Influenza Pandemic
Continued Focus on the Nation's Planning and Preparedness Efforts Remains Essential Gao ID: GAO-09-760T June 3, 2009As the recent outbreak of the H1N1 (swine flu) virus underscores, an influenza pandemic remains a real threat to our nation and to the world. Over the past 3 years, GAO has conducted a body of work to help the nation better prepare for a possible pandemic. In a February 2009 report, GAO synthesized the results of this work, pointing out that while the previous administration had taken a number of actions to plan for a pandemic, including developing a national strategy and implementation plan, much more needs to be done, and many gaps in preparedness and planning still remain. This statement is based on the February 2009 report which synthesized the results of 11 reports and two testimonies covering six thematic areas: (1) leadership, authority, and coordination; (2) detecting threats and managing risks; (3) planning, training, and exercising, (4) capacity to respond and recover; (5) information sharing and communication; and (6) performance and accountability.
(1) Leadership roles and responsibilities for an influenza pandemic need to be clarified, tested, and exercised, and existing coordination mechanisms, such as critical infrastructure coordinating councils, could be better utilized to address challenges in coordination between the federal, state, and local governments and the private sector in preparing for a pandemic. (2) Efforts are underway to improve the surveillance and detection of pandemic-related threats in humans and animals, but targeting assistance to countries at the greatest risk has been based on incomplete information, particularly from developing countries. (3) Pandemic planning and exercising has occurred at the federal, state, and local government levels, but important planning gaps remain at all levels of government. (4) Further actions are needed to address the capacity to respond to and recover from an influenza pandemic, which will require additional capacity in patient treatment space, and the acquisition and distribution of medical and other critical supplies, such as antivirals and vaccines. (5) Federal agencies have provided considerable guidance and pandemic-related information to state and local governments, but could augment their efforts with additional information on state border closures and other topics. (6) Performance monitoring and accountability for pandemic preparedness needs strengthening. For example, the May 2006 National Strategy for Pandemic Influenza Implementation Plan does not establish priorities among its 324 action items and does not provide information on the financial resources needed to implement them. The recent outbreak of the H1N1 influenza virus should serve as a powerful reminder that the threat of a pandemic influenza, which seemed to fade from public awareness in recent years, never really disappeared. While federal agencies have taken action on 13 of GAO's 23 recommendations, 10 of the recommendations that GAO has made over the past 3 years are still not fully implemented. With the possibility that the H1N1 virus could return in a more virulent form in a second wave in the fall or winter, the administration and federal agencies should turn their attention to filling in the planning and preparedness gaps GAO's work has pointed out.
GAO-09-760T, Influenza Pandemic: Continued Focus on the Nation's Planning and Preparedness Efforts Remains Essential
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Testimony before the Ad Hoc Subcommittee on State, Local, and Private
Sector Preparedness and Integration, Senate Committee on Homeland
Security and Governmental Affairs:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 2:00 p.m. EST:
Wednesday, June 3, 2009:
Influenza Pandemic:
Continued Focus on the Nation's Planning and Preparedness Efforts
Remains Essential:
Statement of Bernice Steinhardt:
Director, Strategic Issues:
GAO-09-760T:
GAO Highlights:
Highlights of GAO-09-760T, testimony before the Ad Hoc Subcommittee on
State, Local, and Private Sector Preparedness and Integration, Senate
Committee on Homeland Security and Governmental Affairs.
Why GAO Did This Study:
As the recent outbreak of the H1N1 (swine flu) virus underscores, an
influenza pandemic remains a real threat to our nation and to the
world. Over the past 3 years, GAO has conducted a body of work to help
the nation better prepare for a possible pandemic. In a February 2009
report, GAO synthesized the results of this work, pointing out that
while the previous administration had taken a number of actions to plan
for a pandemic, including developing a national strategy and
implementation plan, much more needs to be done, and many gaps in
preparedness and planning still remain.
This statement is based on the February 2009 report which synthesized
the results of 11 reports and two testimonies covering six thematic
areas: (1) leadership, authority, and coordination; (2) detecting
threats and managing risks; (3) planning, training, and exercising, (4)
capacity to respond and recover; (5) information sharing and
communication; and (6) performance and accountability.
What GAO Found:
* Leadership roles and responsibilities for an influenza pandemic need
to be clarified, tested, and exercised, and existing coordination
mechanisms, such as critical infrastructure coordinating councils,
could be better utilized to address challenges in coordination between
the federal, state, and local governments and the private sector in
preparing for a pandemic.
* Efforts are underway to improve the surveillance and detection of
pandemic-related threats in humans and animals, but targeting
assistance to countries at the greatest risk has been based on
incomplete information, particularly from developing countries.
* Pandemic planning and exercising has occurred at the federal, state,
and local government levels, but important planning gaps remain at all
levels of government.
* Further actions are needed to address the capacity to respond to and
recover from an influenza pandemic, which will require additional
capacity in patient treatment space, and the acquisition and
distribution of medical and other critical supplies, such as antivirals
and vaccines.
* Federal agencies have provided considerable guidance and pandemic-
related information to state and local governments, but could augment
their efforts with additional information on state border closures and
other topics.
* Performance monitoring and accountability for pandemic preparedness
needs strengthening. For example, the May 2006 National Strategy for
Pandemic Influenza Implementation Plan does not establish priorities
among its 324 action items and does not provide information on the
financial resources needed to implement them.
The recent outbreak of the H1N1 influenza virus should serve as a
powerful reminder that the threat of a pandemic influenza, which seemed
to fade from public awareness in recent years, never really
disappeared. While federal agencies have taken action on 13 of GAO‘s 23
recommendations, 10 of the recommendations that GAO has made over the
past 3 years are still not fully implemented. With the possibility that
the H1N1 virus could return in a more virulent form in a second wave in
the fall or winter, the administration and federal agencies should turn
their attention to filling in the planning and preparedness gaps GAO‘s
work has pointed out.
What GAO Recommends:
The February 2009 report made no new recommendations. This statement
discusses the status of GAO‘s prior recommendations on the nation‘s
planning and preparedness for a pandemic.
