear Ms. Steinhardt:
Thank you for the opportunity to review and provide comments on the
Government Accountability Office's (GAO) draft report entitled,
Influenza Pandemic: Federal Agencies Should Continue to Assist States
to Address Gaps in Pandemic Planning (GAO-08-539).
The Department of Homeland Security (DHS) has reviewed the referenced
GAO report, and we concur with the recommendation that "the Secretaries
of Health and Human Services and Homeland Security, 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."
We would like to emphasize that DHS, as part of its efforts to continue
to help states and localities in the five federal influenza pandemic
regions, is currently seeking input from its security partners on
issues in the National Infrastructure Protection Plan (NIPP) that need
to be updated as part of the NIPP triennial review process. DHS is also
developing guidance to states and localities on developing their
critical infrastructure and key resources protection plans and ensuring
that they are in line with the NIPP.
We would also like to highlight a recently completed study, "National
Population Economic and Infrastructure Impacts of Pandemic Influenza
with Strategic Recommendations," developed by the National
Infrastructure Simulation and Analysis Center (NISAC) that could
further inform all ongoing discussions or workshops between federal,
state, and local health officials.
This study was tasked to the NISAC by the 2006 National Strategy for
Pandemic Implementation Plan, and will soon be releasable to private
sector entities as well as to all governmental levels. The report
contains specific recommendations addressing areas of concern
identified by the aforementioned GAO draft report, such as when to
close schools, disease containment strategies applicable to specific
infrastructure sectors, and other perceived gaps in existing Federal
guidance. The NISAC study has been briefed and provided to the
appointed federal Pandemic Influenza Principal Officials and regional
Senior Federal Officials as For Official Use Only (FOUO). Because of
the wide applicability of the recommendations contained in the NISAC
report, it is in the final stages of being made available for
unrestricted release.
DHS is dedicated to assisting our state and local partners in
maintaining the health and resiliency of the homeland. Thank you for
the opportunity to review and provide comments on this draft report.
Sincerely,
Signed by:
Penelope G. McCormack:
Acting Director:
Departmental GAO/OIG Liaison Office:
[End of section]
Related GAO Products:
Emergency Preparedness: States Are Planning for Medical Surge, but
Could Benefit from Shared Guidance for Allocating Scarce Medical
Resources. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?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. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?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. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
08-36]. Washington, D.C.: October 31, 2007.
Influenza Vaccine: Issues Related to Production, Distribution, and
Public Health Messages. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-08-27]. Washington, D.C.: October 31, 2007.
Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer
Federal Leadership Roles and an Effective National Strategy.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-781]. Washington,
D.C.: August 14, 2007.
Homeland Security: Observations on DHS and FEMA Efforts to Prepare for
and Respond to Major and Catastrophic Disasters and Address Related
Recommendations and Legislation. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-1142T]. Washington, D.C.: July 31, 2007.
The Federal Workforce: Additional Steps Needed to Take Advantage of
Federal Executive Boards' Ability to Contribute to Emergency
Operations. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-515].
Washington, D.C.: May 4, 2007.
Financial Market Preparedness: Significant Progress Has Been Made, but
Pandemic Planning and Other Challenges Remain. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-07-399]. Washington, D.C.: March
29, 2007.
Public Health and Hospital Emergency Preparedness Programs: Evolution
of Performance Measurement Systems to Measure Progress. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-07-485R]. Washington, D.C.: March
23, 2007.
Homeland Security: Preparing for and Responding to Disasters.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-395T]. Washington,
D.C.: March 9, 2007.
Catastrophic Disasters: Enhanced Leadership, Capabilities, and
Accountability Controls Will Improve the Effectiveness of the Nation's
Preparedness, Response, and Recovery System. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-06-618]. Washington, D.C.:
September 6, 2006.
Hurricane Katrina: GAO's Preliminary Observations Regarding
Preparedness, Response, and Recovery. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-06-442T]. Washington, D.C.: March
8, 2006.
