Influenza Pandemic
Further Efforts Are Needed to Ensure Clearer Federal Leadership Roles and an Effective National Strategy Gao ID: GAO-07-781 August 14, 2007An influenza pandemic is a real and significant potential threat facing the United States and the world. Pandemics occur when a novel virus emerges that can easily be transmitted among humans who have little immunity. In 2005, the Homeland Security Council (HSC) issued a National Strategy for Pandemic Influenza and, in 2006, an Implementation Plan. Congress and others are concerned about the federal government's preparedness to lead a response to an influenza pandemic. This report assesses how clearly federal leadership roles and responsibilities are defined and the extent to which the Strategy and Plan address six characteristics of an effective national strategy. To do this, GAO analyzed key emergency and pandemic-specific plans, interviewed agency officials, and compared the Strategy and Plan with the six characteristics GAO identified.
The executive branch has taken an active approach to help address this potential threat, including establishing an online information clearinghouse, developing planning guidance and checklists, awarding grants to accelerate development and production of new technologies for influenza vaccines within the United States, and assisting state and local government pandemic planning efforts. However, federal government leadership roles and responsibilities for preparing for and responding to a pandemic continue to evolve, and will require further clarification and testing before the relationships of the many leadership positions are well understood. The Strategy and Plan do not specify how the leadership roles and responsibilities will work in addressing the unique characteristics of an influenza pandemic, which could occur simultaneously in multiple locations and over a long period. A pandemic could extend well beyond health and medical boundaries, affecting critical infrastructure, the movement of goods and services across the nation and the globe, and economic and security considerations. Although the Department of Health and Human Services' (HHS) Secretary is to lead the public health and medical response and the Department of Homeland Security's (DHS) Secretary is to lead overall nonmedical support and response actions, the Plan does not clearly address these simultaneous responsibilities or how these roles are to work together, particularly over an extended period and at multiple locations across the country. In addition, the Secretary of DHS has designated a national Principal Federal Official (PFO) to facilitate pandemic coordination as well as five regional PFOs and five regional Federal Coordinating Officers. Most of these leadership roles and responsibilities have not been tested under pandemic scenarios, leaving it unclear how they will work. Because initial actions may help limit the spread of an influenza virus, the effective exercise of shared leadership roles and responsibilities could have substantial consequences. However, only one national multisector pandemic-related exercise has been held and that was prior to the issuance of the Plan. While the Strategy and Plan are an important first step in guiding national preparedness, they do not fully address all six characteristics of an effective national strategy. Specifically, they fully address only one of the six characteristics, by reflecting a clear description and understanding of problems to be addressed, and do not address one characteristic because the documents do not describe the financial resources needed to implement actions. Although the other characteristics are partially addressed, important gaps exist that could hinder the ability of key stakeholders to effectively execute their responsibilities, including state and local jurisdictions that will play crucial roles in preparing for and responding to a pandemic were not directly involved in developing the Plan, relationships and priorities among actions were not clearly described, performance measures focused on activities that are not always linked to results; insufficient information is provided about how the documents are integrated with other key related plans, and no process is provided for monitoring and reporting on progress.
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Director: Team: Phone:GAO-07-781, Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer Federal Leadership Roles and an Effective National Strategy
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
August 2007:
Influenza Pandemic:
Further Efforts Are Needed to Ensure Clearer Federal Leadership Roles
and an Effective National Strategy:
Leadership and Planning for a Pandemic:
GAO-07-781:
GAO Highlights:
Highlights of GAO-07-781, a report to congressional requesters.
Why GAO Did This Study:
An influenza pandemic is a real and significant potential threat facing
the United States and the world. Pandemics occur when a novel virus
emerges that can easily be transmitted among humans who have little
immunity. In 2005, the Homeland Security Council (HSC) issued a
National Strategy for Pandemic Influenza and, in 2006, an
Implementation Plan.
Congress and others are concerned about the federal government‘s
preparedness to lead a response to an influenza pandemic. This report
assesses how clearly federal leadership roles and responsibilities are
defined and the extent to which the Strategy and Plan address six
characteristics of an effective national strategy. To do this, GAO
analyzed key emergency and pandemic-specific plans, interviewed agency
officials, and compared the Strategy and Plan with the six
characteristics GAO identified.
What GAO Found:
The executive branch has taken an active approach to help address this
potential threat, including establishing an online information
clearinghouse, developing planning guidance and checklists, awarding
grants to accelerate development and production of new technologies for
influenza vaccines within the United States, and assisting state and
local government pandemic planning efforts. However, federal government
leadership roles and responsibilities for preparing for and responding
to a pandemic continue to evolve, and will require further
clarification and testing before the relationships of the many
leadership positions are well understood. The Strategy and Plan do not
specify how the leadership roles and responsibilities will work in
addressing the unique characteristics of an influenza pandemic, which
could occur simultaneously in multiple locations and over a long
period. A pandemic could extend well beyond health and medical
boundaries, affecting critical infrastructure, the movement of goods
and services across the nation and the globe, the economy, and
security. Although the Department of Health and Human Services‘ (HHS)
Secretary is to lead the public health and medical response and the
Department of Homeland Security‘s (DHS) Secretary is to lead overall
nonmedical support and response actions, the Plan does not clearly
address these simultaneous responsibilities or how these roles are to
work together, particularly over an extended period and at multiple
locations across the country. In addition, the Secretary of DHS has
predesignated a national Principal Federal Official (PFO) to facilitate
pandemic coordination as well as five regional PFOs and five regional
Federal Coordinating Officers. Most of these leadership roles and
responsibilities have not been tested under pandemic scenarios, leaving
it unclear how they will work. Because initial actions may help limit
the spread of an influenza virus, the effective exercise of shared
leadership roles and responsibilities could have substantial
consequences. However, only one national multisector pandemic-related
exercise has been held and that was prior to the issuance of the Plan.
While the Strategy and Plan are an important first step in guiding
national preparedness, they do not fully address all six
characteristics of an effective national strategy. Specifically, they
fully address only one of the six characteristics, by reflecting a
clear description and understanding of problems to be addressed, and do
not address one characteristic because the documents do not describe
the financial resources needed to implement actions. Although the other
characteristics are partially addressed, important gaps exist that
could hinder the ability of key stakeholders to effectively execute
their responsibilities, including state and local jurisdictions that
will play crucial roles in preparing for and responding to a pandemic
were not directly involved in developing the Plan, relationships and
priorities among actions were not clearly described, performance
measures focused on activities that are not always linked to results,
insufficient information is provided about how the documents are
integrated with other key related plans, and no process is provided for
monitoring and reporting on progress.
What GAO Recommends:
GAO recommends that (1) DHS and HHS develop rigorous testing, training,
and exercises for pandemic influenza to ensure that federal leadership
roles and responsibilities are clearly defined, understood, and work
effectively and (2) the HSC set a time frame to update the Plan,
involve key nonfederal stakeholders, and more fully address the
characteristics of an effective national strategy. DHS and HHS
concurred with the report. HSC did not comment.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-781].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Bernice Steinhardt at
(202) 512-6543 or steinhardtb@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Federal Government Leadership Roles and Responsibilities Need
Clarification and Testing:
The National Strategy and Its Implementation Plan Do Not Address All
the Characteristics of an Effective Strategy, Thus Limiting Their
Usefulness as Planning Tools:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Homeland Security:
Appendix II: IGAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Summary of Desirable Characteristics for a National Strategy:
Table 2: Extent to Which the Strategy and Plan Address GAO's Desirable
Characteristics of an Effective National Strategy:
Table 3: Extent to Which the Strategy and Plan Address GAO's Desirable
Characteristics of an Effective National Strategy:
Table 4: GAO Desirable Characteristics for a National Strategy:
Figures:
Figure 1: National Strategy and Implementation Plan's Goals, Pillars,
Functional Areas, and Action Items:
Figure 2: Related National Preparedness Strategies, Initiatives, and
Plans:
Abbreviations:
CBO: Congressional Budget Office:
COOP: Continuity of Operations:
CRS: Congressional Research Service:
DHS: Department of Homeland Security:
DOD: Department of Defense:
DOT: Department of Transportation:
ESF: Emergency Support Function:
FCO: Federal Coordinating Officer:
FEMA: Federal Emergency Management Agency:
HHS: Department of Health and Human Services:
HSC: Homeland Security Council:
NIMS: National Incident Management System:
NRP: National Response Plan:
PFO: Principal Federal Official:
USDA: Department of Agriculture:
United States Government Accountability Office:
Washington, DC 20548:
August 14, 2007:
The Honorable Judd Gregg:
Ranking Member:
Committee on the Budget:
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:
An influenza pandemic is a real and significant threat facing the
United States and the world. Pandemics occur when a novel virus emerges
that infects and can be effectively transmitted between humans who have
little immunity to it. Although the timing and severity of the next
pandemic is unpredictable, there is widespread agreement that a
pandemic will occur at some point. Three influenza pandemics occurred
in the 20th century. Notable among these was the influenza pandemic of
1918, called the "Spanish flu," which killed over 50 million people
worldwide, including over 675,000 in the United States. Pandemics have
spread worldwide within months, and a future pandemic is expected to
spread even more quickly given modern travel patterns. While health
experts cannot predict with certainty which strain of influenza virus
will be involved in the next pandemic, the avian influenza virus that
began in Hong Kong in 1997, known as H5N1, could lead to a pandemic if
it acquires the genetic ability to spread efficiently from person to
person.
Unlike incidents that are discretely bounded in space or time (e.g.,
most natural or man-made disasters), a pandemic is not a singular
event, but is likely to come in waves, each lasting weeks or months,
and pass through communities of all sizes across the nation and the
world simultaneously. An influenza pandemic could result in 200,000 to
2 million deaths in the United States, depending on its severity.
Further, an influenza pandemic could have major impacts on society and
the economy. According to a study by the Congressional Budget Office
(CBO), a severe pandemic (similar to the 1918 pandemic) could result in
a 5 percent reduction of the gross domestic product in the United
States over the subsequent year. Further, an influenza pandemic could
cause high rates of absences in schools and workplaces. According to
the Centers for Disease Control and Prevention, in a severe pandemic,
absences attributable to illness, the need to care for ill family
members, and fear of infection may reach 40 percent during the peak
weeks of a community outbreak, with lower rates of absence during the
weeks before and after the peak.
To date, the H5N1 virus has been confirmed in birds in 60 nations, up
from 16 nations reported in May 2005. There have been numerous cases
where the virus has been transmitted from birds to humans, and although
there have been isolated instances of human-to-human transmission, the
virus has not yet transmitted efficiently from person to person. From
January 2003 through July 25, 2007, the World Health Organization
reported more than 300 confirmed human cases, and more than 190 of
these people in 12 countries have died.
To address the potential threat of an influenza pandemic, the President
and his Homeland Security Council (HSC) issued two planning documents.
The first of these, the National Strategy for Pandemic Influenza
(Strategy), was issued in November 2005 and is intended to provide a
high-level overview of the approach that the federal government will
take to prepare for and respond to an influenza pandemic. It also
articulates expectations for nonfederal entities--including state,
local, and tribal governments; the private sector; international
partners; and individuals--to prepare themselves and their communities.
The Implementation Plan for the National Strategy for Pandemic
Influenza (Plan) was issued in May 2006. It is intended to lay out
broad implementation requirements and responsibilities among the
appropriate federal agencies and clearly define expectations for
nonfederal entities. The Plan includes 324 action items related to
these requirements, responsibilities, and expectations.
In light of the problems experienced during prior disasters, such as
Hurricane Katrina, members of Congress and others have expressed
concern about whether the federal government is adequately prepared to
lead the nation in planning for and responding to an influenza
pandemic. In response to your request, this report examines the clarity
of federal leadership roles and responsibilities for preparing for and
responding to a pandemic influenza and provides a detailed review of
the Strategy and Plan.
The objectives of this report are to address the extent to which (1)
federal leadership roles and responsibilities for preparing for and
responding to a pandemic are clearly defined and documented and (2) the
Strategy and the Plan address the characteristics of an effective
national strategy. To address the first objective, we analyzed the
Strategy and Plan and reviewed a variety of federal emergency
documents, including the National Response Plan's (NRP) base plan and
annexes, the draft implementation plan developed by the Department of
Homeland Security (DHS), and the implementation plan developed by the
Department of Health and Human Services (HHS). We interviewed officials
from DHS (including the Federal Emergency Management Agency (FEMA)),
HHS, and others with federal leadership roles in preparing for and
responding to a pandemic, including the Departments of Agriculture
(USDA), Defense (DOD), Transportation (DOT), and State. Some of these
officials were involved in the development of the Plan. We also
interviewed the Vice Commandant of the U.S. Coast Guard who has been
predesignated as the national Principal Federal Official for pandemic
influenza. Additionally, we studied the findings in prior GAO products
as well as reports issued by Congress, the Congressional Research
Service (CRS), CBO, the HSC, DHS's Office of the Inspector General, and
other experts.