View [hyperlink, http://www.gao.gov/products/GAO-09-760T] or key
components. For more information, contact Bernice Steinhardt at (202)
512-6543 or steinhardtb@gao.gov.
[End of section]
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today to discuss key themes from the body of
work GAO has developed over the past several years to help the nation
better prepare for, respond to, and recover from a possible influenza
pandemic. An influenza pandemic remains a real threat to our nation and
to the world, as we are witnessing during the current outbreak of the
H1N1 (swine flu) virus. The previous administration took a number of
actions to plan for a pandemic, including developing a national
strategy and implementation plan. However, much more needs to be done,
and many gaps in preparedness and planning still remain. At the same
time, national priorities have been shifting as a global pandemic has
yet to occur, and the nation's financial crisis and other national
issues have become more immediate and pressing. Strengthening
preparedness for large-scale public health emergencies, such as an
influenza pandemic, is one of 13 urgent issues that we identified
earlier this year as among those needing the immediate attention of the
new administration and Congress.[Footnote 1]
In the past 3 years, GAO has issued 11 reports and two testimonies on
influenza pandemic planning.[Footnote 2] We synthesized the results of
this work in a February 2009 report, which I will discuss in more
detail today.[Footnote 3] We have made 23 recommendations based on the
findings from these reports and testimonies, thirteen of which have
been acted upon by the responsible federal agencies. While the
responsible federal agencies have generally agreed with our
recommendations and some actions are underway to address them, 10
recommendations have not yet been fully implemented. While our February
2009 report made no new recommendations, we updated the status of
recommendations that had not yet been implemented as of February 2009.
Many of the recommendations that remain unimplemented have become even
more pressing in light of the very real possibility of a more serious
return of the H1N1 virus later this year. Lists of our open
recommendations and related GAO products that are referenced throughout
this statement are located in attachments I and II.
In summary, my statement will address the following issues which were
drawn from the key themes of GAO's pandemic work:
* Leadership roles and responsibilities for an influenza pandemic need
to be clarified, tested, and exercised, and existing coordination
mechanisms, such as critical infrastructure coordinating councils,
could be better utilized to address challenges in coordination between
the federal, state, and local governments and the private sector in
preparing for a pandemic.
* Efforts are underway to improve the surveillance and detection of
pandemic-related threats in humans and animals, but targeting
assistance to countries at the greatest risk has been based on
incomplete information, particularly from developing countries.
* Pandemic planning and exercising has occurred at the federal, state,
and local government levels, but important planning gaps remain at all
levels of government.
* Further actions are needed to address the capacity to respond to and
recover from an influenza pandemic, which will require additional
capacity in patient treatment space, and the acquisition and
distribution of medical and other critical supplies, such as antivirals
and vaccines.
* Federal agencies have provided considerable guidance and pandemic-
related information to state and local governments, but could augment
their efforts with additional information on state border closures and
other topics.
* Performance monitoring and accountability for pandemic preparedness
needs strengthening. For example, the May 2006 National Strategy for
Pandemic Influenza Implementation Plan (National Pandemic
Implementation Plan) does not establish priorities among its 324 action
items and does not provide information on the financial resources
needed to implement them.
This statement is largely based on our prior work, which was conducted
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background:
Given the consequences of a severe influenza pandemic, in 2006 GAO
developed a strategy for our work that would help support Congress's
decision making and oversight related to pandemic planning. Our
strategy was built on a large body of work spanning two decades,
including reviews of government responses to prior disasters such as
Hurricanes Andrew and Katrina, the devastation caused by the 9/11
terror attacks, efforts to address the Year 2000 (Y2K) computer
challenges, and assessments of public health capacities in the face of
bioterrorism and emerging infectious diseases such as Severe Acute
Respiratory Syndrome (SARS). The strategy was built around six key
themes, as shown in figure 1. While all of these themes are
interrelated, our earlier work underscored the importance of
leadership, authority, and coordination, a theme that touches on all
aspects of preparing for, responding to, and recovering from an
influenza pandemic.
Figure 1: Key Themes of GAO's Pandemic Strategy:
[Refer to PDF for image: illustration]
Key Themes of GAO's Pandemic Strategy (shown as potentially
interlocking puzzle pieces);
* Performance and accountability;
* Leadership, authority, and coordination;
* Detecting threats and managing risks;
* Information sharing and communication;
* Capacity to respond and recover;
* Planning, training, and exercising.
Source: GAO.
[End of figure]
Influenza pandemic--caused by a novel strain of influenza virus for
which there is little resistance and which therefore is highly
transmissible among humans--continues to be a real and significant
threat facing the United States and the world. Unlike incidents that
are discretely bounded in space or time (e.g., most natural or man-made
disasters), an influenza pandemic is not a singular event, but is
likely to come in waves, each lasting weeks or months, and pass through
communities of all sizes across the nation and the world
simultaneously. While the current H1N1 outbreak seems to have been
relatively mild, the history of an influenza pandemic suggests it could
return in a second wave this fall or winter in a more virulent form.
While a pandemic will not directly damage physical infrastructure such
as power lines or computer systems, it threatens the operation of
critical systems by potentially removing the essential personnel needed
to operate them from the workplace for weeks or months. In a severe
pandemic, absences attributable to illnesses, the need to care for ill
family members, and fear of infection may, according to the Centers for
Disease Control and Prevention (CDC), reach a projected 40 percent
during the peak weeks of a community outbreak, with lower rates of
absence during the weeks before and after the peak.[Footnote 4] In
addition, an influenza pandemic could result in 200,000 to 2 million
deaths in the United States, depending on its severity.
The Homeland Security Council (HSC) took an active approach to this
potential disaster by, among other things, issuing the National
Strategy for Pandemic Influenza (National Pandemic Strategy) in
November 2005, and the National Pandemic Implementation Plan in May
2006.[Footnote 5] The National Pandemic Strategy 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
provides expectations for nonfederal entities--including state, local,
and tribal governments; the private sector; international partners; and
individuals--to prepare themselves and their communities. The National
Pandemic Implementation Plan is intended to lay out broad
implementation requirements and responsibilities among the appropriate
federal agencies and clearly define expectations for nonfederal
entities. The plan contains 324 action items related to these
requirements, responsibilities, and expectations, most of which were to
be completed before or by May 2009. HSC publicly reported on the status
of the action items that were to be completed by 6 months, 1 year, and
2 years in December 2006, July 2007, and October 2008, respectively.
