Influenza Pandemic
Monitoring and Assessing the Status of the National Pandemic Implementation Plan Needs Improvement Gao ID: GAO-10-73 November 24, 2009The current H1N1 pandemic highlights the threat posed to our nation by an influenza pandemic. The previous administration's Homeland Security Council (HSC) issued the Implementation Plan for the National Strategy for Pandemic Influenza (Plan) in May 2006 to help address a pandemic. The Government Accountability Office (GAO) was asked to (1) determine how the HSC and responsible federal agencies monitor the progress and completion of the Plan's action items; and (2) assess the extent to which selected action items have been completed. To do this, GAO interviewed officials from the HSC and the six federal agencies responsible for implementing most of the Plan, and analyzed a random sample of 60 action items. While this report does not assess the response efforts for the H1N1 pandemic, GAO continues to monitor the outbreak and the federal response.
To oversee agencies' progress in implementing the Plan's action items, the HSC, which is supported by the White House National Security Staff in this administration, convenes regular interagency meetings, asks agencies for summaries of progress; and leads the interagency process that monitors the progress of the Plan. Officials from the six agencies stated that they monitor action items tasked to more than one agency by selecting one or two agencies to report a consolidated summary of progress, approved by each responsible agency, to the HSC. However, neither the HSC nor the agencies monitor or report on the 17 action items intended for nonfederal entities, including, for example, action items asking state, local, and tribal entities to ensure their preparedness plans address mass immunization, even though the information may have been available from other sources, such as the interagency review of state pandemic plans led by the Department of Health and Human Services. In addition, the Plan does not describe the types of information needed to carry out the Plan's response-related action items, although agencies may have operational plans or other existing guidance that would provide this information. The HSC reported in October 2008 that the majority of the 324 action items were designated as complete. However, GAO's review of 60 action items found that it was difficult to determine the actual status of some of the 49 designated as complete. All of the action items reviewed have both a description of activities to be carried out and a measure of performance, which the HSC stated that it used to assess completion. However, for more than half of the action items considered complete, the measures of performance do not fully address all of the activities contained in their descriptions. While the HSC's progress summaries sometimes corrected for this by either referring to activities in the action item's description or some other information not reflected in either the measure of performance or description, future progress reports would benefit from using measures of performance that are more consistent with the action items' descriptions. The Plan is predicated on a type of pandemic different in severity and origin than the current H1N1 pandemic, but it is serving as the foundation for the response to the outbreak, supplemented by an additional plan tailored specifically to the characteristics of the H1N1 pandemic. Nevertheless, the National Strategy for Pandemic Influenza and Plan will still be needed for future events as most of the action items in the Plan were to be completed by May 2009. As recommended in earlier GAO work, but not yet implemented, the Plan should be updated to take into account certain missing elements and lessons learned from the H1N1 pandemic; the update should also address the monitoring and assessment improvements GAO identified in this report.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-10-73, Influenza Pandemic: Monitoring and Assessing the Status of the National Pandemic Implementation Plan Needs Improvement
This is the accessible text file for GAO report number GAO-10-73
entitled 'Influenza Pandemic: Monitoring and Assessing the Status of
the National Pandemic Implementation Plan Needs Improvement' which was
released on December 14, 2009.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to the Chairman, Committee on Homeland Security, House of
Representatives:
United States Government Accountability Office:
GAO:
November 2009:
Influenza Pandemic:
Monitoring and Assessing the Status of the National Pandemic
Implementation Plan Needs Improvement:
GAO-10-73:
GAO Highlights:
Highlights of GAO-10-73, a report to the Chairman, Committee on
Homeland Security, House of Representatives.
Why GAO Did This Study:
The current H1N1 pandemic highlights the threat posed to our nation by
an influenza pandemic. The previous administration‘s Homeland Security
Council (HSC) issued the Implementation Plan for the National Strategy
for Pandemic Influenza (Plan) in May 2006 to help address a pandemic.
GAO was asked to (1) determine how the HSC and responsible federal
agencies monitor the progress and completion of the Plan‘s action
items; and (2) assess the extent to which selected action items have
been completed. To do this, GAO interviewed officials from the HSC and
the six federal agencies responsible for implementing most of the Plan,
and analyzed a random sample of 60 action items. While this report does
not assess the response efforts for the H1N1 pandemic, GAO continues to
monitor the outbreak and the federal response.
What GAO Found:
To oversee agencies‘ progress in implementing the Plan‘s action items,
the HSC, which is supported by the White House National Security Staff
in this administration, convenes regular interagency meetings, asks
agencies for summaries of progress; and leads the interagency process
that monitors the progress of the Plan. Officials from the six agencies
stated that they monitor action items tasked to more than one agency by
selecting one or two agencies to report a consolidated summary of
progress, approved by each responsible agency, to the HSC. However,
neither the HSC nor the agencies monitor or report on the 17 action
items intended for nonfederal entities, including, for example, action
items asking state, local, and tribal entities to ensure their
preparedness plans address mass immunization, even though the
information may have been available from other sources, such as the
interagency review of state pandemic plans led by the Department of
Health and Human Services. In addition, the Plan does not describe the
types of information needed to carry out the Plan‘s response-related
action items, although agencies may have operational plans or other
existing guidance that would provide this information.