For the second objective, we assessed the Strategy and Plan to
determine how well they jointly addressed the six desirable
characteristics of an effective national strategy that we developed in
previous work, including reviewing several elements related to each
characteristic. We have used this methodology to assess and report on
the administration's strategies relating to combating terrorism,
rebuilding Iraq, and improving citizens' financial literacy.[Footnote
1] National strategies that address these characteristics offer
policymakers and implementing agencies a management tool that can help
ensure accountability and more effective results. Table 1 provides the
desirable characteristics and a brief description of each
characteristic.
Table 1: Summary of Desirable Characteristics for a National Strategy:
Desirable characteristic: Purpose, scope, and methodology;
Brief description: Addresses why the strategy was produced, the scope
of its coverage, and the process by which it was developed.
Desirable characteristic: Problem definition and risk assessment;
Brief description: Addresses the particular national problems and
threats the strategy is directed toward.
Desirable characteristic: Goals, subordinate objectives, activities,
and performance measures;
Brief description: Addresses what the strategy is trying to achieve;
steps to achieve those results;
as well as the priorities, milestones, and performance measures to
gauge results.
Desirable characteristic: Resources, investments, and risk management;
Brief description: Addresses what the strategy will cost, the sources
and types of resources and investments needed, and where resources and
investments should be targeted by balancing risk reductions and costs.
Desirable characteristic: Organizational roles, responsibilities, and
coordination;
Brief description: Addresses who will be implementing the strategy,
what their roles will be compared to others, and mechanisms for them to
coordinate their efforts.
Desirable characteristic: Integration and implementation;
Brief description: Addresses how a national strategy relates to other
strategies' goals, objectives, and activities--and to subordinate
levels of government and their plans to implement the strategy.
Source: GAO.
[End of table]
We rated the Strategy and Plan on each of the characteristics, giving a
rating of "addresses," "partially addresses," or "does not address."
According to our methodology, a strategy "addresses" a characteristic
when it explicitly cites all, or nearly all, elements of the
characteristic, and has sufficient specificity and detail. A strategy
"partially addresses" a characteristic when it explicitly cites one or
a few of the elements of a characteristic, and the documents have
sufficient specificity and detail. It should be noted that the
"partially addresses" category includes a range that varies from
explicitly citing most of the elements to citing as few as one of the
elements of a characteristic. A strategy "does not address" a
characteristic when it does not explicitly cite or discuss any elements
of a characteristic, any references are either too vague or general to
be useful, or both. The elements are provided in appendix I.
We conducted our review from May 2006 through June 2007 in accordance
with generally accepted government auditing standards. Further details
on our scope and methodology are in appendix I. A list of other related
GAO reports on pandemic preparedness, emergency preparedness, and other
related topics is included at the end of this report.[Footnote 2]
Results in Brief:
While an influenza pandemic will most likely occur in the future, there
is a high level of uncertainty about when a pandemic might occur and
its level of severity. The administration has taken an active approach
to this potential disaster by developing a Strategy and Plan and has
taken a number of other actions. These include establishing an
information clearinghouse for pandemic information; developing planning
guidance and checklists for governments, businesses, nongovernmental
organizations, and individuals; issuing the Strategy and Plan; and
starting work on completing the action items contained in the Plan. In
addition to these actions, HHS has awarded grants totaling $350 million
to state and local governments for pandemic planning and more than $1
billion to accelerate development and production of new technologies
for influenza vaccines within the United States. While these approaches
have been significant, considerably more work needs to be done.
To begin with, federal government leadership roles and responsibilities
for preparing for and responding to a pandemic continue to evolve and
will require further clarification and testing before the relationships
of the many leadership positions are well-understood. The Strategy and
the Plan do not specify how the leadership roles and responsibilities
would work in addressing the unique characteristics of a pandemic
influenza, which could occur simultaneously in multiple locations and
over a long period, coming in waves, each lasting weeks or months. A
pandemic necessitates a strategy that extends well beyond health and
medical boundaries, to include sustaining critical infrastructure,
private sector activities, the movement of goods and services across
the nation and the globe, and economic and security considerations. The
Strategy and Plan indicate that both the Secretary of Health and Human
Services and the Secretary of Homeland Security will have leadership
responsibilities that are consistent with the NRP--the former for
leading the federal medical response to a pandemic and the latter for
overall domestic incident management and federal coordination. However,
it is not clear how, in a pandemic, the Secretaries of Health and Human
Services and Homeland Security would share leadership responsibilities
in practice. For example, a pandemic could threaten critical
infrastructure, a DHS responsibility, by removing essential personnel
from the workplace for weeks or months, requiring both a medical
response as well as actions to protect and sustain critical
infrastructure. Yet, the Plan does not clearly address these
simultaneous responsibilities or how these roles are to work together,
particularly over an extended period and at multiple locations across
the country. Moreover, under recent legislation, the FEMA Administrator
was designated the principal domestic emergency management advisor to
the President, the HSC, and the Secretary of Homeland Security, adding
further complexity to the leadership structure in the case of a
pandemic.
In addition to these positions, the NRP includes leadership roles for
Principal Federal Officials (PFO) and Federal Coordinating Officers
(FCO). To assist in planning and coordinating efforts to respond to a
pandemic, in December 2006 the Secretary predesignated a national PFO,
and established five pandemic regions each with a regional PFO and FCO.
PFOs are responsible for facilitating federal domestic incident
planning and coordination, and FCOs are responsible for coordinating
federal resource support in a presidentially declared major disaster or
emergency. However, the relationship of these roles to each other as
well as with other leadership roles in a pandemic is unclear.
Most of these leadership roles and responsibilities have not been
tested under pandemic scenarios, leaving unclear how all of these new
and developing relationships would work. According to a 2007 CRS
report, although pandemic influenza scenarios have been used to
exercise specific response elements, such as the distribution of
stockpiled medications at specific locations or jurisdictions, there
have been no national exercises to test a multisector,
multijurisdictional response or any exercises to test the new national
leadership structure for pandemic influenza.[Footnote 3] The only
national multisector pandemic exercise to date was a tabletop
simulation conducted by members of the cabinet in December 2005--prior
to the release of the Plan in May 2006 and the establishment of PFO and
FCO positions for a pandemic.
The Strategy and Plan represent an important first step in guiding the
nation's preparedness and response activities, calling for a series of
actions by federal agencies and expectations for states and
communities, the private sector, global partners, and individuals.
However, when viewed together, the Strategy and Plan do not fully
address the six characteristics of an effective national strategy. Gaps
and deficiencies in these documents are particularly troubling because
they can affect the usefulness of the planning documents to those with
key roles to play and affect their ability to effectively carry out
their responsibilities.
As shown in table 2, while the Strategy and Plan address one of the
desirable characteristics of an effective national strategy, they do
not address another characteristic and partially address the remaining
four characteristics. For example, the documents address the problem
definition and risk assessment characteristic by identifying the
potential problems associated with a pandemic as well as potential
threats, challenges, and vulnerabilities. However, they did not address
the resources, investments, and risk management characteristic because
they do not discuss the financial resources and investments needed to
implement the actions called for. Therefore, they do not provide a
picture of priorities or how adjustments might be made in view of
resource constraints.
Table 2: Extent to Which the Strategy and Plan Address GAO's Desirable
Characteristics of an Effective National Strategy:
Desirable characteristic: Clear purpose, scope, and methodology;
Addresses: [Empty];
Partially addresses: X;
Does not address: [Empty].
Desirable characteristic: Problem definition and risk assessment;
Addresses: X;
Partially addresses: [Empty];
Does not address: [Empty].
Desirable characteristic: Goals, subordinate objectives, activities,
and performance measures;
Addresses: [Empty];
Partially addresses: X;
Does not address: [Empty].
Desirable characteristic: Resources, investments, and risk management;
Addresses: [Empty];
Partially addresses: [Empty];
Does not address: X.
Desirable characteristic: Organizational roles, responsibilities, and
coordination;
Addresses: [Empty];
Partially addresses: X;
Does not address: [Empty].
Desirable characteristic: Integration and implementation;
Addresses: [Empty];
Partially addresses: X;
Does not address: [Empty].
Source: GAO analysis of the National Strategy for Pandemic Influenza
and Implementation Plan for the National Strategy for Pandemic
Influenza.
[End of table]
The Strategy and Plan partially address the remaining four
characteristics. Some of the gaps we found include the following:
* Purpose, scope and methodology: Key stakeholders, such as state,
local, and tribal governments, were not directly involved in developing
actions and the performance measures that are to assess progress, even
though the Strategy and Plan rely on these stakeholders' efforts. The
Plan contains 17 actions in which state, local, and tribal governments
should lead national and subnational efforts and identifies another 64
actions where their involvement is needed.
* Integration and implementation: The Strategy and Plan provide little
detail about how the set of pandemic plans they propose, such as the
individual agencies' pandemic plans, are to be integrated with other
existing national strategies that are to provide an overall all-hazards
framework. For example, although the Strategy and Plan's leadership
framework is consistent with provisions of the NRP, there are no
linkages between the 39 response action items in the plan and the NRP
or other response-related plans.
* Goals, objectives, activities, and performance measures: Most of the
Plan's performance measures are focused on activities, such as
disseminating guidance, and are not always clearly linked to the goals
and objectives described in the Strategy and Plan. This lack of a clear
linkage between the performance measures and intended results makes it
difficult to ascertain whether any progress beyond the completion of
activities has in fact been made. Also, the Plan does not establish
priorities among the 324 actions it calls for, and although the intent
expressed in the Plan is that it will be updated, there are no
mechanisms provided in the Plan to do so. Further, while officials told
us they periodically report to the HSC the status of the action items
for which their agencies have lead responsibility, there is no
prescribed process for publicly reporting nor is there a process for
monitoring actions led by other entities, such as states and local
governments. In December 2006, the HSC publicly reported on the status
of most of the actions that were to have been completed within 6 months
of the Plan's release. However, some of the actions the HSC reported as
complete are actually still under way, and other actions that were
supposed to be completed were omitted from the report.
* Organizational roles, responsibilities, and coordination: As noted
earlier, the Strategy and Plan did not clarify how responsible
officials will share leadership responsibilities.
This report contains two recommendations to enhance preparedness
efforts for a possible pandemic. First, we recommend that the
Secretaries of Homeland Security and Health and Human Services work
together to develop and conduct rigorous testing, training, and
exercises for pandemic influenza to ensure that the federal leadership
roles are clearly defined and understood and that leaders are able to
effectively execute shared responsibilities to address emerging
challenges. The second recommendation is that the HSC establish a
specific process and time frame for updating the Plan. The process
should involve key nonfederal stakeholders and incorporate lessons
learned from exercises and other sources. The Plan can also be improved
by including the following information in the next update: (1)
resources and investments needed to complete the action items and where
they should be targeted, (2) a process and schedule for monitoring and
publicly reporting on progress made on completing the action items, (3)
clearer linkages with other strategies and plans, and (4) clearer
descriptions of relationships or priorities among actions items and
greater use of outcome-focused performance measures.
DHS officials we met with said that they are developing a Federal
Concept Plan for Pandemic Influenza that focuses on federal interagency
tasks and is intended to help ensure coordinated federal preparation,
response, and recovery operations if there is an outbreak. In May 2007,
DHS provided a draft to federal agencies for review and comment, and
officials think it may help address some of the gaps we identified in
the Plan. DHS had not determined when the Concept Plan would be issued.
We provided a draft of this report to DHS, HHS, and the HSC for review
and comment. DHS provided written comments which are reprinted in
appendix II. In commenting on the draft report, DHS concurred with the
first recommendation and stated that it is taking action on many of the
shortfalls identified in the report. DHS also provided us with
technical comments, which we incorporated in the report as appropriate.
HHS informed us that it had no comments and concurred with the draft
report. The HSC did not comment on the draft report.
Background:
The Strategy lays out three high-level goals to prepare for and respond
to an influenza pandemic: (1) stop, slow, or otherwise limit the spread
of a pandemic to the United States; (2) limit the domestic spread of a
pandemic and mitigate disease, suffering, and death; and (3) sustain
infrastructure and mitigate impact on the economy and the functioning
of society. These goals are underpinned by three pillars that are
intended to guide the federal government's approach to a pandemic
threat: (1) preparedness and communication, (2) surveillance and
detection, and (3) response and containment. Each pillar describes
domestic and international efforts, animal and human health efforts,
and efforts that would need to be undertaken at all levels of
government and in communities to prepare for and respond to a pandemic.