HSC indicated in its October 2008 progress report that 75 percent of
the action items have been completed. At the request of the House
Homeland Security Committee, we have ongoing work assessing the status
of implementing this plan.
Leadership Roles and Responsibilities Need to Be Clarified and Tested,
and Coordination Mechanisms Could Be Better Utilized:
Federal government leadership roles and responsibilities for pandemic
preparedness and response are evolving, and will require further
testing before the relationships among the many federal leadership
positions are well understood. Such clarity in leadership is even more
crucial now, given the change in administration and the associated
transition of senior federal officials. Most of these federal
leadership roles involve shared responsibilities between the Department
of Health and Human Services (HHS) and the Department of Homeland
Security (DHS), and it is not clear how these would work in practice.
According to the National Pandemic Strategy and Plan, the Secretary of
HHS is to lead the federal medical response to a pandemic, and the
Secretary of Homeland Security will lead the overall domestic incident
management and federal coordination. In addition, under the Post-
Katrina Emergency Management Reform Act of 2006, the Administrator of
the Federal Emergency Management Agency (FEMA) was designated as 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.[Footnote 6] To
assist in planning and coordinating efforts to respond to a pandemic,
in December 2006 the Secretary of Homeland Security predesignated a
national Principal Federal Official (PFO) for influenza pandemic and
established five pandemic regions each with a regional PFO and Federal
Coordinating Officers (FCO) for influenza pandemic. PFOs are
responsible for facilitating federal domestic incident planning and
coordination, and FCOs are responsible for coordinating federal
resources 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. Moreover, as we
testified in July 2007, state and local first responders were still
uncertain about the need for both FCOs and PFOs and how they would work
together in disaster response.[Footnote 7] Accordingly, we recommended
in our August 2007 report on federal leadership roles and the National
Pandemic Strategy that DHS and HHS develop rigorous testing, training,
and exercises for influenza pandemic to ensure that federal leadership
roles and responsibilities for a pandemic are clearly defined and
understood and that leaders are able to effectively execute shared
responsibilities to address emerging challenges.[Footnote 8] In
response to our recommendation, HHS and DHS officials stated in January
2009 that several influenza pandemic exercises had been conducted since
November 2007 that involved both agencies and other federal officials,
but it is unclear whether these exercises rigorously tested federal
leadership roles in a pandemic.
In addition to concerns about clarifying federal roles and
responsibilities for a pandemic and how shared leadership roles would
work in practice, private sector officials told us that they are
unclear about the respective roles and responsibilities of the federal
and state governments during a pandemic emergency. The National
Pandemic Implementation Plan states that in the event of an influenza
pandemic, the distributed nature and sheer burden of the disease across
the nation would mean that the federal government's support to any
particular community is likely to be limited, with the primary response
to a pandemic coming from states and local communities. Further,
federal and private sector representatives we interviewed at the time
of our October 2007 report identified several key challenges they face
in coordinating federal and private sector efforts to protect the
nation's critical infrastructure in the event of an influenza pandemic.
[Footnote 9] One of these was a lack of clarity about the roles and
responsibilities of federal and state governments on issues such as
state border closures and influenza pandemic vaccine distribution.
Coordination Mechanisms:
Mechanisms and networks for collaboration and coordination on pandemic
preparedness between federal and state governments and the private
sector exist, but they could be better utilized. In some instances, the
federal and private sectors are working together through a set of
coordinating councils, including sector-specific and cross-sector
councils. To help protect the nation's critical infrastructure, DHS
created these coordinating councils as the primary means of
coordinating government and private sector efforts for industry sectors
such as energy, food and agriculture, telecommunications,
transportation, and water.[Footnote 10] Our October 2007 report found
that DHS has used these critical infrastructure coordinating councils
primarily to share pandemic information across sectors and government
levels rather than to address many of the challenges identified by
sector representatives, such as clarifying the roles and
responsibilities between federal and state governments.[Footnote 11] We
recommended in the October 2007 report that DHS encourage the councils
to consider and address the range of coordination challenges in a
potential influenza pandemic between the public and private sectors for
critical infrastructure. DHS concurred with our recommendation and DHS
officials informed us at the time of our February 2009 report that the
department was working on initiatives to address it, such as developing
pandemic contingency plan guidance tailored to each of the critical
infrastructure sectors, and holding a series of "webinars" with a
number of the sectors.
Federal executive boards (FEB) bring together federal agency and
community leaders in major metropolitan areas outside of Washington,
D.C., to discuss issues of common interest, including an influenza
pandemic. The Office of Personnel Management (OPM), which provides
direction to the FEBs, and the FEBs have designated emergency
preparedness, security, and safety as an FEB core function. The FEBs'
emergency support role with its regional focus may make the boards a
valuable asset in pandemic preparedness and response. As a natural
outgrowth of their general civic activities and through activities such
as hosting emergency preparedness training, some of the boards have
established relationships with, for example, federal, state, and local
governments; emergency management officials; first responders; and
health officials in their communities. In a May 2007 report on the
FEBs' ability to contribute to emergency operations, we found that many
of the selected FEBs included in our review were building capacity for
influenza pandemic response within their member agencies and community
organizations by hosting influenza pandemic training and exercises.
[Footnote 12] We recommended that, since FEBs are well positioned
within local communities to bring together federal agency and community
leaders, the Director of OPM work with FEMA to formally define the
FEBs' role in emergency planning and response. As a result of our
recommendation, FEBs were included in the National Response Framework
(NRF)[Footnote 13] in January 2008 as one of the regional support
structures that have the potential to contribute to development of
situational awareness during an emergency. OPM and FEMA also signed a
memorandum of understanding in August 2008 in which FEBs and FEMA
agreed to work collaboratively in carrying out their respective roles
in the promotion of the national emergency response system.