Emergency Preparedness and Response: Some Issues and Challenges
Associated with Major Emergency Incidents. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-06-467T]. Washington, D.C.:
February 23, 2006.
Statement by Comptroller General David M. Walker on GAO's Preliminary
Observations Regarding Preparedness and Response to Hurricanes Katrina
and Rita. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-365R].
Washington, D.C.: February 1, 2006.
Influenza Pandemic: Applying Lessons Learned from the 2004-05 Influenza
Vaccine Shortage. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-
221T]. Washington, D.C.: November 4, 2005.
Influenza Vaccine: Shortages in 2004-05 Season Underscore Need for
Better Preparation. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
05-984]. Washington, D.C.: September 30, 2005.
Influenza Pandemic: Challenges in Preparedness and Response.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-863T]. Washington,
D.C.: June 30, 2005.
Flu Vaccine: Recent Supply Shortages Underscore Ongoing Challenges.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-177T]. Washington,
D.C.: November 18, 2004.
Emerging Infectious Diseases: Review of State and Federal Disease
Surveillance Efforts. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
04-877]. Washington, D.C.: September 30, 2004.
Infectious Disease Preparedness: Federal Challenges in Responding to
Influenza Outbreaks. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
04-1100T]. Washington, D.C.: September 28, 2004.
Public Health Preparedness: Response Capacity Improving, but Much
Remains to Be Accomplished. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-04-458T]. Washington, D.C.: February 12, 2004.
Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but
Lack Certain Capacities for Bioterrorism Response. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-03-924]. Washington, D.C.: August
6, 2003.
Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have
Improved Public Health Response Capacity, but Gaps Remain. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-03-654T]. Washington, D.C.: April
9, 2003.
[End of section]
Footnotes:
[1] GAO, Influenza Pandemic: Further Efforts Are Needed to Ensure
Clearer Federal Leadership Roles and an Effective National Strategy,
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-781] (Washington,
D.C.: Aug. 14, 2007).
[2] We discuss the various HHS and DHS funding that could be used for
influenza pandemic planning and exercising later in the report.
[3] The five territories are American Samoa, Guam, Northern Mariana
Islands, Puerto Rico, and the United States Virgin Islands.
[4] Hereafter, we will refer to these entities collectively as states
for both the five influenza pandemic regional workshops and guidance
documents to assist them in updating their pandemic plans.
[5] The Robert T. Stafford Disaster Relief and Emergency Assistance Act
of 1974 is codified, as amended, at 42 U.S.C. § 5121-5207.
[6] Issued in January 2008 and effective in March 2008, the NRF is a
guide to how the nation conducts all-hazards incident response. It
focuses on how the federal government is organized to support
communities and states in catastrophic incidents. The NRF builds upon
the National Incident Management System, which provides a national
template for managing incidents.
[7] See 42 U.S.C. § 247d.
[8] Pub. L. No. 109-417, 120 Stat. 2831, December 19, 2006.
[9] Section 101 of Pub. L. No. 109-417. See 42 U.S.C. § 300hh.
[10] See programs authorized under 42 U.S.C. § 247d-3a and § 247d-3b.
[11] Section 201 and 305 of Pub. L. No. 109-417, amending 42 U.S.C. §
247d-3a and §247d-3b, respectively.
[12] Antivirals are drugs that are used to prevent or cure a disease
caused by a virus, such as influenza, by interfering with the ability
of the virus to multiply in number or spread from cell to cell.
[13] See Department of Defense Emergency Supplemental Appropriations to
Address Hurricanes in the Gulf of Mexico, and Pandemic Influenza Act,
2006, Pub. L. No. 109-148, 119 Stat. 2680, 2783, 2786 and Emergency
Supplemental Appropriations Act for Defense, the Global War on Terror
and Hurricane Recovery, 2006, Pub. L. No. 109-234, 120 Stat. 418, 479-
80 (includes $30 million to be transferred to the U.S. Agency for
International Development).