The Plan is intended to support the broad framework and goals
articulated in the Strategy by outlining specific steps that federal
departments and agencies should take to achieve these goals. It also
describes expectations regarding preparedness and response efforts of
state and local governments and tribal entities and the private sector.
The Plan's chapters cover categories of actions that are intended to
address major considerations raised by a pandemic, including protecting
human and animal health; transportation and borders; and international,
security, and institutional considerations. The Plan is not intended to
describe the operational details of how federal departments and
agencies would accomplish their objectives to support the Strategy.
Rather, these operational details are supposed to be included in the
departments' and agencies' pandemic implementation plans along with
additional considerations raised during a pandemic involving (1)
protection of employees, (2) maintenance of essential functions and
services, and (3) the manner in which departments and agencies would
communicate messages about pandemic planning and respond to their
stakeholders.
All-Hazards Emergency Management Policies Provide the Overarching
Context for the Strategy and Plan:
The Homeland Security Act of 2002 required the newly established DHS to
develop a comprehensive National Incident Management System (NIMS) and
a comprehensive NRP.[Footnote 4] NIMS and the NRP are intended to
provide an integrated all-hazards approach to emergency incident
management. As such, they are expected to form the basis of the federal
response to a pandemic. NIMS defines "how" to manage an emergency
incident. It defines roles and responsibilities of federal, state, and
local responders for emergency incidents regardless of the cause, size,
or complexity of the situation. Its intent is to establish a core set
of concepts, principles, terminology, and organizational processes to
enable effective, efficient, and collaborative emergency incident
management at all levels. The NRP, on the other hand, defines "what"
needs to be done to manage an emergency incident. It is designed to
integrate federal government domestic prevention, protection, response,
and recovery plans into a single operational plan for all hazards and
all emergency response disciplines. Using the framework provided by
NIMS, the NRP is intended to provide the structure and mechanisms for
national-level policy and operational direction for domestic incident
management where federal support is necessary.
States may need federal assistance in the event of a pandemic to
maintain essential services. Upon receiving such requests, the
President may issue emergency or major disaster declarations pursuant
to the Robert T. Stafford Disaster Relief and Emergency Assistance Act
of 1974 (the Stafford Act).[Footnote 5] The Stafford Act primarily
establishes the programs and processes for the federal government to
provide major disaster and emergency 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, including direct payments, grants, and loans. FEMA is
responsible for carrying out the functions and authorities of the
Stafford Act.
The Secretary of Health and Human Services also has authority, under
the Public Health Service Act, to declare a public health emergency and
to take actions necessary to respond to that emergency consistent with
his/her authorities.[Footnote 6] 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. The Secretary's declaration may
also initiate the authorization of emergency use of unapproved products
or approved products for unapproved uses as well as waiving of certain
HHS regulatory requirements.
The NRP, as revised in May 2006, applies to all incidents requiring a
coordinated federal response. The most severe of these incidents,
termed Incidents of National Significance, must be personally declared
and managed by the Secretary of Homeland Security. According to the
Plan, the Secretary of Homeland Security may declare a pandemic an
Incident of National Significance, perhaps as early as when an outbreak
occurs in foreign countries but before the disease reaches the United
States. In addition to the base response plan, the NRP has 31 annexes
consisting of 15 Emergency Support Function (ESF) annexes, 9 support
annexes, and 7 incident annexes. The ESFs are the primary means through
which the federal government provides support to state, local, and
tribal governments, and the ESF structure provides a mechanism for
interagency coordination during all phases of an incident--some
departments and agencies may provide resources during the early stages,
while others would be more prominent in supporting recovery efforts.
The ESFs group capabilities and resources into the functions that are
most likely needed during actual or potential incidents where
coordinated federal response is required.
Of the 15 ESF annexes, ESF-8, the public health and medical services
ESF, would be the primary ESF used for the public health and medical
care aspects of a pandemic involving humans.[Footnote 7] Although HHS
is the lead agency for ESF-8, the ESFs are carried out through a
"unified command" approach and several other federal agencies,
including the Departments of Agriculture, Defense, Energy, Homeland
Security (and the U.S. Coast Guard), Justice, and Labor, are
specifically supporting agencies.
ESF-11 pertains to agriculture and natural resources, and its purpose
includes control and eradication of an outbreak of a highly contagious
or economically devastating animal/zoonotic disease including avian
influenza. The purpose of ESF-11 is to ensure, in coordination with ESF-
8, that animal/veterinary/wildlife issues in natural disasters are
supported. The Departments of Agriculture and the Interior share
responsibilities as primary agencies for this ESF.[Footnote 8]
FEMA has or shares lead responsibility for several of the ESFs,
including those that would be applicable during a pandemic. For
example, FEMA is the lead agency for ESF-5 (emergency management), ESF-
6 (mass care, housing, and human services), and ESF-14 (long-term
community recovery and mitigation) and is the primary agency for ESF-15
(external affairs). Additionally, FEMA is responsible for carrying out
the functions and authorities of the Stafford Act.
The incident annexes describe the policies, situations, concept of
operations, and responsibilities pertinent to the type of incident in
question. Included among the seven incident annexes within the NRP is
the Catastrophic Incident Annex.[Footnote 9] The Catastrophic Incident
Annex could be applicable to a pandemic influenza as it applies to any
incident that results in extraordinary levels of mass casualties,
damage, or disruption severely affecting the population,
infrastructure, environment, economy, national morale, and/or
government functions.
The NRP also addresses two key leadership positions in the event of a
Stafford Act emergency or major disaster. One official, the FCO, who
can be appointed by the Secretary of Homeland Security on behalf of the
President, manages and coordinates federal resource support activities
related to Stafford Act disasters and emergencies.[Footnote 10] The
other official, the PFO, is designated by the Secretary of Homeland
Security to facilitate federal support to established incident command
structures and to coordinate overall federal incident management and
assistance activities across the spectrum of prevention, preparedness,
response, and recovery. The PFO is to provide a primary point of
contact and situational awareness for the Secretary of Homeland
Security. While the PFO is supposed to work closely with the FCO during
an incident, the PFO has no operational authority over the FCO.
The Executive Branch Has Taken Other Steps to Prepare for a Pandemic:
The executive branch has also developed tools and guidance to aid in
preparing for and responding to a pandemic influenza. Among these are
the following:
* A Web site, [hyperlink, http://www.pandemicflu.gov], to provide one-
stop access to U.S. government avian and pandemic influenza
information. This site is managed by HHS.
* Planning checklists for state and local governments, businesses,
schools, community organizations, health care providers, and
individuals and families. As of July 2007, there were 16 checklists
included on the Web site.[Footnote 11]
* Interim planning guidance for state, local, tribal, and territorial
communities on nonpharmaceutical interventions (i.e., other than
vaccines and drug treatment) to mitigate an influenza pandemic. This
guidance, called the Interim Pre-pandemic Planning Guidance: Community
Strategy for Pandemic Influenza Mitigation in the United States,
includes a Pandemic Severity Index to characterize the severity of a
pandemic, provides planning recommendations for specific interventions
for a given level of pandemic severity, and suggests when those
interventions should be started and how long they should be used.
* In March 2006, FEMA issued guidance for federal agencies to revise
their Continuity of Operations (COOP) Plans to address pandemic
threats. COOP plans are intended to ensure that essential government
services are available in emergencies. We testified in May 2006, on the
need for agencies to adequately prepare their telework capabilities for
use during a COOP event.[Footnote 12]
* In September 2006, DHS issued guidance to assist owners and operators
of critical infrastructure and key resources to prepare for a localized
outbreak, as well as a broader influenza pandemic.[Footnote 13]
In addition to these tools and guidance, other actions included HHS
grant awards totaling $350 million to state and local governments for
pandemic planning and more than $1 billion to accelerate development
and production of new technologies for influenza vaccines within the
United States.
Federal Government Leadership Roles and Responsibilities Need
Clarification and Testing:
While the Strategy and Plan describe the broad roles and
responsibilities for preparing for and responding to a pandemic
influenza, they do little to clarify existing emergency response roles
and responsibilities. Instead, the documents restate the shared roles
and responsibilities of the Secretaries of Health and Human Services
and Homeland Security already prescribed by the NRP and related annexes
and plans. These and other leadership roles and responsibilities
continue to evolve, such as with the establishment of a national PFO
and regional PFOs and FCOs and potential changes from ongoing efforts
to revise the NRP. Congress has also passed legislation to address
prior problems that emerged regarding federal leadership roles and
responsibilities for emergency management that have ramifications for
pandemic influenza. Although pandemic influenza scenarios have been
used to exercise specific response elements, such as the distribution
of stockpiled medications at specific locations or jurisdictions, no
national exercises have tested the new federal leadership structure for
pandemic influenza.[Footnote 14] The only national multisector pandemic
exercise to date was a tabletop simulation conducted by members of the
cabinet in December 2005, which was prior to the release of the Plan
and the establishment of the PFO and FCO positions for a pandemic.
The Strategy and Plan Do Not Clarify Leadership Roles and
Responsibilities:
The Strategy and Plan do not clarify the specific leadership roles and
responsibilities for a pandemic. Instead, they restate the existing
leadership roles and responsibilities, particularly for the Secretaries
of Homeland Security and Health and Human Services, prescribed in the
NRP--an all-hazards plan for emergencies ranging from hurricanes to
wildfires to terrorist attacks. However, the leadership roles and
responsibilities prescribed under the NRP may need to operate somewhat
differently because of the characteristics of a pandemic that
distinguish it from other emergency incidents. For example, because a
pandemic influenza is likely to occur in successive waves, planning has
to consider how to sustain response mechanisms for several months to
over a year--issues that are not clearly addressed in the Plan. In
addition, the distributed nature of a pandemic, as well as the sheer
burden of disease across the nation, means that the support states,
localities, and tribal entities can expect from the federal government
would be limited in comparison to the aid it mobilizes for
geographically and temporarily bounded disasters like earthquakes and
hurricanes. Consequently, legal authorities, roles and
responsibilities, and lines of authority at all levels of government
must be clearly defined, effectively communicated, and well-understood
to facilitate rapid and effective decision making. This is also
important for public and private sector organizations and international
partners so everyone can better understand what is expected of them
before and during a pandemic.
The Strategy and Plan describe the Secretary of Health and Human
Services as being responsible for leading the medical response in a
pandemic, while the Secretary of Homeland Security is responsible for
overall domestic incident management and federal coordination. However,
since a pandemic extends well beyond health and medical boundaries, to
include sustaining critical infrastructure, private sector activities,
the movement of goods and services across the nation and the globe, and
economic and security considerations, it is not clear when, in a
pandemic, the Secretary of Health and Human Services would be in the
lead and when the Secretary of Homeland Security would lead.
Specifically, the Plan states that the Secretary of Health and Human
Services, consistent with his/her role under the NRP as the coordinator
for ESF-8, would be responsible for the overall coordination of the
public health and medical emergency response during a pandemic,
including coordinating all federal medical support to communities;
providing guidance on infection control and treatment strategies to
state, local, and tribal entities and the public; maintaining,
prioritizing, and distributing countermeasures in the Strategic
National Stockpile; conducting ongoing epidemiologic assessment and
modeling of the outbreak; and researching the influenza virus, novel
countermeasures, and rapid diagnostics. The Plan calls for the
Secretary to be the principal federal spokesperson for public health
issues, coordinating closely with DHS on public messaging pertaining to
the pandemic.
Also similar to the NRP, the Plan states that the Secretary of Homeland
Security, as the principal federal official for domestic incident
management, would be responsible for coordinating federal operations
and resources; establishing reporting requirements; and conducting
ongoing communications with federal, state, local, and tribal
governments, the private sector, and nongovernmental organizations. It
also states that in the context of response to a pandemic, the
Secretary of Homeland Security would coordinate overall nonmedical
support and response actions, sustain critical infrastructure, and
ensure necessary support to the Secretary of Health and Human Services'
coordination of public health and medical emergency response efforts.
Additionally, the Plan states that the Secretary of Homeland Security
would be responsible for coordinating the overall response to the
pandemic; implementing policies that facilitate compliance with
recommended social distancing measures; providing for a common
operating picture for all departments and agencies of the federal
government; and ensuring the integrity of the nation's infrastructure,
domestic security, and entry and exit screening for influenza at the
borders.[Footnote 15]
Other DHS responsibilities include operating and maintaining the
National Biosurveillance Integration System, which is intended to
provide an all-source biosurveillance common operating picture to
improve early warning capabilities and facilitate national response
activities through better situational awareness. This responsibility,
however, appears to be both a public health issue and an overall
incident management issue, raising similar issues about the
interrelationship of DHS and HHS roles and responsibilities. In
addition, a pandemic could threaten our critical infrastructure, such
as the capability to deliver electricity or food, by removing essential
personnel from the workplace for weeks or months.[Footnote 16] The
extent to which this would be considered a medical response with the
Secretary of Health and Human Services in the lead, or when it would be
under the Secretary of Homeland Security's leadership as part of his/
her responsibility for ensuring that critical infrastructure is
protected, is unclear. According to HHS officials we interviewed,
resolving this ambiguity will depend on several factors, including how
the outbreak occurs and the severity of the pandemic.