Efforts Are Underway to Improve the Surveillance and Detection of
Pandemic-Related Threats in Humans and Animals, but Targeting
Assistance to Countries at the Greatest Risk Has Been Based on
Incomplete Information:
International disease surveillance and detection efforts serve as an
early warning system that could prevent the spread of an influenza
pandemic outbreak. The United States and its international partners are
involved in efforts to improve pandemic surveillance, including
diagnostic capabilities, so that outbreaks can be quickly detected.
Yet, as reported in 2007, international capacity for surveillance has
many weaknesses, particularly in developing countries.[Footnote 14] As
a result, assessments of the risks of the emergence of an influenza
pandemic by U.S. agencies and international organizations, which were
used to target assistance to countries at risk, were based on
insufficiently detailed or incomplete information, limiting their value
for comprehensive comparisons of risk levels by country.
Pandemic Planning and Exercising Has Occurred, but Planning Gaps
Remain:
While the National Pandemic Strategy and National Pandemic
Implementation Plan are important first steps in guiding national
preparedness, important gaps exist that could hinder the ability of key
stakeholders to effectively execute their responsibilities. In our
August 2007 report on the National Pandemic Strategy and Implementation
Plan, we found that while these documents are an important first step
in guiding national preparedness, they do not fully address all six
characteristics of an effective national strategy, as identified in our
work.[Footnote 15] The documents fully address only one of the six
characteristics, by reflecting a clear description and understanding of
problems to be addressed. Further, the National Pandemic Strategy and
Implementation Plan do not address one characteristic at all; they
contain no discussion of what it will cost, where resources will be
targeted to achieve the maximum benefits, and how benefits, risks, and
costs will be balanced. Moreover, the documents do not provide a
picture of priorities or how adjustments might be made in view of
resource constraints. Although the remaining four characteristics are
partially addressed, important gaps exist that could hinder the ability
of key stakeholders to effectively execute their responsibilities. For
example, state and local jurisdictions that will play crucial roles in
preparing for and responding to a pandemic were not directly involved
in developing the National Pandemic Implementation Plan, even though it
relies on these stakeholders' efforts. Stakeholder involvement during
the planning process is important to ensure that the federal
government's and nonfederal entities' responsibilities are clearly
understood and agreed upon. Further, relationships and priorities among
actions were not clearly described, performance measures were not
always linked to results, and insufficient information was provided
about how the documents are integrated with other response-related
plans, such as the NRF. We recommended that HSC establish a process for
updating the National Pandemic Implementation Plan and that the updated
plan should address these and other gaps. HSC did not comment on our
recommendation and has not indicated if it plans to implement it.
State and Local Pandemic Planning:
We reported in June 2008 that, according to CDC, all 50 states and the
three localities that received federal pandemic funds have developed
influenza pandemic plans and conducted pandemic exercises in accordance
with federal funding guidance. A portion of the $5.62 billion that
Congress appropriated in supplemental funding to HHS for pandemic
preparedness in 2006--$600 million--was allocated for state and local
planning and exercising. All of the 10 localities that we reviewed in
depth had also developed plans and conducted exercises, and had
incorporated lessons learned from pandemic exercises into their
planning.[Footnote 16] However, an HHS-led interagency assessment of
states' plans found on average that states had "many major gaps" in
their influenza pandemic plans in 16 of 22 priority areas, such as
school closure policies and community containment, which are community-
level interventions designed to reduce the transmission of a pandemic
virus. The remaining six priority areas were rated as having "a few
major gaps." Subsequently, HHS led another interagency assessment of
state influenza pandemic plans and reported in January 2009 that
although they had made important progress, most states still had major
gaps in their pandemic plans.[Footnote 17]
As we had reported in June 2008, HHS, in coordination with DHS and
other federal agencies, had convened a series of regional workshops for
states in five influenza pandemic regions across the country. Because
these workshops could be a useful model for sharing information and
building relationships, we recommended that HHS and DHS, in
coordination with other federal agencies, convene additional meetings
with states to address the gaps in the states' pandemic plans. As
reported in February 2009, HHS and DHS generally concurred with our
recommendation, but have not yet held these additional meetings. HHS
and DHS indicated at the time of our February 2009 report that while no
additional meetings had been planned, states will have to continuously
update their pandemic plans and submit them for review.
We have also reported on the need for more guidance from the federal
government to help states and localities in their planning. In June
2008, we reported that although the federal government has provided a
variety of guidance, officials of the states and localities we reviewed
told us that they would welcome additional guidance from the federal
government in a number of areas, such as community containment, to help
them to better plan and exercise for an influenza pandemic. Other state
and local officials have identified similar concerns. According to the
National Governors Association's (NGA) September 2008 issue brief on
states' pandemic preparedness, states are concerned about a wide range
of school-related issues, including when to close schools or dismiss
students, how to maintain curriculum continuity during closures, and
how to identify the appropriate time at which classes could resume.
[Footnote 18] NGA also reported that states generally have very little
awareness of the status of disease outbreaks, either in real time or in
near real time, to allow them to know precisely when to recommend a
school closure or reopening in a particular area. NGA reported that
states wanted more guidance in the following areas: (1) workforce
policies for the health care, public safety, and private sectors; (2)
schools; (3) situational awareness such as information on the arrival
or departure of a disease in a particular state, county, or community;
(4) public involvement; and (5) public-private sector engagement.
Private Sector Pandemic Planning:
The private sector has also been planning for an influenza pandemic,
but many challenges remain. To better protect critical infrastructure,
federal agencies and the private sector have worked together across a
number of sectors to plan for a pandemic, including developing general
pandemic preparedness guidance, such as checklists for continuity of
business operations during a pandemic. However, federal and private
sector representatives have acknowledged that sustaining preparedness
and readiness efforts for an influenza pandemic is a major challenge,
primarily because of the uncertainty associated with a pandemic,
limited financial and human resources, and the need to balance pandemic
preparedness with other, more immediate, priorities, such as responding
to outbreaks of foodborne illnesses in the food sector and, now, the
effects of the financial crisis.