[14] According to 31 U.S.C. § 6304 and § 6305, unlike federal grants,
where there is no substantial involvement between a federal agency and
the recipient, cooperative agreements are used in cases where
substantial involvement is expected between a federal agency and the
recipient.
[15] The five territories included Puerto Rico, the U.S. Virgin
Islands, American Samoa, Northern Mariana Islands, and Guam.
[16] The three Freely Associated States of the Pacific included the
Republic of the Marshall Islands, the Republic of Palau, and the
Federated States of Micronesia.
[17] The three localities included Chicago, Los Angeles County, and New
York City.
[18] Of the $250 million awarded for Phase II, CDC awarded $225 million
in July 2006. States and localities could apply for $24 million by
March 2008 on a competitive basis to develop plans to develop,
implement, and evaluate influenza pandemic interventions, and $990,000
was awarded to the National Governors Association in September 2006 to
conduct a series of influenza pandemic regional workshops for states in
2007 and 2008 to enhance intergovernmental and interstate coordination.
[19] Of the $250 million awarded for Phase III, $175 million was
awarded to recipients. Recipients of the Hospital Preparedness Program
cooperative agreement had the opportunity to apply for an additional
$75 million in October 2007. These Phase III funds were awarded to
assist states and localities in upgrading their influenza pandemic
preparedness capacities. For example, they will allow states and
localities to establish stockpiles of critical medical equipment and
supplies, support the planning and development of alternate care sites,
and conduct medical surge exercises for an influenza pandemic.
[20] Prophylactic use of medications is providing the medicine before
an individual is diagnosed.
[21] Nonpharmaceutical interventions are used to reduce the spread of
an infectious disease without use of pharmaceutical products such as
vaccines. Examples of nonpharmaceutical interventions include isolation
and treatment with influenza antiviral medications, voluntary home
quarantine, dismissal of students from school and school-based
activities, and use of social distance measures to reduce contact
between adults in the community and workplace.
[22] A community containment plan includes community-level
interventions designed to limit the transmission of a pandemic virus.
[23] According to HHS, for example, CDC reviewed whether recipients
developed and exercised the antiviral drug distribution plan and
submitted state operational pandemic plans.
[24] HSEEP is a capabilities-and performance-based exercise program
that provides a standardized policy, methodology, and terminology for
exercise design, development, conduct, evaluation, and improvement
planning.
[25] National Governors Association Center for Best Practices, Issue
Brief: Pandemic Preparedness in the States: An Interim Assessment from
Five Regional Workshops (Washington, D.C.: February 2008).
[26] CDC conducted an assessment of six priority thematic areas, which
included mass vaccination, continuity of operations plan,
communications, surveillance and laboratory, antiviral distribution,
and community containment.
[27] CDC analyzed data taken from its Pandemic Influenza State Self-
Assessments conducted in April 2006 using 49 states where progress was
reported in a number of key activities as either being completed, in
progress, or not started.
[28] Trust for America's Health, Ready or Not? Protecting the Public's
Health from Diseases, Disasters, and Bioterrorism (Washington, D.C.:
December 2007).
[29] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-781].
[30] National Governors Association Center for Best Practices, Issue
Brief: Pandemic Preparedness.
[31] Initially, there were 24 priority areas that states had to
address. However, HHS officials in ASPR stated that the interagency
reviewers combined two priority areas into one priority area related to
human resources and did not review one priority area related to state
advisories regarding diplomatic missions. So, in total, states were
assessed on 22 priority areas.
[32] Action item 6.1.1.2. of the National Pandemic Implementation Plan
states that HHS, in coordination with DHS, shall review and approve
State Pandemic Influenza plans to supplement and support DHS state
Homeland Security Strategies to ensure that federal homeland security
grants, training, exercises, technical assistance, and other forms of
assistance are applied to a common set of priorities, capabilities, and
performance benchmarks.