Officials from other agencies also need greater clarity about these
roles and responsibilities. For example, USDA is not planning for DHS
to assume the lead coordinating role if an outbreak of avian flu among
poultry occurs sufficient in scope to warrant a presidential
declaration of an emergency or major disaster.[Footnote 17] The federal
response may be slowed as agencies resolve their roles and
responsibilities following the onset of a significant outbreak. In
addition, although DHS and HHS officials emphasize that they are
working together on a frequent basis, these roles and responsibilities
have not been thoroughly tested and exercised.
Additional Key Leadership Roles and Responsibilities Are Evolving and
Untested:
The executive branch has several efforts, some completed and others
under way, to strengthen and clarify leadership roles and
responsibilities for preparing for and responding to a pandemic
influenza. However, many of these efforts are new, untested through
exercises, or both. For example, on December 11, 2006, the Secretary of
Homeland Security predesignated the Vice Commandant of the U.S. Coast
Guard as the national PFO for pandemic influenza, and also established
five pandemic regions, each with a regional PFO.[Footnote 18] Also,
FCOs were predesignated for each of the regions. In addition to the
five regional FCOs, a FEMA official with significant FCO experience has
been selected to serve as the senior advisor to the national PFO. DOD
has selected Defense Coordination Officers and HHS has selected senior
health officials to work together within this national pandemic
influenza preparedness and response structure.
DHS is taking steps to further clarify federal leadership roles and
responsibilities. Specifically, it is developing a Federal Concept Plan
for Pandemic Influenza, which is intended to identify specific federal
response roles and responsibilities for each stage of an outbreak.
According to DHS, the Concept Plan, which is based on the
Implementation Plan and other related documents, would also identify
"seams and gaps that must be addressed to ensure integration of all
federal departments and agencies prior to, during, and after a pandemic
outbreak in the U.S." According to DHS officials, they sent a draft to
federal agencies in May for comment and have not yet determined when
the Concept Plan will be issued.
U.S. Coast Guard and FEMA officials we met with recognized that
planning for and responding to a pandemic would require different
operational leadership roles and responsibilities than for most other
emergencies. For example, a FEMA official said that given the number of
people who would be involved in responding to a pandemic, collaboration
between HHS, DHS, and FEMA would need to be greater than for any other
past emergencies. Officials are starting to build relationships among
the federal actors for a pandemic. For example, some of the federal
officials with leadership roles for an influenza pandemic met during
the week of March 19, 2007, to continue to identify issues and begin
developing solutions. One of the participants, however, told us that
although additional coordination meetings are needed, it may be
challenging since there is no dedicated funding for the staff working
on pandemic issues to participate in these and other related meetings.
The national PFO for pandemic influenza said that a draft charter has
also been developed to establish a Pandemic Influenza PFO Working Group
to help identify and address many policy and operational issues before
a pandemic. According to a FEMA official, some of these issues include
staff availability, protective measures for staff, and how to ensure
that the assistance to be provided under the Stafford Act is
implemented and coordinated in a unified and consistent manner across
the country during a pandemic. As of June 7, 2007, the draft charter
was undergoing some revisions and was expected to be sent to the
Secretary of Homeland Security for review and approval around the end
of June. Additionally, there are plans to identify related exercises,
within and outside of the federal government, to create a consolidated
schedule of exercises for the national PFO for pandemic influenza and
regional PFOs and FCOs to participate in by leveraging existing
exercise plans. DHS officials said that they expect FEMA would retain
responsibility for maintaining this consolidated schedule.
It is unclear whether the newly established national and regional
positions for a pandemic will further clarify leadership roles. For
example, in 2006, DHS made revisions to the NRP and released a
Supplement to the Catastrophic Incident Annex--both designed to further
clarify federal roles and responsibilities and relationships among
federal, state, and local governments and responders. However, we
reported in February 2007 that these revisions had not been tested and
there was little information available on the extent to which these and
other actions DHS was taking to improve readiness were
operational.[Footnote 19] Additionally, DHS is currently coordinating a
comprehensive review of the NRP and NIMS to assess their effectiveness,
identify improvements, and recommend modifications. One of the issues
expected to be addressed during this review is clarifying of roles and
responsibilities of key structures, positions, and levels of
government, including the role of the PFO and that position's current
lack of operational authority during an emergency. The review is
expected to be done, and a revised NRP and NIMS issued, by the summer
of 2007.
Recent Congressional Actions Addressed Leadership Roles and
Responsibilities:
In 2006, Congress passed two acts addressing leadership roles and
responsibilities for emergency management--the Pandemic and All-
Hazards Preparedness Act[Footnote 20] and the Post-Katrina Emergency
Management Reform Act of 2006[Footnote 21]--which were enacted into law
on December 19, 2006 and October 4, 2006, respectively.
Pandemic and All-Hazards Preparedness Act and Its Implementation:
The Pandemic and All-Hazards Preparedness Act codifies preparedness and
response federal leadership roles and responsibilities for public
health and medical emergencies that are now in the NRP by designating
the Secretary of Health and Human Services as the lead federal official
for public health and medical preparedness and response, consistent
with the NRP. The act also requires the Secretary to establish an
interagency agreement, in collaboration with DOD, DHS, DOT, the
Department of Veterans Affairs, and other relevant federal agencies,
prescribing that consistent with the NRP, HHS would assume operational
control of emergency public health and medical response assets in the
event of a public health emergency. Further, the act requires that the
Secretary develop a coordinated National Health Security Strategy and
accompanying implementation plan for public health emergency
preparedness and response. This health security strategy and
accompanying implementation plan are to be completed by 2009 and
updated every 4 years.
The act also prescribes several new preparedness responsibilities for
HHS. For example, the Secretary must develop and disseminate criteria
for an effective state plan for responding to a pandemic influenza.
Additionally, the Secretary is required to develop and require the
application of measurable evidence-based benchmarks and objective
standards that measure the levels of preparedness in such areas as
hospitals and state and local public health security.
The act seeks to further strengthen HHS's public health leadership role
by transferring the National Disaster Medical System from DHS back to
HHS, thus placing these public health resources within HHS.[Footnote
22] It also creates the Office of the Assistant Secretary for
Preparedness and Response (replacing the Office of the Assistant
Secretary for Public Health Emergency Preparedness) and consolidates
other preparedness and response functions within HHS in the new
Assistant Secretary's office.
HHS has set up an implementation team involving over 200 HHS staff to
implement the provisions of this act. According to a HHS official, an
interim implementation plan is expected to be made available for public
comment sometime during the summer of 2007.
Post-Katrina Reform Act and Its Implementation:
In response to the findings and recommendations from several reports,
the Post-Katrina Emergency Management Reform Act (referred to as the
Post-Katrina Reform Act in this report) designated the FEMA
Administrator as the principal domestic emergency management advisor to
the President, the HSC, and the Secretary of Homeland Security.
Therefore, the FEMA Administrator also has a leadership role in
preparing for and responding to an influenza pandemic, including key
areas such as planning and exercising. For example, under the Post-
Katrina Reform Act, the FEMA Administrator is responsible for carrying
out a national exercise program to test and evaluate preparedness for a
national response to natural and man-made disasters.
The act made FEMA a distinct entity within DHS for leading and
supporting the nation in a risk-based, comprehensive emergency
management system of preparedness, protection, response, recovery, and
mitigation. As part of the reorganization, DHS transferred several
offices and divisions of its National Preparedness Directorate to FEMA,
including the Offices of Grants and Training and National Capital
Region Coordination.[Footnote 23] FEMA's National Preparedness
Directorate contains functions related to preparedness doctrine,
policy, and contingency planning and includes DHS's exercise
coordination and evaluation program and emergency management training.
Other transfers included the Chemical Stockpile Emergency Preparedness
Division, Radiological Emergency Preparedness Program, and the United
States Fire Administration. The reorganization took effect on March 31,
2007, and it will likely take some time before it is fully implemented
and key leadership positions within FEMA are filled.
Rigorous and Robust Exercises Are Important for Testing Federal
Leadership for a Pandemic:
Disaster planning, including for a pandemic influenza, needs to be
tested and refined with a rigorous and robust exercise program to
expose weaknesses in plans and allow planners to refine them.
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. Our prior work
examining the preparation for and response to Hurricane Katrina
highlighted the importance of realistic exercises to test and refine
assumptions, capabilities, and operational procedures; and build upon
strengths.[Footnote 24] In response to the experiences during Hurricane
Katrina, the Post-Katrina Reform Act called for a national exercise
program to evaluate preparedness of a national response to natural and
man-made disasters.
While pandemic influenza scenarios have been used to exercise specific
response elements and locations, such as for distributing stockpiled
medications, there has been no national exercise to test a multisector,
multijurisdictional response or any exercises to test the working and
operational relationships of the national PFO and the five regional
PFOs and FCOs for pandemic influenza. According to a CRS report, the
only national multisector pandemic exercise to date was a tabletop
simulation involving members of the federal cabinet in December
2005.[Footnote 25] This tabletop exercise was prior to the release of
the Plan in May 2006, the establishment of a national PFO and regional
PFO and FCO positions for a pandemic, and enactment of the Pandemic and
All-Hazards Preparedness Act in December 2006 and the Post-Katrina
Reform Act in October 2006.
The National Strategy and Its Implementation Plan Do Not Address All
the Characteristics of an Effective Strategy, Thus Limiting Their
Usefulness as Planning Tools:
The Strategy and Plan represent important efforts to guide the nation's
preparedness and response activities, setting forth actions to be taken
by federal agencies and expectations for a wide range of actors,
including states and communities, the private sector, global partners,
and individuals. However, the Strategy and Plan do not address all of
the characteristics of an effective national strategy as we identified
in our prior work. While national strategies necessarily vary in
content, the six characteristics we identified apply to all such
planning documents and can help ensure that they are effective
management tools. Gaps and deficiencies in these documents are
particularly troubling in that a pandemic represents a complex
challenge that will require the full understanding and collaboration of
a multitude of entities and individuals. The extent to which these
documents, that are to provide an overall framework to ensure
preparedness and response to a pandemic influenza, fail to adequately
address key areas, could have critical impact on whether the public and
key stakeholders have a clear understanding and can effectively execute
their roles and responsibilities.
As shown in table 3, the Strategy and its Plan address one of the six
characteristics of an effective national strategy. However, they only
partially address four and do not address one of the characteristics at
all. As a result, the Strategy and Plan fall short as an effective
national strategy in important areas.
Table 3: Extent to Which the Strategy and Plan Address GAO's Desirable
Characteristics of an Effective National Strategy:
Desirable characteristic: Clear purpose, scope, and methodology;
Addresses: [Empty];
Partially addresses: X;
Does not address: [Empty].
Desirable characteristic: Problem definition and risk assessment;
Addresses: X;
Partially addresses: [Empty];
Does not address: [Empty].
Desirable characteristic: Goals, subordinate objectives, activities,
and performance measures;
Addresses: [Empty];
Partially addresses: X;
Does not address: [Empty].
Desirable characteristic: Resources, investments, and risk management;
Addresses: [Empty];
Partially addresses: [Empty];
Does not address: X.
Desirable characteristic: Organizational roles, responsibilities, and
coordination;
Addresses: [Empty];
Partially addresses: X;
Does not address: [Empty].
Desirable characteristic: Integration and implementation;
Addresses: [Empty];
Partially addresses: X;
Does not address: [Empty].
Source: GAO analysis of the National Strategy for Pandemic Influenza
and Implementation Plan for the National Strategy for Pandemic
Influenza.
[End of table]
The Strategy and Plan Partially Address Purpose, Scope, and
Methodology:
A national strategy should address its purpose, scope, and methodology,
including the process by which it was developed, stakeholder
involvement, and how it compares and contrasts with other national
strategies. Addressing this characteristic helps make a strategy more
useful to organizations responsible for implementing the strategy, as
well as those responsible for oversight. We found that the Strategy and
Plan partially address this characteristic by describing their purpose
and scope. However, neither document described in adequate detail their
methodology for involving key stakeholders, how they relate to other
national strategies, or a process for updating the Plan.
In describing its purpose, the Strategy states that it was developed to
provide strategic direction for the departments and agencies of the
U.S. government and guide the U.S. preparedness and response activities
to mitigate the impact of a pandemic. In support of the Strategy, the
Plan states that its purpose is to translate the Strategy into tangible
action and direct federal departments and agencies to take specific,
coordinated steps to achieve the goals of the Strategy and outline
expectations for state, local, and tribal entities; businesses; schools
and universities; communities; nongovernmental organizations; and
international partners.