In our March 2007 report on preparedness for an influenza pandemic in
one of these critical infrastructure sectors--financial markets--we
found that despite significant progress in preparing markets to
withstand potential disease pandemics, securities and banking
regulators could take additional steps to improve the readiness of the
securities markets.[Footnote 19] The seven organizations that we
reviewed--which included exchanges, clearing organizations, and payment-
system processors--were working on planning and preparation efforts to
reduce the likelihood that a worldwide influenza pandemic would disrupt
their critical operations. However, only one of the seven had completed
a formal plan. To increase the likelihood that the securities markets
will be able to function during a pandemic, we recommended that the
Chairman, Federal Reserve; the Comptroller of the Currency; and the
Chairman, Securities and Exchange Commission (SEC); consider taking
additional actions to ensure that market participants adequately
prepare for a pandemic outbreak. In response to our recommendation, the
Federal Reserve and the Office of the Comptroller of the Currency, in
conjunction with the Federal Financial Institutions Examination Council
and the SEC, directed all banking organizations under their supervision
to ensure that the pandemic plans the financial institutions have in
place are adequate to maintain critical operations during a severe
outbreak. SEC issued similar requirements to the major securities
industry market organizations.
Further Actions Are Needed to Address the Capacity to Respond to and
Recover from an Influenza Pandemic:
Improving the nation's response capability to catastrophic disasters,
such as an influenza pandemic, is essential. Following a mass casualty
event, health care systems would need the ability to adequately care
for a large number of patients or patients with unusual or highly
specialized medical needs. The ability of local or regional health care
systems to deliver services could be compromised, at least in the short
term, because the volume of patients would far exceed the available
hospital beds, medical personnel, pharmaceuticals, equipment, and
supplies. Further, in natural and man-made disasters, assistance from
other states may be used to increase capacity, but in a pandemic,
states would likely be reluctant to provide assistance to each other
due to scarce resources and fears of infection.
The $5.62 billion that Congress provided in supplemental funding to HHS
in 2006 was for, among other things, (1) monitoring disease spread to
support rapid response, (2) developing vaccines and vaccine production
capacity, (3) stockpiling antivirals and other countermeasures, (4)
upgrading state and local capacity, and (5) upgrading laboratories and
research at CDC. Figure 2 shows that the majority of this supplemental
funding--about 77 percent--was allocated for developing antivirals and
vaccines for a pandemic, and purchasing medical supplies. Also, a
portion of the funding for state and local preparedness--$170 million-
-was allocated for state antiviral purchases for their state
stockpiles.[Footnote 20]
Figure 2: HHS Influenza Pandemic Supplemental Appropriations, Fiscal
Year 2006 (dollars in millions):
[Refer to PDF for image: pie-chart]
Vaccine: 58%; $3,233;
Antivirals[C]: 16%; $911;
State and local preparedness[C]: 14%; $770;
Other domestic[B]: 5%; $276;
International activities[A]: 3%; $179;
Medical supplies (personal protective equipment, ventilators, etc.):
3%; $170;
Risk communications: 1%; $51.
Total: $5,590[D].
Source: GAO, HHS.
Notes: Data are from HHS, Pandemic Planning Update III: A Report from
Secretary Michael O. Leavitt (Washington, D.C.: Nov. 13, 2006).
[A] International activities includes: international preparedness,
surveillance, response, and research.
[B] Other domestic includes: surveillance, quarantine, lab capacity,
and rapid tests.
[C] State and local preparedness includes funding for state subsidies
of antiviral drugs.
[D] This figure does not include $30 million in supplemental funding
that was transferred to the U.S. Agency for International Development.
[End of figure]
An outbreak will require additional capacity in many areas, including
the procurement of additional patient treatment space and the
acquisition and distribution of medical and other critical supplies,
such as antivirals and vaccines for an influenza pandemic.[Footnote 21]
In a severe pandemic, the demand would exceed the available hospital
bed capacity, which would be further challenged by the existing
shortages of health care providers and their potential high rates of
absenteeism. In addition, the availability of antivirals and vaccines
could be inadequate to meet demand due to limited production,
distribution, and administration capacity.
The federal government has provided some guidance and funding to help
states plan for additional capacity. For example, the federal
government provided guidance for states to use when preparing for
medical surge and on prioritizing target groups for an influenza
pandemic vaccine. Some state officials reported, however, that they had
not begun work on altered standards of care guidelines, that is, for
providing care while allocating scarce equipment, supplies, and
personnel in a way that saves the largest number of lives in mass
casualty event, or had not completed drafting guidelines, because of
the difficulty of addressing the medical, ethical, and legal issues
involved. We recommended that HHS serve as a clearinghouse for sharing
among the states altered standards of care guidelines developed by
individual states or medical experts. HHS did not comment on the
recommendation, and it has not indicated if it plans to implement it.
[Footnote 22] Further, in our June 2008 report on state and local
planning and exercising efforts for an influenza pandemic, we found
that state and local officials reported that they wanted federal
influenza pandemic guidance on facilitating medical surge, which was
also one of the areas that the HHS-led assessment rated as having "many
major gaps" nationally among states' influenza pandemic plans.[Footnote
23]
Federal Agencies Have Provided Considerable Guidance and Pandemic-
Related Information, but Could Augment Their Efforts:
The National Pandemic Implementation Plan emphasizes that government
and public health officials must communicate clearly and continuously
with the public throughout a pandemic. Accordingly, HHS, DHS, and other
federal agencies have shared pandemic-related information in a number
of ways, such as through Web sites, guidance, and state summits and
meetings, and are using established networks, including coordinating
councils for critical infrastructure protection, to share information
about pandemic preparedness, response, and recovery. Federal agencies
have established an influenza pandemic Web site [hyperlink,
http://www.pandemicflu.gov] and disseminated pandemic preparedness
checklists for workplaces, individuals and families, schools, health
care and community organizations, and state and local governments.
However, state and local officials from all of the states and
localities we interviewed wanted additional federal influenza pandemic
guidance from the federal government on specific topics, such as
implementing community interventions, fatality management, and
facilitating medical surge. Although the federal government has issued
some guidance, it may not have reached state and local officials or may
not have addressed the particular concerns or circumstances of the
state and local officials we interviewed. In addition, private sector
officials have told us that they would like clarification about the
respective roles and responsibilities of the federal and state
governments during an influenza pandemic emergency, such as for state
border closures and influenza pandemic vaccine distribution.