[33] HHS Assistant Secretary for Preparedness and Response, Pandemic
and All-Hazards Preparedness Act Progress Report, Public Law 109-417
(Washington, D.C.: November 2007).
[34] The national average for each of the 22 priority areas was
computed as follows. Each of the 50 states, five territories, and the
District of Columbia were given a score ranging from 0 to 7 on each of
the 22 priority areas. For each priority area, this score was
determined by adding the number of points received by the state or
territory on three key factors: (1) preparedness planning (a maximum of
3 points could be given)--assessing whether the 56 entities addressed
major preparedness objectives in guidance documents and other
publications for each priority area, (2) operations orientation (a
maximum of 3 points could be given)--assessing whether roles and
responsibilities are assigned for each priority area, and (3) self-
assessment of operations plan (a maximum of 1 point could be given)--
assessing whether states provided evidence that an exercise was
conducted for at least one of the priority areas. The national average
for each priority was then calculated by adding up all 56 scores and
dividing by 56. HHS ASPR officials explained that a total score of 0-1
equated to no or inadequate information provided, 2-3 equated to many
major gaps, 4-5 equated to a few major gaps, and 6-7 equated to
adequate or no major gaps.
[35] These six priority areas were mass vaccination, public health
continuity of operations plan, surveillance and laboratory,
communication, antiviral drug distribution plan, and community
containment plan.
[36] HHS and CDC, State and Local Pandemic Influenza Checklist (Dec. 2,
2005).
[37] RAND Corporation, Facilitated Look Backs: A New Quality
Improvement Tool for Management of Routine Annual and Pandemic
Influenza (Santa Monica, Calif.: 2006) and Tabletop Exercises for
Pandemic Influenza Preparedness in Local Public Health Agencies (Santa
Monica, Calif.: 2006).
[38] Draft Guidance on Allocating and Targeting Pandemic Influenza
Vaccine (Oct. 17, 2007), and Proposed Considerations for Antiviral Drug
Stockpiling by Employers In Preparation for an Influenza Pandemic and
Proposed Guidance on Antiviral Drug Use during an Influenza Pandemic.
[39] Medical surge is the capability to rapidly expand the capacity of
the existing health care system. In an influenza pandemic, however,
communities will not be able to count on receiving personnel or medical
equipment from elsewhere, as they might in other types of emergencies.
In our report on medical surge in a mass casualty event, we reviewed
four key components of preparing for medical surge: increasing hospital
capacity, identifying alternate care sites when hospitals are full,
registering medical volunteers, and planning for altering established
standards of care. The term "altered standards" generally means a shift
to providing care and allocating scarce equipment, supplies, and
personnel in a way that saves the largest number of lives, in contrast
to the traditional focus of treating the sickest or most injured
patients first. GAO, Emergency Preparedness: States Are Planning for
Medical Surge, but Could Benefit from Shared Guidance for Allocating
Scarce Medical Resources, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-08-668] (Washington, D.C.: June 13, 2008).
[40] National Governors Association Center for Best Practices, Issue
Brief: Pandemic Preparedness.
[41] City Auditor's Office, City of Kansas City, Missouri, Performance
Audit: Pandemic Flu Preparedness (October 2007).
[42] HHS conducted these workshops with states to fulfill the
requirement under PAHPA of 2006 for the Secretary of Health and Human
Services to develop and disseminate criteria for an effective plan for
responding to a pandemic. See Section 201 of the act, amending 42
U.S.C. § 247d-3a.
[43] GAO, Influenza Pandemic: Opportunities Exist to Address Critical
Infrastructure Protection Challenges That Require Federal and Private
Sector Coordination, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
08-36] (Washington, D.C.: Oct. 31, 2007).
[44] City Auditor's Office, City of Kansas City, Missouri, Performance
Audit: Pandemic Flu Preparedness (October 2007); Office of City
Auditor, Portland, Oregon, Pandemic Flu Planning: City bureaus aware of
national plans, A Report from the City Auditor (March 2007).
[End of section]
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