As a part of its scope, the Plan identifies six major functions: (1)
protecting human health, (2) protecting animal health, (3)
international considerations, (4) transportation and borders, (5)
security considerations, and (6) institutional considerations. The Plan
proposes that departments and agencies undertake a series of actions in
support of these functional areas with operational details on how
departments would accomplish these objectives to be provided by
separate departmental plans. Additionally, the Strategy and Plan
describe the principles and planning assumptions that guided their
development. The Strategy's guiding principles include recognition of
the private sector's integral role and leveraging global partnerships.
The Plan's principles are more expansive, listing 12 planning
assumptions that it identifies as facilitating its planning efforts.
For example, 1 of the assumptions is that illness rates would be
highest among school-aged children (about 40 percent).
Another element under this characteristic is the involvement of key
stakeholders in the development of the strategy. Neither the Strategy
nor Plan described the involvement of key stakeholders, such as state,
local, and tribal entities, in the development of the Strategy or Plan,
even though they would be on the front lines in a pandemic and the Plan
identifies actions they should complete. The Plan contains 17 actions
calling for state, local, and tribal governments to lead national and
subnational efforts, and identifies another 64 actions where their
involvement is needed. Officials told us that federal stakeholders had
opportunities to review and comment on the Plan but that state, local,
and tribal entities were not directly involved, although the drafters
of the Plan were generally aware of their concerns. 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.
Therefore, the Strategy and Plan may not fully reflect a national
perspective on this critical national issue since nonfederal
stakeholders were not involved in the process to develop the actions
where their leadership, support, or both would be needed. Further,
these nonfederal stakeholders need to understand their critical roles
in order to be prepared to work effectively under difficult and
challenging circumstances.
Both documents address the scope of their coverage and include several
important elements in their discussions, but do not address how they
compare and contrast to other national strategies. The Strategy
recognizes that preparing for a pandemic is more than a purely federal
responsibility, and that the nation must have a system of plans at all
levels of government and in all sectors outside of government that can
be integrated to address the pandemic threat. It also extends its scope
to include the development of an international effort as a central
component of overall capacity. The Strategy lays out the major
functions, mission areas, and activities considered under the extent of
its coverage. For example, the Strategy's scope is defined as extending
well beyond health and medical boundaries, to include sustaining
critical infrastructure, private sector activities, the movement of
goods and services across the nation and the globe, and economic and
security considerations. Although the Strategy states that it will be
consistent with the National Security Strategy and the Strategy for
Homeland Security, it does not specify how they are related. The Plan
mentions the NRP and states that it will guide the federal pandemic
response. Because a pandemic would affect all facets of our society,
including the nation's security, it is important to recognize and
reflect an understanding of how these national strategies relate to one
another.
The Plan does not describe a mechanism for updating it to reflect
policy decisions, such as clarifications in leadership roles and
responsibilities and other lessons learned from exercising and testing
or other changes. Although the Plan was developed with the intent of
being initial guidance and being updated and expanded over time,
officials in several agencies told us that specific processes or time
frames for updating and revising it have not been established. In
addition to incorporating lessons learned, such updates are important
in ensuring that the Plan accurately reflects entities' capabilities
and a clear understanding of roles and responsibilities. Additionally,
an update would also provide the opportunity for input from nonfederal
entities that have not had an opportunity to directly provide input to
the Strategy and Plan.
Strategy and Plan Address Problem Definition and Risk Assessment:
National strategies need to reflect a clear description and
understanding of the problems to be addressed, their causes, and
operating environment. In addition, the strategy should include a risk
assessment, including an analysis of the threats to and vulnerabilities
of critical assets and operations. We found that the Strategy and Plan
address this characteristic by describing the potential problems
associated with a pandemic as well as potential threats and
vulnerabilities.
In defining the problem, both documents provide information on what a
pandemic is and how influenza viruses are transmitted, and explain that
a threat stems from an unprecedented outbreak of avian influenza in
Asia and Europe, caused by the H5N1 strain of the influenza A virus.
The President, in releasing the Strategy, stated that it presented an
approach to address the threat of pandemic influenza, whether it
results from the strain currently in birds in Asia or another influenza
virus. Additionally, the problem definition includes a historical
perspective of other pandemics in the United States.
The Plan used the severity of the 1918 influenza pandemic as the basis
for its risk assessment. A CBO study[Footnote 26] was used to describe
the possible economic consequences of such a severe pandemic on the
U.S. economy today. While the Plan did not discuss the likelihood of a
severe pandemic or analyze the possibility of whether the H5N1 strain
would be the specific virus strain to cause a pandemic, it stated that
history suggests that a pandemic would occur some time in the future.
As a result, it recognizes the importance of preparing for an outbreak.
The Strategy and Plan included discussions of the constraints and
challenges involved in a pandemic. For example, the Plan included
challenges such as severe shortfalls in surge capacity in the nation's
health care facilities, limited vaccine production capabilities, the
lack of real-time surveillance among most of the systems, and the
inability to quantify the value of many infection control strategies.
In acknowledging the challenges involved in pandemic preparedness, the
Plan also describes a series of circumstances to enable preparedness,
such as viewing pandemic preparedness as a national security issue,
connectivity between communities, and communicating risk and
responsibility. In this regard, the Plan recognizes that one of the
nation's greatest vulnerabilities is the lack of connectivity between
communities responsible for pandemic preparedness. The Plan
specifically cites vulnerabilities in coordination of efforts between
the animal and human health communities, as well as between the public
health and medical communities. In the case of public health and
medical communities, the public health community has responsibility for
communitywide health promotion and disease prevention and mitigation
efforts, and the medical community is largely focused on actions at the
individual level.
The Strategy and Plan Partially Address Goals, Objectives, Activities,
and Performance Measures:
A national strategy should describe its goals and the steps needed to
achieve those results, as well as the priorities, milestones, and
outcome-related performance measures to gauge results. Identifying
goals, objectives, and outcome-related performance measures aids
implementing parties in achieving results and enables more effective
oversight and accountability. We found that the Strategy and Plan
partially address this characteristic by identifying the overarching
goals and objectives for pandemic planning. However, the documents did
not describe relationships or priorities among the action items, and
some of the action items lacked a responsible entity for ensuring their
completion. The Plan also did not describe a process for monitoring and
reporting on the action items. Further, many of the performance
measures associated with action items were not clearly linked with
results nor assigned clear priorities.[Footnote 27]
The Strategy and Plan identify a hierarchy of major goals, pillars,
functional areas, and specific activities (i.e., action items), as
shown in figure 1. The Plan includes and expands upon the Strategy's
framework by including 324 action items.
Figure 1: National Strategy and Implementation Plan's Goals, Pillars,
Functional Areas, and Action Items:
[See PDF for image]
Source: GAO analysis of the National Strategy for Pandemic Influenza
and the Implementation Plan for the National Strategy for Pandemic
Influenza.
[End of figure]
The Plan uses the Strategy's three major goals that are underpinned by
three pillars as its framework and expands on this organizing structure
by presenting chapters on six functional areas with various objectives,
action items, and performance measures. For example, pillar 2,
surveillance and detection, under the transportation and borders
functional area, includes an objective to develop and exercise
mechanisms to provide active and passive surveillance during an
outbreak, both within and outside our borders. Under this objective is
an action item for HHS, in coordination with other specific federal
agencies, to develop policy recommendations for transportation and
borders entry and exit protocols, screening, or both and to review the
need to develop domestic response protocols and screening within 6
months. The item's performance measure is policy recommendations for
response protocols, screening, or both.
While some action items depend on other action items, these linkages
are not always apparent in the Plan. For example, one action item,
concerning the development of a joint strategy for deploying federal
health care and public health assets and personnel, is under the
preparedness and communication pillar. However, another action item
concerning the development of strategic principles for deployment of
federal medical assets is under the response and containment pillar
within the same chapter. While these two action items are clearly
related, the plan does not make a connection between the two or discuss
their relationship. An HHS official who helped draft the Plan
acknowledged that while an effort was made to ensure linkages among
action items, there may be gaps in the linkages among interdependent
action items within and across the Plan's chapters on the six
functional areas (i.e., the chapters that contain action items).
Some action items, particularly those that are to be completed by
state, local, and tribal governments or the private sector, do not
identify an entity responsible for carrying out the action. Although
the plan specifies actions to be carried out by states, local
jurisdictions, and other entities, including the private sector, it
gives no indication of how these actions will be monitored and how
their completion will be ensured. For example, one such action item
states that "all health care facilities should develop and test
infectious disease surge capacity plans that address challenges
including: increased demand for services, staff shortages, infectious
disease isolation protocols, supply shortages, and security."
Similarly, another action item states that "all Federal, State, local,
tribal, and private sector medical facilities should ensure that
protocols for transporting influenza specimens to appropriate reference
laboratories are in place within 3 months." Yet the plan does not make
clear who will be responsible for making sure that these actions are
completed.
While most of the action items have deadlines for completion, ranging
from 3 months to 3 years, the Plan does not identify a process to
monitor and report on the progress of the action items nor does it
include a schedule for reporting progress. Agency officials told us
that they had identified individuals to act as overall coordinators to
monitor the action items for which their agencies have lead
responsibility and provide periodic progress reports to the HSC.
However, we could not identify a similar mechanism to monitor the
progress of the action items that fall to state and local governments
or the private sector. The first public reporting on the status of the
action items occurred in December 2006 when the HSC reported on the
status of the action items that were to have been completed by November
3, 2006--6 months after the release of the Plan. Of the 119 action
items that were to be completed by that time, we found that the HSC
omitted the status of 16 action items. Two of the action items that
were omitted from the report were to (1) establish an interagency
transportation and border preparedness working group and (2) engage in
contingency planning and related exercises to ensure preparedness to
maintain essential operations and conduct missions.
Additionally, we found that several of the action items that were
reported by the HSC as being completed were still in progress. For
example, DHS, in coordination with the Department of State (State),
HHS, the Department of the Treasury (Treasury), and the travel and
trade industry, was to tailor existing automated screening programs and
extended border programs to increase scrutiny of travelers and cargo
based on potential risk factors within 6 months. The measure of
performance was to implement enhanced risk-based screening protocols.
Although this action item was reported as complete, the HSC reported
that DHS was still developing risk-based screening protocols, a major
component of this action. A DHS official, responsible for coordinating
the completion of DHS-led action items, acknowledged that all action
items are a work in progress and that they would continue to be
improved, including those items that were listed as completed in the
report. The HSC's report included a statement that a determination of
"complete" does not necessarily mean that work has ended; in many cases
work is ongoing. Instead, the complete determination means that the
measure of performance associated with an action item was met. It
appears that this determination has not been consistently or accurately
applied for all items. Our recent report on U.S. agencies'
international efforts to forestall a pandemic influenza also reported
that eight of the Plan's international-related action items included in
the HSC's report either did not directly address the associated
performance measure or did not indicate that the completion deadline
had been met.[Footnote 28]
Most of the Plan's performance measures are focused on activities such
as disseminating guidance, but the measures are not always clearly
linked with intended results. This lack of clear linkages makes it
difficult to ascertain whether progress has in fact been made toward
achieving the national goals and objectives described in the Strategy
and Plan. Most of the Plan's performance measures consist of actions to
be completed, such as guidance developed and disseminated. Without a
clear linkage to anticipated results, these measures of activities do
not give an indication of whether the purpose of the activity is
achieved. Further, 18 of the action items have no measure of
performance associated with them. In addition, the plan does not
establish priorities among its 324 action items, which becomes
especially important as agencies and other parties strive to
effectively manage scarce resources and ensure that the most important
steps are accomplished.
The Strategy and Plan Do Not Address Resources, Investments, and Risk
Management:
A national strategy needs to describe what the strategy will cost;
identify where resources will be targeted to achieve the maximum
results; and describe how the strategy balances benefits, risks, and
costs. Guidance on costs and resources needed using a risk management
approach helps implementing parties allocate resources according to
priorities, track costs and performance, and shift resources, as
appropriate. We found that neither the Strategy nor Plan contain these
elements.
While neither document addresses the overall cost to implement the
Plan, the Plan refers to the administration's budget request of $7.1
billion and a congressional appropriation of $3.8 billion to support
the objectives of the Strategy. In November 2005, the administration
requested $7.1 billion in emergency supplemental funding over 3 years
to support the implementation of the Strategy. In December 2005,
Congress appropriated $3.8 billion to support budget requirements to
help address pandemic influenza issues.[Footnote 29] The Plan states
that much of this funding would be directed toward domestic
preparedness and the establishment of countermeasure stockpile and
production capacity, with $400 million directed to bilateral and
multilateral international efforts. However, the 3-year $7.1 billion
budget proposal does not coincide with the period of the Plan.