Performance Monitoring and Accountability For Pandemic Preparedness
Needs Strengthening:
While the National Pandemic Strategy and Implementation Plan identify
overarching goals and objectives for pandemic planning, the documents
are not altogether clear on the roles, responsibilities, and
requirements to carry out the plan. Some of the action items in the
National Pandemic Implementation Plan, 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. Most of the plan's performance measures consist of actions to
be completed, 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 National Pandemic Strategy and Implementation Plan. 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.
In addition, as discussed earlier, the National Pandemic Implementation
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. Moreover, the National Pandemic Strategy and
Implementation Plan do not provide information on the financial
resources needed to implement them, which is one of six characteristics
of an effective national strategy that we have identified. As a result,
the documents do not provide a picture of priorities or how adjustments
might be made in view of resource constraints.
Concluding Observations:
The recent outbreak of H1N1 influenza virus should serve as a powerful
reminder that the threat of a pandemic influenza, which seemed to fade
from public awareness in recent years, never really disappeared. While
federal agencies have taken action on many of our recommendations,
almost half the recommendations that we have made over the past 3 years
are still not fully implemented. For one thing, it is essential, given
the change in administration and the associated transition of senior
federal officials, that the shared leadership roles that have been
established between HHS and DHS along with other responsible federal
officials, are tested in rigorous tests and exercises. Likewise, DHS
should continue to work with other federal agencies and private sector
members of the critical infrastructure coordinating councils to help
address the challenges of coordination and clarify roles and
responsibilities of federal and state governments. DHS and HHS should
also, in coordination with other federal agencies, continue to work
with states and local governments to help them address identified gaps
in their pandemic planning. Moreover, the 3-year period covered by the
National Pandemic Implementation Plan is now over and it will be
important for HSC to establish a process for updating the National
Pandemic Implementation Plan so that the updated plan can address the
gaps we have identified, as well as lessons learned from the current
H1N1 outbreak.
Pandemic influenzas, as I noted earlier, differ from other types of
disasters in that they are not necessarily discrete events. While the
current H1N1 outbreak seems to have been relatively mild, it could
return in a second wave this fall or winter in a more virulent form.
Given this risk, the administration and federal agencies should turn
their attention to filling in some of the gaps our work has pointed
out, while time is still on our side.
Chairman Pryor, Senator Ensign, and Members of the Subcommittee, this
concludes my prepared statement. I would be happy to respond to any
questions you may have.
Contacts and Staff Acknowledgements:
For further information regarding this statement, please contact
Bernice Steinhardt, Director, Strategic Issues, 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
statement. Individuals making key contributions to this testimony
include Sarah Veale, Assistant Director; Maya Chakko; Melissa Kornblau;
Susan Sato; Ellen Grady; Karin Fangman; and members of GAO's Pandemic
Working Group.
[End of section]
Attachment I: Open Recommendations from GAO's Work on an Influenza
Pandemic as of February 2009:
Title and GAO product number: Influenza Pandemic: HHS Needs to Continue
Its Actions and Finalize Guidance for Pharmaceutical Interventions, GAO-
08-671, September 30, 2008;
Summary of open recommendations: The Secretary of HHS should
expeditiously finalize guidance to assist state and local jurisdictions
to determine how to effectively use limited supplies of antivirals and
pre-pandemic vaccine in a pandemic, including prioritizing target
groups for pre-pandemic vaccine;
Status: In December 2008, HHS released final guidance on antiviral drug
use during an influenza pandemic. HHS officials informed us that they
are drafting the guidance on pre-pandemic influenza vaccination.
Title and GAO product number: Influenza Pandemic: Federal Agencies
Should Continue to Assist States to Address Gaps in Pandemic Planning,
GAO-08-539, June 19, 2008;
Summary of open recommendations: The Secretaries of HHS and Homeland
Security should, in coordination with other federal agencies, convene
additional meetings of the states in the five federal influenza
pandemic regions to help them address identified gaps in their
planning;
Status: HHS and DHS officials indicated that while no additional
meetings are planned at this time, states will have to continuously
update their pandemic plans and submit them for review.
Title and GAO product number: Influenza Pandemic: Opportunities Exist
to Address Critical Infrastructure Protection Challenges That Require
Federal and Private Sector Coordination, GAO-08-36, October 31, 2007;
Summary of open recommendations: The Secretary of Homeland Security
should work with sector-specific agencies and lead efforts to encourage
the government and private sector members of the councils to consider
and help address the challenges that will require coordination between
the federal and private sectors involved with critical infrastructure
and within the various sectors, in advance of, as well as during, a
pandemic;
Status: DHS officials informed us that the department is working on
initiatives, such as developing pandemic contingency plan guidance
tailored to each of the critical infrastructure sectors, and holding a
series of webinars with a number of the sectors.
Title and GAO product number: Influenza Pandemic: Further Efforts Are
Needed to Ensure Clearer Federal Leadership Roles and an Effective
National Strategy, GAO-07-781, August 14, 2007; Influenza Pandemic:
Opportunities Exist to Clarify Federal Leadership Roles and Improve
Pandemic Planning, GAO-07-1257T, September 26, 2007;
Summary of open recommendations:
(1) The Secretaries of Homeland Security and HHS should work together
to develop and conduct rigorous testing, training, and exercises for an
influenza pandemic 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. Once
the leadership roles have been clarified through testing, training, and
exercising, the Secretaries of Homeland Security and HHS should ensure
that these roles are clearly understood by state, local, and tribal
governments; the private and nonprofit sectors; and the international
community;
(2) The Homeland Security Council (HSC) should establish a specific
process and time frame for updating the National Pandemic
Implementation Plan. The process should involve key nonfederal
stakeholders and incorporate lessons learned from exercises and other
sources. The National Pandemic Implementation Plan should also be
improved by including the following information in the next update: (a)
resources and investments needed to complete the action items and where
they should be targeted, (b) a process and schedule for monitoring and
publicly reporting on progress made on completing the action items, (c)
clearer linkages with other strategies and plans, and (d) clearer
descriptions of relationships or priorities among action items and
greater use of outcome-focused performance measures;
Status:
(1) HHS and DHS officials stated that several influenza pandemic
exercises had been conducted since November 2007 that involved both
agencies and other federal officials, but it is unclear whether these
exercises rigorously tested federal leadership roles in a pandemic;
(2) HSC did not comment on the recommendation and has not indicated if
it plans to implement it.