Additionally, whereas the Plan does not allocate funds to specific
action items, our analysis of budget documents indicates that the funds
were allocated primarily toward those action items related to vaccines
and antivirals.
Developing and sustaining the capabilities stipulated in the Plan would
require the effective use of federal, state, and local funds. Given
that funding needs may not be readily addressed through existing
mechanisms and could stress existing government and private resources,
it is critical for the Plan to lay out funding requirements. For
example, the Plan states that one of the primary objectives of domestic
vaccine production capacity would be for domestic manufacturers to
produce enough vaccine for the entire U.S. population within 6 months.
However, it states that production capacity would depend on the
availability of future appropriations. Despite the fact that the
production of enough vaccine for the population would be critical if a
pandemic were to occur, the Plan does not provide even a rough estimate
of how much the vaccine could cost for consideration in future
appropriations.
Despite the numerous action items and specific implementing directives
and guidance directed toward federal agencies, states, organizations,
and businesses, neither document addresses what it would cost to
complete the actions that are stipulated. Rather, the Plan states that
the local communities would have to address the medical and nonmedical
effects of the pandemic with available resources, and also that
pandemic influenza response activities may exceed the budgetary
resources of responding federal and state government agencies.
The overall uncertainty of funding to complete action items stipulated
in the Plan has been problematic. For example, there were more than 50
actions in the Plan that were to be completed before the end of 2006
for which DOD was either a lead or support agency. We reported that
because DOD had not yet requested funding, it was unclear whether DOD
could address the tasks assigned to it in the Plan and pursue its own
preparedness efforts for its workforce departmentwide within current
resources.[Footnote 30]
The Strategy and Plan Partially Address Organizational Roles,
Responsibilities, and Coordination:
A national strategy should address which organizations would implement
the strategy, their roles and responsibilities, and mechanisms for
coordinating their efforts. It helps to answer the fundamental question
about who is in charge, not only during times of crisis, but also
during all phases of emergency management, as well as the organizations
that will provide the overall framework for accountability and
oversight. This characteristic entails identifying the specific federal
departments, agencies, and offices involved and, where appropriate, the
different sectors, such as state, local, private, and international
sectors. We found that the Strategy and Plan partially address this
characteristic by containing broad information on roles and
responsibilities. But, as we noted earlier, while the Plan describes
coordination mechanisms for responding to a pandemic, it does not
clarify how responsible officials would share leadership
responsibilities. In addition, it does not describe mechanisms for
coordinating preparations and completing the action items, nor does it
describe an overall accountability and oversight framework.
The Strategy identifies lead agencies for preparedness and response.
Specifically, HHS is the lead agency for medical response; USDA for
veterinary response; State for international activities; and DHS for
overall domestic incident management, sustainment of critical
infrastructure and key resources, and federal coordination. The Plan
also briefly describes the preparedness and response roles and
responsibilities of DOD, the Department of Labor, DOT, and Treasury.
The Plan states that these and all federal cabinet agencies are
responsible for their respective sectors and developing pandemic
response plans. In addition, the Strategy and Plan broadly describe the
expected roles and responsibilities of state, local, and tribal
governments; international partners; the private and nonprofit sectors;
and individuals and families. For example, in the functional area of
transportation and borders, the Plan states that it expects state and
local communities to involve transportation and health professionals to
identify transportation options, consequences, and implications in the
event of a pandemic.
The Plan states that the primary mechanism for coordinating the federal
government's response to a pandemic is the NRP. In this regard, the
Plan acknowledges that sustaining mechanisms for several months to over
a year will present unique challenges, and thus day-to-day monitoring
of the response to a pandemic influenza would occur through the
national operations center with an interagency body composed of senior
decision makers from across the government and chaired by the White
House. Additionally, the Plan states that policy issues that cannot be
resolved at the department level would be addressed through the HSC-
National Security Council policy coordination process. As stipulated in
the Plan, the specifics of this policy coordination mechanism were
included in the May 2006 revisions to the NRP.
The Plan also generally identifies lead and support roles for the
action items federal agencies are responsible for completing, but it is
not explicit in defining these roles or processes for coordination and
collaboration. While it identifies which federal agencies have lead and
support roles for completing 305 action items, the Plan does not define
the roles of the lead and support agencies. Rather, it leaves it to the
agencies to interpret and negotiate their roles. According to DOT
officials we met with, this lack of clarity, coupled with staff
turnover, left them unclear about their roles and responsibilities in
completing action items. Thus, they had to seek clarification from DHS
and HHS officials to assist them in defining what it meant to be the
lead agency for an action item. Additionally, the Plan does not
describe specific processes for coordination and collaboration between
federal and nonfederal organizations and sectors for completing the
action items.
Related to this issue, we recently reported that some of DOD's
combatant commands, tasked with providing support in the event of a
pandemic, had received limited detailed guidance from the lead agencies
about what support they may be asked to provide during a
pandemic.[Footnote 31] This has hindered these commands' ability to
plan to provide support to lead federal agencies domestically and
abroad during a pandemic.
The Plan also does not describe the role played by organizations that
are to provide the overall framework for accountability and oversight,
such as the HSC. According to agency officials, the HSC is monitoring
executive branch agencies' efforts to complete the action items.
However, there is no specific documentation describing this process or
institutionalizing it. This is important since some of the action items
are not expected to be completed during this administration. Also, a
similar oversight process for those actions items for which nonfederal
entities have the lead responsibility does not appear to exist.
The Strategy and Plan Partially Address Integration and Implementation:
A national strategy should make clear how it relates to the goals,
objectives, and activities of other strategies and to subordinate
levels of government and their plans to implement the strategy. A
strategy might also discuss, as appropriate, various strategies and
plans produced by state, local, private, and international sectors. A
clear relationship between the strategy and other critical implementing
documents helps agencies and other entities understand their roles and
responsibilities, foster effective implementation, and promote
accountability. We found that the Strategy and Plan partially address
this characteristic. Although the documents mention other related
national strategies and plans, they do not provide sufficient detail
describing the relationships among these strategies and plans nor do
they describe how subordinate levels of government and independent
plans proposed by the Plan would be integrated to implement the
Strategy.
Since September 11, 2001, various national strategies, presidential
directives, and national initiatives have been developed to better
prepare the nation to respond to incidents of national significance,
such as a pandemic influenza. As noted in figure 2, these include the
National Security Strategy and the NRP. However, although the Strategy
states that it is consistent with the National Security Strategy and
the National Strategy for Homeland Security, it does not state how it
is consistent or describe its relationship with these two strategies.
In addition, the Plan does not specifically address how the Strategy or
other related pandemic plans should be integrated with the goals,
objectives, and activities of the national initiatives already in
place.
Figure 2: Related National Preparedness Strategies, Initiatives, and
Plans:
[See PDF for image]
Source: GAO.
[End of figure]
Whereas the Plan states that it supports Homeland Security Presidential
Directive 8, which required the development of a domestic all-hazards
preparedness goal--the National Preparedness Goal (Goal)--it does not
describe how it supports the directive or its relationship to the
Goal.[Footnote 32] The current interim Goal is particularly important
for determining what capabilities are needed for a catastrophic
disaster. It defines 36 major capabilities that first responders should
possess to prevent, protect from, respond to, and recover from a wide
range of incidents and the most critical tasks associated with these
capabilities. An inability to effectively perform these critical tasks
would, by definition, have a detrimental effect on protection,
prevention, response, and recovery capabilities. The interim Goal also
includes 15 planning scenarios, including one for pandemic influenza
that outlines universal and critical tasks to be undertaken for
planning for an influenza pandemic and target capabilities, such as
search and rescue and economic and community recovery. Yet, the
Strategy and Plan do not integrate this already-developed planning
scenario and related tasks and capabilities. One federal agency
official who assisted in drafting the Plan told us that the Goal and
its pandemic influenza scenario had been considered but omitted because
the Goal's pandemic influenza scenario is geared to a less severe
pandemic--such as those that occurred in 1957 and 1968--while the Plan
is based on the more severe 1918-level mortality and morbidity rates.
Further, the Strategy and Plan do not provide sufficient detail about
how the Strategy, action items, and proposed set of independent plans
are to be integrated with other national strategies and framework.
Without clearly providing this linkage, the Plan may limit a common
understanding of the overarching framework, thereby hindering the
nation's ability to effectively prepare for, respond to, and recover
from a pandemic. For example, the Plan contains 39 action items that
are response related (i.e., specific actions are to be taken within a
prescribed number of hours or days after an outbreak). However, these
action items are interspersed among the 324 action items, and the Plan
does not describe the linkages of these response-related action items
with the NRP or other response related plans. Further, DHS officials
have recognized the need for a common understanding across federal
agencies and better integration of agencies plans to prepare for and
respond to a pandemic. DHS officials are developing a Federal Concept
Plan for Pandemic Influenza to enhance interagency preparedness,
response, and recovery efforts.
The Plan also requires the federal departments and agencies to develop
their own pandemic plans that describe the operational details related
to the respective action items and cover the following areas: (1)
protection of their employees; (2) maintenance of their essential
functions and services; (3) how they would support both the federal
response to a pandemic and those of states, localities, and tribal
entities; and (4) the manner in which they would communicate messages
about pandemic planning and response to their stakeholders. Further, it
is unclear whether all the departments will share some or all of the
information in their plans with nonfederal entities. While some
agencies-such as HHS, DOD, and the Department of Veterans Affairs-have
publicly released their pandemic plans, at least one agency, DHS, has
indicated that it does not intend to publicly release its plan. Since
DHS is a lead agency for planning for and responding to a pandemic,
this gap may make it more challenging to fully advance joint and
integrated planning across all levels of government and the private
sector.
The Plan recognizes and discusses the need for integrating planning
across all levels of government and the private sector to ensure that
the plans and response actions are complementary, compatible, and
coordinated. In this regard, the Plan provides initial planning
guidance for state, local, and tribal entities; businesses; schools and
universities; and nongovernmental organizations for a pandemic. It also
includes various action items that when completed, would produce
additional planning guidance and materials for these entities. However,
the Plan is unclear as to how the existing guidance relates to broad
federal and specific departmental and agency plans as well as how the
additional guidance would be integrated and how any gaps or conflicts
that exist would be identified and addressed.
Conclusions:
Although it is likely that an influenza pandemic will occur in the
future, there is a high level of uncertainty about when a pandemic
might occur and its level of severity. The administration has taken an
active approach to this potential disaster by establishing an
information clearinghouse for pandemic information; developing numerous
planning guidelines for governments, businesses, nongovernmental
organizations, and individuals; issuing the Strategy and Plan;
completing many action items contained in the Plan; and continuing
efforts to complete the remaining action items.
A pandemic poses some unique challenges. Other disasters, such as
hurricanes, earthquakes, or terrorist attacks, generally occur within a
short period and the immediate effects are experienced in specific
locations. By contrast, a pandemic would likely occur in multiple
waves, each lasting weeks or months and affecting communities across
the nation. Initial actions may help limit the spread of an influenza
virus, reflecting the importance of a swift and effective response.
Therefore, the effective exercise of shared leadership roles and
responsibilities could have substantial consequences, both in the short
and long term. However, these roles and responsibilities continue to
evolve, leaving uncertainty about how the federal government would lead
preparations for and response to a pandemic. Since the release of the
Plan in May 2006, no national pandemic exercises of federal leadership
roles and responsibilities have been conducted. Without rigorous
testing, training, and exercising, the administration lacks information
to determine whether current and evolving leadership roles and
responsibilities are clear and clearly understood or if more changes
are needed to ensure clarity.
The Strategy and Plan are important because they broadly describe the
federal government's approach and planned actions to prepare for and
respond to a pandemic, as well as expectations for states and
communities, the private sector, and global partners. Although they
contain a number of important characteristics, the documents lack
several key elements. As a result, their usefulness as a management
tool for ensuring accountability and achieving results is limited. For
example, because the Strategy and Plan do not address the resources and
investments needed to implement the actions called for, it is unclear
what resources are needed to build capacity and whether they would be
available. Further, because they did not include stakeholders that are
expected to be the primary responders to a pandemic in the development
of the Strategy and Plan, these documents may not fully reflect a
national perspective on this critical national issue, and stakeholders
and the public may not have a full understanding of their critical
roles. In addition, the linkages among pandemic planning efforts and
with all-hazards plans and initiatives need to be clear so that the
numerous parties involved can operate in an integrated manner. Finally,
because many of the performance measures do not provide information
about the impacts of proposed actions, it will be difficult to assess
the extent to which we are better prepared or to identify areas needing
additional attention. Opportunities exist to improve the usefulness of
the Plan because it is viewed as an evolving document and is intended
to be updated on a regular basis to reflect ongoing policy decisions,
as well as improvements in domestic preparedness. Currently, however,
time frames or mechanisms for updating the Plan are undefined.
While the HSC publicly reported on the status of approximately 100
action items that were to have been completed by November 2006, the
Plan lacks a prescribed process for monitoring and reporting on the
progress of the action items or what has been accomplished as a result.
Therefore, it is unclear when the next report will be issued or how
much information will be released. In addition, some of the information
reported was incorrect. This lack of transparency makes it difficult to
inform a national dialogue on the progress made to date or what further
steps are needed. It also inhibits congressional oversight of
strategies, funding priorities, and critical efforts to enhance the
nation's level of preparedness.
DHS officials believe that their efforts to develop a Federal Concept
Plan for Pandemic Influenza may help to more fully address some of the
characteristics that we found the Strategy and Plan lack. According to
those officials, the proposed Concept Plan may help, for example,
better integrate the organizational roles, responsibilities, and
coordination of interagency partners. They recognized, however, that
the Concept Plan would not fully address all of the gaps we have
identified. For example, they told us that the Concept Plan may not
address actual or estimated costs or investments of the resources that
will be required. Overall, they agreed that more needs to be done,
especially in view of the long time requirements and challenging issues
presented by a potential pandemic influenza.
Recommendations for Executive Action:
To enhance preparedness efforts for a possible pandemic, we are making
the following two recommendations:
We recommend that the Secretaries of Homeland Security and Health and
Human Services work together to develop and conduct rigorous testing,
training, and exercises for pandemic influenza to ensure that federal
leadership roles are clearly defined and understood and that leaders
are able to effectively execute shared responsibilities to address
emerging challenges. Once the leadership roles have been clarified
through testing, training, and exercising, the Secretaries of Homeland
Security and Health and Human Services should ensure that these roles
are clearly understood by state, local, and tribal governments; the
private and nonprofit sectors; and the international community.
We also recommend that the Homeland Security Council establish a
specific process and time frame for updating the Implementation Plan
for the National Strategy for Pandemic Influenza. The process for
updating the Plan should involve key nonfederal stakeholders and
incorporate lessons learned from exercises and other sources. The Plan
should also be improved by including the following information in the
next update:
* the cost, sources, and types of resources and investments needed to
complete the action items and where they should be targeted;
* a process and schedule for monitoring and publicly reporting on
progress made on completing the actions;
* clearer linkages with other strategies and plans; and:
* clearer descriptions of relationships or priorities among action
items and greater use of outcome-focused performance measures.
Agency Comments and Our Evaluation:
We provided a draft of this report to DHS, HHS, and the HSC for review
and comment. DHS provided written comments, which are reprinted in
appendix II. In commenting on the draft report, DHS concurred with the
first recommendation and stated that DHS is taking action on many of
the shortfalls identified in the report. For example, DHS stated that
it is working closely with HHS and other interagency partners to
develop and implement a series of coordinated interagency pandemic
exercises and will include all levels of government as well as the
international community and the private and nonprofit sectors.
Additionally, DHS stated that its Incident Management Planning Team
intends to use our list of desirable characteristics of an effective
national strategy as one of the review metrics for all future plans.
DHS also provided us with technical comments, which we incorporated in
the report as appropriate.
HHS informed us that it had no comments and concurred with the draft
report. The HSC did not comment on the draft report.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution of it until 30
days from its date. We will then send copies of this report to the
appropriate congressional committees and to the Assistant to the
President for Homeland Security; the Secretaries of HHS, DHS, USDA,
DOD, State, and DOT; and other interested parties. We will also make
copies available to others upon request. In addition, this report will
be available at no charge on the GAO Web site at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions regarding 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. GAO staff who made major contributions
to this report are listed in appendix III.
Signed by:
Bernice Steinhardt:
Director Strategic Issues:
[End of section]
Appendix I: Scope and Methodology:
Our reporting objectives were to review the extent to which (1) federal
leadership roles and responsibilities for preparing for and responding
to a pandemic are clearly defined and (2) the National Strategy for
Pandemic Influenza (Strategy) and the Implementation Plan for the
National Strategy for Pandemic Influenza (Plan) address the
characteristics of an effective national strategy.
To determine to what extent federal leadership roles and
responsibilities for preparing for and responding to a pandemic are
clearly defined, we drew upon our extensive body of work on the federal
government's response to hurricanes Katrina and Rita as well as our
prior work on pandemic influenza. We also studied the findings in
reports issued by Congress, the Department of Homeland Security's
Office of the Inspector General, the Homeland Security Council (HSC),
and the Congressional Research Service. Additionally, we reviewed the
Strategy and Plan and a variety of federal emergency documents,
including the National Response Plan's base plan and supporting annexes
and the implementation plans developed by the Departments of Homeland
Security and Health and Human Services. HSC officials declined to meet
with us, stating that we should rely upon information provided by
agency officials. We interviewed officials in the departments of
Agriculture, Defense, Health and Human Services, Homeland Security,
Transportation, and State and the Federal Emergency Management Agency
and the U.S. Coast Guard. Some of these officials were involved in the
development of the Plan.
To review the extent to which the Strategy and Plan address the
characteristics of an effective national strategy, we analyzed the
Strategy and Plan; reviewed key relevant sections of major statutes,
regulations, directives, national strategies, and plans discussed in
the Plan; and interviewed officials in agencies that the Strategy and
Plan identified as lead agencies in preparing for and responding to a
pandemic.
We assessed the extent to which the Strategy and Plan jointly addressed
the six desirable characteristics, and the related elements under each
characteristic, of an effective national strategy by using the six
characteristics developed in previous GAO work.[Footnote 33] Table 4
provides the desirable characteristics and examples of their elements.
Table 4: GAO Desirable Characteristics for a National Strategy:
Desirable characteristic: Purpose, scope, and methodology;
Brief description: Addresses why the strategy was produced, the scope
of its coverage, and the process by which it was developed;
Examples of elements:
* Statement of broad or narrow purpose, as appropriate;
* How it compares and contrasts with other national strategies;
* What major functions, mission areas, or activities it covers;
* Principles or theories that guided its development;
* Impetus for strategy, for example, statutory requirement or event;
* Process to produce strategy, for example, interagency task force or
state, local, or private input;
* Definition of key terms.
Desirable characteristic: Problem definition and risk assessment;
Brief description: Addresses the particular national problems and
threats the strategy is directed toward;
Examples of elements:
* Discussion or definition of problems, their causes, and operating
environment;
* Risk assessment, including an analysis of threats and
vulnerabilities;
* Quality of data available, for example, constraints, deficiencies,
and "unknowns.".
Desirable characteristic: Goals, subordinate objectives, activities,
and performance measures;
Brief description: Addresses what the strategy is trying to achieve;
steps to achieve those results;
as well as the priorities, milestones, and performance measures to
gauge results;
Examples of elements:
* Overall results desired, that is, "end state.";
* Hierarchy of strategic goals and subordinate objectives;
* Specific activities to achieve results;
* Priorities, milestones, and outcome-related performance measures;
* Specific performance measures;
* Process for monitoring and reporting on progress;
* Limitations on progress indicators.
Desirable characteristic: Resources, investments, and risk management;
Brief description: Addresses what the strategy will cost, the sources
and types of resources and investments needed, and where resources and
investments should be targeted by balancing risk reductions and costs;
Examples of elements:
* Resources and investments associated with the strategy;
* Types of resources required, such as budgetary, human capital,
information technology, research and development, and contracts;
* Sources of resources, for example, federal, state, local, and
private;
* Economic principles, such as balancing benefits and costs;
* Resource allocation mechanisms, such as grants, in-kind services,
loans, or user fees;
* "Tools of government," for example, mandates or incentives to spur
action;
* Importance of fiscal discipline;
* Linkage to other resource documents, for example, federal budget;
* Risk management principles.
Desirable characteristic: Organizational roles, responsibilities, and
coordination;
Brief description: Addresses who will be implementing the strategy,
what their roles will be compared to others, and mechanisms for them to
coordinate their efforts;
Examples of elements:
* Roles and responsibilities of specific federal agencies, departments,
or offices;
* Roles and responsibilities of state, local, private, and
international sectors;
* Lead, support, and partner roles and responsibilities;
* Accountability and oversight framework;
* Potential changes to current organizational structure;
* Specific processes for coordination and collaboration;
* How conflicts will be resolved.
Desirable characteristic: Integration and implementation;
Brief description: Addresses how a national strategy relates to other
strategies' goals, objectives, and activities--and to subordinate
levels of government and their plans to implement the strategy;
Examples of elements:
* Integration with other national strategies (horizontal);
* Integration with relevant documents from implementing organizations
(vertical);
* Details on specific federal, state, local, or private strategies and
plans;
* Implementation guidance;
* Details on subordinate strategies and plans for implementation, for
example, human capital and enterprise architecture.
[End of table]
Source: GAO.
National strategies with these characteristics offer policymakers and
implementing agencies a management tool that can help ensure
accountability and more effective results. We have used this
methodology to assess and report on the administration's strategies
relating to terrorism, rebuilding of Iraq, and financial
literacy.[Footnote 34]
To assess whether the documents addressed these desirable
characteristics, two analysts independently assessed both documents
against each of the elements of a characteristic. If the analysts did
not agree, a third party reviewed, discussed, and made the final
determination to rate that element. Each characteristic was given a
rating of either "addresses," "partially addresses," or "does not
address." According to our methodology, a strategy "addresses" a
characteristic when it explicitly cites all, or nearly all, elements of
the characteristic and has sufficient specificity and detail. A
strategy "partially addresses" a characteristic when it explicitly
cites one or a few of the elements of a characteristic and has
sufficient specificity and detail. It should be noted that the
"partially addresses" category includes a range that varies from
explicitly citing most of the elements to citing as few as one of the
elements of a characteristic. A strategy "does not address" a
characteristic when it does not explicitly cite or discuss any elements
of a characteristic, any references are either too vague or general to
be useful, or both.
We reviewed relevant sections of major statutes, regulations,
directives, and plans discussed in the Plan to better understand if and
how they were related. Specifically, our review included Homeland
Security Presidential Directive 5 on the Management of Domestic
Incidents; the National Response Plan; and the Robert T. Stafford
Disaster Relief and Emergency Assistance Act of 1974 (as amended) as
well as other national strategies.
We conducted our review from May 2006 through June 2007 in accordance
with generally accepted government auditing standards.
[End of section]
Appendix II: Comments from the Department of Homeland Security:
U.S. Department of Homeland Security:
Washington, DC 20528:
Homeland Security:
July 10, 2007:
Mr. Norman J. Rabkin:
Managing Director:
Homeland Security and Justice Issues:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Rabkin:
The Department of Homeland Security (DHS) appreciates the opportunity
to review and respond to the Government Accountability Office's (GAO)
draft report entitled, "Influenza Pandemic: Further Efforts Are Needed
to Ensure Clearer Federal Leadership Roles and Effective National
Strategy," (GAO-07-81).
The Department appreciates the work done in this engagement to identify
any issues that hinder the effectiveness of the National Strategy for
Pandemic Influenza and Implementation Plan, both designed to minimize
the negative effects of pandemic influenza. Although we feel the report
offers an accurate depiction of the current pandemic preparedness
issues from a broad and strategic perspective, the scope of the report
does not address the significant planning efforts occurring at the
operational and tactical levels among Federal, State, Tribal, Local,
and private sector stakeholders. Over the last year, the Federal
Government has conducted an extensive outreach effort to the private
sector, particularly critical infrastructure businesses. In the last
year, over 150 presentations, workshops, and forums have been conducted
and have been attended by thousands of key stakeholders from critical
infrastructure entities (e.g., healthcare operations, banking and
finance entities, operations centers, retail operations, transportation
and trucking operations, supply warehousing operations, grocery and
food suppliers, and supply distributors) as well as businesses of all
types. These information sharing sessions have provided practical
action- oriented information to identify essential functions and
critical planning elements, and to assist businesses in protecting the
health of employees and in maintaining continuity of business
operations during a pandemic.
We concur with the recommendation that the Secretaries of the DHS and
Health and Human Services (HHS) work together to develop and conduct
rigorous testing, training, and exercises for pandemic influenza,
ensuring that not only federal leadership roles, but the roles of all
involved parties are clearly defined and understood, and that leaders
are able to effectively execute shared responsibilities to address
emerging challenges. DHS has identified and through the Incident
Management Planning Team (IMPT), is already taking action on many of
the shortfalls identified in this report. The IMPT now intends to use
the GAO planning review methodology as one of our review metrics for
all future IMPT plans. DHS is also working closely with the Department
of Health and Human Services (HHS) and other interagency partners to
develop and implement a series of coordinated interagency pandemic
exercises that will include all levels of the Federal, State, Local,
Tribal and Territorial governments. These exercises will include the
private sector, volunteer, faith based organizations, and the
international community. The Planning, Training, Exercises and
Evaluations (PTEE-PCC) will coordinate these efforts to ensure
interagency collaboration.