Title and GAO product number: Avian Influenza: USDA Has Taken Important
Steps to Prepare for Outbreaks, but Better Planning Could Improve
Response, GAO-07-652, June 11, 2007;
Summary of open recommendations:
(1) The Secretaries of Agriculture and Homeland Security should develop
a memorandum of understanding that describes how the U.S. Department of
Agriculture (USDA) and DHS will work together in the event of a
declared presidential emergency or major disaster, or an Incident of
National Significance, and test the effectiveness of this coordination
during exercises;
(2) The Secretary of Agriculture should, in consultation with other
federal agencies, states, and the poultry industry, identify the
capabilities necessary to respond to a probable scenario or scenarios
for an outbreak of highly pathogenic avian influenza. The Secretary of
Agriculture should also use this information to develop a response plan
that identifies the critical tasks for responding to the selected
outbreak scenario and, for each task, identifies the responsible
entities, the location of resources needed, time frames, and completion
status. Finally, the Secretary of Agriculture should test these
capabilities in ongoing exercises to identify gaps and ways to overcome
those gaps;
(3) The Secretary of Agriculture should develop standard criteria for
the components of state response plans for highly pathogenic avian
influenza, enabling states to develop more complete plans and enabling
USDA officials to more effectively review them;
(4) The Secretary of Agriculture should focus additional work with
states on how to overcome potential problems associated with unresolved
issues, such as the difficulty in locating backyard birds and disposing
of carcasses and materials;
(5) The Secretary of Agriculture should determine the amount of
antiviral medication that USDA would need in order to protect animal
health responders, given various highly pathogenic avian influenza
scenarios. The Secretary of Agriculture should also determine how to
obtain and provide supplies within 24 hours of an outbreak;
Status:
(1) Both USDA and DHS officials told us that they have taken
preliminary steps to develop additional clarity and better define their
coordination roles. For example the two agencies meet regularly to
discuss such coordination;
(2) USDA officials told us that it has created a draft preparedness and
response plan that identifies federal, state, and local actions,
timelines, and responsibilities for responding to highly pathogenic
avian influenza, but the plan has not been issued yet;
(3) USDA told us that it has drafted large volumes of guidance
documents that are available on a secure Web site. However, the
guidance is still under review and it is not clear what standard
criteria from these documents USDA officials and states should apply
when developing and reviewing plans;
(4) USDA officials have told us that the agency has developed online
tools to help states make effective decisions about carcass disposal.
In addition, USDA has created a secure Internet site that contains
draft guidance for disease response, including highly pathogenic avian
influenza, and it includes a discussion about many of the unresolved
issues;
(5) USDA officials told us that the National Veterinary Stockpile now
contains enough antiviral medication to protect 3,000 animal health
responders for 40 days. However, USDA has yet to determine the number
of individuals that would need medicine based on a calculation of those
exposed to the virus under a specific scenario. Further, USDA officials
told us that a contract for additional medication for the stockpile has
not yet been secured, which would better ensure that medications are
available in the event of an outbreak of highly pathogenic avian
influenza.
Source: GAO.
[End of table]
[End of section]
Attachment II: Related GAO Products:
Influenza Pandemic: HHS Needs to Continue Its Actions and Finalize
Guidance for Pharmaceutical Interventions. [hyperlink,
http://www.gao.gov/products/GAO-08-671]. Washington, D.C.: September
30, 2008.
Influenza Pandemic: Federal Agencies Should Continue to Assist States
to Address Gaps in Pandemic Planning. [hyperlink,
http://www.gao.gov/products/GAO-08-539]. Washington, D.C.: June 19,
2008.
Emergency Preparedness: States Are Planning for Medical Surge, but
Could Benefit from Shared Guidance for Allocating Scarce Medical
Resources. [hyperlink, http://www.gao.gov/products/GAO-08-668].
Washington, D.C.: June 13, 2008.
Influenza Pandemic: Efforts Under Way to Address Constraints on Using
Antivirals and Vaccines to Forestall a Pandemic. [hyperlink,
http://www.gao.gov/products/GAO-08-92]. Washington, D.C.: December 21,
2007.
Influenza Pandemic: Opportunities Exist to Address Critical
Infrastructure Protection Challenges That Require Federal and Private
Sector Coordination. [hyperlink,
http://www.gao.gov/products/GAO-08-36]. Washington, D.C.: October 31,
2007.
Influenza Pandemic: Federal Executive Boards' Ability to Contribute to
Pandemic Preparedness. [hyperlink,
http://www.gao.gov/products/GAO-07-1259T]. Washington, D.C.: September
28, 2007.
Influenza Pandemic: Opportunities Exist to Clarify Federal Leadership
Roles and Improve Pandemic Planning. [hyperlink,
http://www.gao.gov/products/GAO-07-1257T]. Washington, D.C.: September
26, 2007.
Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer
Federal Leadership Roles and an Effective National Strategy.
[hyperlink, http://www.gao.gov/products/GAO-07-781]. Washington, D.C.:
August 14, 2007.
Emergency Management Assistance Compact: Enhancing EMAC's Collaborative
and Administrative Capacity Should Improve National Disaster Response.
[hyperlink, http://www.gao.gov/products/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. [hyperlink, http://www.gao.gov/products/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. [hyperlink,
http://www.gao.gov/products/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. [hyperlink,
http://www.gao.gov/products/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. [hyperlink, http://www.gao.gov/products/GAO-07-515].
Washington, D.C.: May 4, 2007.
Financial Market Preparedness: Significant Progress Has Been Made, but
Pandemic Planning and Other Challenges Remain. [hyperlink,
http://www.gao.gov/products/GAO-07-399]. Washington, D.C.: March 29,
2007.
Influenza Pandemic: DOD Has Taken Important Actions to Prepare, but
Accountability, Funding, and Communications Need to be Clearer and
Focused Departmentwide. [hyperlink,
http://www.gao.gov/products/GAO-06-1042]. Washington, D.C.: September
21, 2006.
Catastrophic Disasters: Enhanced Leadership, Capabilities, and
Accountability Controls Will Improve the Effectiveness of the Nation's
Preparedness, Response, and Recovery System. [hyperlink,
http://www.gao.gov/products/GAO-06-618]. Washington, D.C.: September 6,
2006.
[End of section]
Footnotes:
[1] GAO's 2009 Congressional and Presidential Transition Web site:
[hyperlink, http://www.gao.gov/transition_2009].
[2] We also have three pandemic-related reviews underway on the
following topics: (1) plans to protect the federal workforce in a
pandemic; (2) the status of implementing the National Strategy for
Pandemic Influenza Implementation Plan (National Pandemic
Implementation Plan); and (3) the effect of a pandemic on the
telecommunications capacity needed to sustain critical financial market
activities.
[3] GAO, Influenza Pandemic: Sustaining Focus on the Nation's Planning
and Preparedness Efforts, [hyperlink,
http://www.gao.gov/products/GAO-09-334] (Washington, D.C.: Feb. 26,
2009).
[4] GAO, Influenza Pandemic: Further Efforts Are Needed to Ensure
Clearer Federal Leadership Roles and an Effective National Strategy,
[hyperlink, http://www.gao.gov/products/GAO-07-781] (Washington, D.C.:
Aug. 14, 2007).
[5] On May 26, 2009, the President announced the full integration of
White House staff supporting national security and homeland security.
The HSC will be maintained as the principal venue for interagency
deliberations on issues that affect the security of the homeland, such
as an influenza pandemic.
[6] Pub. L. No. 109-295, Title VI.
[7] GAO, 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).
[8] [hyperlink, http://www.gao.gov/products/GAO-07-781].
[9] GAO, Influenza Pandemic: Opportunities Exist to Address Critical
Infrastructure Protection Challenges That Require Federal and Private
Sector Coordination, [hyperlink, http://www.gao.gov/products/GAO-08-36]
(Washington, D.C.: Oct. 31, 2007).
[10] The 18 critical infrastructure and key resource sectors are: food
and agriculture; banking and finance; chemical; commercial facilities;
commercial nuclear reactors, materials, and water; dams; defense
industrial base; drinking water and water treatment systems; emergency
services; energy; governmental facilities; information technology;
national monuments and icons; postal and shipping; public health and
healthcare; telecommunications; transportation systems; and critical
manufacturing. Critical infrastructure are systems and assets, whether
physical or virtual, so vital to the United States that their
incapacity or destruction would have a debilitating effect on national
security, national economic security, and national public health or
safety, or any combination of those matters. Key resources are publicly
or privately controlled resources essential to minimal operations of
the economy or government, including individual targets whose
destruction would not endanger vital systems but could create a local
disaster or profoundly damage the nation's morale or confidence.
[11] [hyperlink, http://www.gao.gov/products/GAO-08-36].
[12] GAO, The Federal Workforce: Additional Steps Needed to Take
Advantage of Federal Executive Boards' Ability to Contribute to
Emergency Operations, [hyperlink,
http://www.gao.gov/products/GAO-07-515] (Washington, D.C.: May 4,
2007).
[13] Issued in January 2008 by the Department of Homeland Security
(DHS) and effective in March 2008, the NRF is a guide to how the nation
conducts all-hazards incident response and replaces the National
Response Plan. It focuses on how the federal government is organized to
support communities and states in catastrophic incidents. The NRF
builds upon the National Incident Management System, which provides a
national template for managing incidents.
[14] GAO, Influenza Pandemic: Efforts Under Way to Address Constraints
on Using Antivirals and Vaccines to Forestall a Pandemic, [hyperlink,
http://www.gao.gov/products/GAO-08-92] (Washington, D.C.: Dec. 21,
2007).
[15] The six characteristics of an effective national strategy include
(1) purpose, scope, and methodology; (2) problem definition and risk
assessment; (3) goals, subordinate objectives; activities, and
performance measures; (4) resources, investments, and risk management;
(5) organizational roles, responsibilities, and coordination; and (6)
integration and implementation. GAO, Combating Terrorism: Evaluation of
Selected Characteristics in National Strategies Related to Terrorism,
[hyperlink, http://www.gao.gov/products/GAO-04-408T] (Washington, D.C.:
Feb. 3, 2004).
[16] We conducted site visits to the five most populous states--
California, Florida, Illinois, New York, and Texas--for a number of
reasons, including that these states constituted over one-third of the
United States population, received over one-third of the total funding
from HHS and DHS that could be used for planning and exercising
efforts, and were likely entry points for individuals coming from
another country given that the states either bordered Mexico or Canada
or contained major ports, or both. Within each state, we also
interviewed officials at 10 localities, which consisted of five urban
areas and five rural counties.
[17] DHS and HHS and other agencies, Assessment of States' Operating
Plans to Combat Pandemic Influenza: Report to Homeland Security Council
(Washington, D.C.: Jan. 2009).
[18] National Governors Association Center for Best Practices, Issue
Brief: Pandemic Preparedness in the States--An Assessment of Progress
and Opportunity (Sept. 2008).
[19] GAO, Financial Market Preparedness: Significant Progress Has Been
Made, but Pandemic Planning and Other Challenges Remain, [hyperlink,
http://www.gao.gov/products/GAO-07-399] (Washington, D.C.: Mar. 29,
2007).
[20] Supplemental funding for pandemic preparedness and response is
provided in both the Senate-and House-passed versions of a 2009
supplemental appropriation currently under consideration. The Senate
bill includes $1.5 billion as requested by the administration and the
House bill provides a total of $2.05 billion.
[21] Antivirals can prevent or reduce the severity of a viral
infection, such as influenza. Vaccines are used to stimulate the
production of an immune system response to protect the body from
disease.
[22] [hyperlink, http://www.gao.gov/products/GAO-08-668].
[23] [hyperlink, http://www.gao.gov/products/GAO-08-539].
[End of section]
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