Thank you again for the opportunity to provide comments on this draft
report and we look forward to working with you again on future homeland
security and justice issues. Technical comments will be provided under
a separate cover.
Sincerely,
Signed by:
Steven J. Pecinovsky:
Director:
Departmental GAO/OIG Liaison Office:
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Bernice Steinhardt, (202) 512-6543 or steinhardtb@gao.gov:
Acknowledgments:
In addition to the contact named above, Susan Ragland, Assistant
Director; Allen Lomax; David Dornisch; Donna Miller; Catherine Myrick;
and members of GAO's Pandemic Working Group made key contributions to
this report.
[End of section]
Related GAO Products:
Homeland Security: Observations on DHS and FEMA Efforts to Prepare for
and Respond to Major and Catastrophic Disasters and Address Related
Recommendations and Legislation. GAO-07-1142T. Washington, D.C.: July
31, 2007.
Emergency Management Assistance Compact: Enhancing EMAC's Collaborative
and Administrative Capacity Should Improve National Disaster Response.
GAO-07-854. Washington, D.C.: June 29, 2007.
Influenza Pandemic: DOD Combatant Commands' Preparedness Efforts Could
Benefit from More Clearly Defined Roles, Resources, and Risk
Mitigation. GAO-07-696. Washington, D.C.: June 20, 2007.
Influenza Pandemic: Efforts to Forestall Onset Are Under Way;
Identifying Countries at Greatest Risk Entails Challenges. GAO-07-604.
Washington, D.C.: June 20, 2007.
Avian Influenza: USDA Has Taken Important Steps to Prepare for
Outbreaks, but Better Planning Could Improve Response. GAO-07-652.
Washington, D.C.: June 11, 2007.
The Federal Workforce: Additional Steps Needed to Take Advantage of
Federal Executive Boards' Ability to Contribute to Emergency
Operations. GAO-07-515. Washington, D.C.: May 4, 2007.
Financial Market Preparedness: Significant Progress Has Been Made, but
Pandemic Planning and Other Challenges Remain. GAO-07-399. Washington,
D.C.: March 29, 2007.
Public Health and Hospital Emergency Preparedness Programs: Evolution
of Performance Measurement Systems to Measure Progress. GAO-07-485R.
Washington, D.C.: March 23, 2007.
Homeland Security: Preparing for and Responding to Disasters. GAO-07-
395T. Washington, D.C.: March 9, 2007.
Influenza Pandemic: DOD Has Taken Important Actions to Prepare, but
Accountability, Funding, and Communications Need to be Clearer and
Focused Departmentwide. GAO-06-1042. Washington, D.C.: September 21,
2006.
Hurricane Katrina: Better Plans and Exercises Needed to Guide the
Military's Response to Catastrophic Natural Disasters. GAO-06-643.
Washington, D.C.: May 15, 2006.
Continuity of Operations: Agencies Could Improve Planning for Telework
during Disruptions. GAO-06-740T. Washington, D.C.: May 11, 2006.
Hurricane Katrina: GAO's Preliminary Observations Regarding
Preparedness, Response, and Recovery. GAO-06-442T. Washington, D.C.:
March 8, 2006.
Emergency Preparedness and Response: Some Issues and Challenges
Associated with Major Emergency Incidents. 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. GAO-06-365R. Washington, D.C.: February 1, 2006.
Influenza Pandemic: Applying Lessons Learned from the 2004-05 Influenza
Vaccine Shortage. GAO-06-221T. Washington, D.C.: November 4, 2005.
Influenza Vaccine: Shortages in 2004-05 Season Underscore Need for
Better Preparation. GAO-05-984. Washington, D.C.: September 30, 2005.
Influenza Pandemic: Challenges in Preparedness and Response. GAO-05-
863T. Washington, D.C.: June 30, 2005.
Influenza Pandemic: Challenges Remain in Preparedness. GAO-05-760T.
Washington, D.C.: May 26, 2005.
Flu Vaccine: Recent Supply Shortages Underscore Ongoing Challenges. GAO-
05-177T. Washington, D.C.: November 18, 2004.
Emerging Infectious Diseases: Review of State and Federal Disease
Surveillance Efforts. GAO-04-877. Washington, D.C.: September 30, 2004.
Infectious Disease Preparedness: Federal Challenges in Responding to
Influenza Outbreaks. GAO-04-1100T. Washington, D.C.: September 28,
2004.
Emerging Infectious Diseases: Asian SARS Outbreak Challenged
International and National Responses. GAO-04-564. Washington, D.C.:
April 28, 2004.
Public Health Preparedness: Response Capacity Improving but Much
Remains to Be Accomplished. GAO-04-458T. Washington, D.C.: February 12,
2004.
HHS Bioterrorism Preparedness Programs: States Reported Progress but
Fell Short of Program Goals for 2002. GAO-04-360R. Washington, D.C.:
February 10, 2004.
Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but
Lack Certain Capacities for Bioterrorism Response. GAO-03-924.
Washington, D.C.: August 6, 2003.
Severe Acute Respiratory Syndrome: Established Infectious Disease
Control Measures Helped Contain Spread, But a Large-Scale Resurgence
May Pose Challenges. GAO-03-1058T. Washington, D.C.: July 30, 2003.
SARS Outbreak: Improvements to Public Health Capacity Are Needed for
Responding to Bioterrorism and Emerging Infectious Diseases. GAO-03-
769T. Washington, D.C.: May 7, 2003.
Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have
Improved Public Health Response Capacity, but Gaps Remain. GAO-03-654T.
Washington, D.C.: April 9, 2003.
Flu Vaccine: Steps Are Needed to Better Prepare for Possible Future
Shortages. GAO-01-786T. Washington, D.C.: May 30, 2001.
Flu Vaccine: Supply Problems Heighten Need to Ensure Access for High-
Risk People. GAO-01-624. Washington, D.C.: May 15, 2001.
Influenza Pandemic: Plan Needed for Federal and State Response. GAO-01-
4. Washington, D.C.: October 27, 2000.
Global Health: Framework for Infectious Disease Surveillance. GAO/
NSIAD-00-205R. Washington, D.C.: July 20, 2000.
Footnotes:
[1] See GAO, Combating Terrorism: Evaluation of Selected
Characteristics in National Strategies Related to Terrorism, GAO-04-
408T (Washington, D.C.: Feb. 3, 2004); Rebuilding Iraq: More
Comprehensive National Strategy Needed to Help Achieve U.S. Goals, GAO-
06-788 (Washington, D.C.: July 11, 2006); and Financial Literacy and
Education Commission: Further Progress Needed to Ensure an Effective
National Strategy, GAO-07-100 (Washington, D.C.: Dec. 4, 2006).
[2] In addition to these published reports, GAO has engagements under
way to examine other aspects of preparing for and responding to a
pandemic, including efforts by DHS, HHS, and state and local
governments.
[3] Congressional Research Service, Pandemic Influenza: Domestic
Preparedness Efforts, RL 33145 (Washington, D.C.: Feb. 20, 2007).
[4] Pub. L. No. 107-296, 116 Stat. 2135 (2002).
[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] The Public Health Service Act is codified, as amended, at 42 U.S.C.
§ 201-300ii-4.
[7] The 15 ESF annexes are in (1) transportation; (2) communications;
(3) public works and engineering; (4) firefighting; (5) emergency
management; (6) mass care, housing, and human services; (7) resource
support; (8) public health and medical services; (9) urban search and
rescue; (10) oil and hazardous materials response; (11) agriculture and
natural resources; (12) energy; (13) public safety and security; (14)
long-term community recovery and mitigation; and (15) external affairs.
[8] ESF-11 supporting agencies include the Departments of Commerce,
Defense, Energy, Justice, and Labor.
[9] The NRP includes the seven incident annexes: biological,
catastrophic, cyber, food and agriculture, nuclear/radiological, oil
and hazardous materials, and terrorism incident law enforcement and
investigation.
[10] For non-Stafford Act incidents, the NRP refers to Federal Resource
Coordinators.
[11] As of July 25, 2007, the checklists included State and Local
Pandemic Influenza Planning Checklist, Pandemic Preparedness Planning
for United States Businesses with Overseas Operations, Business
Pandemic Influenza Planning Checklist, Health Insurer Pandemic
Influenza Planning Checklist, Travel Industry Pandemic Influenza
Planning Checklist, Child Care and Preschool Pandemic Influenza
Planning Checklist, School District (K-12) Pandemic Influenza Planning
Checklist, Colleges and Universities Pandemic Influenza Planning
Checklist, Faith-Based and Community Organizations Pandemic Influenza
Planning Checklist, Home Health Care Services Pandemic Influenza
Planning Checklist, Medical Offices and Clinics Checklist, Emergency
Medical Services and Medical Transport Checklist, Hospital Preparedness
Checklist, Long-term Care and Other Residential Facilities Pandemic
Influenza Planning Checklist, and Pandemic Flu Planning Checklist for
Individuals and Families.
[12] GAO, Continuity of Operations: Agencies Could Improve Planning for
Telework during Disruptions, GAO-06-740T (Washington, D.C.: May 11,
2006).
[13] Department of Homeland Security, Pandemic Influenza Preparedness,
Response, and Recovery Guide for Critical Infrastructure and Key
Resources, (Washington, D.C.: Sept. 19, 2006).
[14] Congressional Research Service, Pandemic Influenza.
[15] Social distancing includes measures such as limiting public
gatherings or closing buildings to help people avoid exposure to
infectious diseases.
[16] Critical infrastructure and key resource sectors include
agriculture and food; banking and finance; chemical; commercial
facilities; dams; defense industrial base; drinking water and water
treatment systems; emergency services; energy; government facilities;
information technology; national monuments and icons; nuclear reactors,
materials, and waste; postal and shipping; public health and health
care; telecommunications; and transportation systems.
[17] GAO, Avian Influenza: USDA Has Taken Important Steps to Prepare
for Outbreaks, but Better Planning Could Improve Response, GAO-07-652
(Washington, D.C.: June 11, 2007).
[18] The Secretary of Homeland Security combined the jurisdictions
covered by FEMA's 10 regional offices into 5 pandemic regions.
[19] GAO, Homeland Security: Management and Programmatic Challenges
Facing the Department of Homeland Security, GAO-07-398T (Washington,
D.C.: Feb. 6, 2007).
[20] Pub. L. No. 109-417.
[21] Pub. L. No. 109-295, Title VI.
[22] The National Disaster Medical System was transferred to DHS from
HHS as part of the Homeland Security Act of 2002 establishing DHS.
[23] On January 18, 2007, DHS provided Congress with a notice of
implementation of the Post-Katrina Reform Act reorganization
requirements and additional organizational changes made under the
Homeland Security Act of 2002.
[24] GAO, Hurricane Katrina: GAO's Preliminary Observations Regarding
Preparedness, Response, and Recovery, GAO-06-442T (Washington, D.C.:
Mar. 8, 2006).
[25] Congressional Research Service, Pandemic Influenza.
[26] Congressional Budget Office, A Potential Influenza Pandemic:
Possible Macroeconomic Effects and Policy Issues (Washington, D.C.:
Dec. 8, 2005).
[27] Of the 324 action items, 39 were response related with performance
measures requiring certain efforts within a prescribed time frame after
an outbreak and thus not included in the universe of action items
assessed for this purpose. Additionally, there were no performance
measures associated with 18 action items.
[28] GAO, Influenza Pandemic: Efforts to Forestall Onset Are Under Way;
Identifying Countries at Greatest Risk Entails Challenges, GAO-07-604
(Washington, D.C.: June 20, 2007).
[29] Emergency Supplemental Appropriations to Address Hurricanes in the
Gulf of Mexico and Pandemic Influenza Act of 2006, Division B of Pub.L.
No. 109-148 (2005).
[30] GAO, Influenza Pandemic: DOD Has Taken Important Actions to
Prepare, but Accountability, Funding, and Communications Need to be
Clearer and Focused Departmentwide, GAO-06-1042 (Washington, D.C.:
Sept. 21, 2006).
[31] GAO, Influenza Pandemic: DOD Combatant Commands' Preparedness
Efforts Could Benefit from More Clearly Defined Roles, Resources, and
Risk Mitigation, GAO-07-696 (Washington, D.C.: June 20, 2007).
[32] The Goal establishes the national vision and priorities to guide
the nation's efforts to set measurable readiness benchmarks and targets
to strengthen the nation's preparedness, and attempts to provide a
comprehensive preparedness effort.
[33] GAO-04-408T.
[34] GAO-04-408T, GAO-06-788, and GAO-07-100.
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