The HSC reported in October 2008 that the majority of the 324 action
items were designated as complete. However, GAO‘s review of 60 action
items found that it was difficult to determine the actual status of
some of the 49 designated as complete. All of the action items reviewed
have both a description of activities to be carried out and a measure
of performance, which the HSC stated that it used to assess completion.
However, for more than half of the action items considered complete,
the measures of performance do not fully address all of the activities
contained in their descriptions. While the HSC‘s progress summaries
sometimes corrected for this by either referring to activities in the
action item‘s description or some other information not reflected in
either the measure of performance or description, future progress
reports would benefit from using measures of performance that are more
consistent with the action items‘ descriptions.
The Plan is predicated on a type of pandemic different in severity and
origin than the current H1N1 pandemic, but it is serving as the
foundation for the response to the outbreak, supplemented by an
additional plan tailored specifically to the characteristics of the
H1N1 pandemic. Nevertheless, the National Strategy for Pandemic
Influenza and Plan will still be needed for future events as most of
the action items in the Plan were to be completed by May 2009. As
recommended in earlier GAO work, but not yet implemented, the Plan
should be updated to take into account certain missing elements and
lessons learned from the H1N1 pandemic; the update should also address
the monitoring and assessment improvements GAO identified in this
report.
What GAO Recommends:
GAO makes recommendations to the HSC related to the Plan and any future
updates, including developing a monitoring and reporting process for
action items intended for nonfederal entities, identifying the types of
information needed to carry out the response-related action items, and
improving how completion is assessed. The Principal Deputy Counsel to
the President stated that the administration will consider GAO‘s
recommendations. The HSC also provided technical comments. Comments
from other agencies are discussed in the report.
View [hyperlink, http://www.gao.gov/products/GAO-10-73] or key
components. For more information, contact Bernice Steinhardt at (202)
512-6543 or steinhardtb@gao.gov.
[End of section]
Contents:
Letter:
Background:
The HSC Monitors Agencies' Progress on Most Action Items:
Status of Some Selected Action Items Considered Complete Was Difficult
to Determine:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: Sample of 60 Selected Action Items in the Implementation
Plan for the National Strategy for Pandemic Influenza:
Appendix III: Comments from the White House:
Appendix IV: Comments from the Department of Health and Human Services:
Appendix V: Comments from the Department of Homeland Security:
Appendix VI: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: The 10 Response-Related Action Items in Our Sample:
Table 2: Examples of Selected Action Items Where Measures of
Performance Fully or Partially Addressed the Plan's Respective
Descriptions:
Table 3: Examples of Selected Action Items Where the HSC's 2-Year
Progress Report Summaries Partially Addressed or Did Not Address the
Plan's Respective Measures of Performance:
Figures:
Figure 1: WHO Pandemic Influenza Phases:
Figure 2: Elements of the Strategy and Plan:
Abbreviations:
DHS: Department of Homeland Security:
DOC: Department of Commerce:
DOD: Department of Defense:
DOI: Department of the Interior:
DOJ: Department of Justice:
DOL: Department of Labor:
DOS: Department of State:
DOT: Department of Transportation:
EMS: Emergency Medical Services:
ESF: Emergency Support Function:
FAO: Food and Agriculture Organization:
HHS: Department of Health and Human Services:
HSC: Homeland Security Council:
NGO: nongovernmental organization:
NSS: White House National Security Staff:
NVS: National Veterinary Stockpile:
OIE: World Organisation for Animal Health:
Plan: Implementation Plan for the National Strategy for Pandemic
Influenza:
REDI: Regional Emerging Disease Intervention:
Strategy: National Strategy for Pandemic Influenza:
Treasury: Department of the Treasury:
USAID: United States Agency for International Development:
USDA: United States Department of Agriculture:
USTR: United States Trade Representative:
VA: Department of Veterans Affairs:
WHO: World Health Organization:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
November 24, 2009:
The Honorable Bennie G. Thompson:
Chairman:
Committee on Homeland Security:
House of Representatives:
Dear Mr. Chairman:
An influenza pandemic remains a real threat to our nation and to the
world, as we are witnessing during the current H1N1 pandemic, which
began in spring 2009 and continues today. The previous administration's
Homeland Security Council (HSC) took an active approach to the
potential disaster of an influenza pandemic by, among other things,
issuing the National Strategy for Pandemic Influenza (Strategy) in
November 2005, and the Implementation Plan for the National Strategy
for Pandemic Influenza (Plan) in May 2006.[Footnote 1] The Strategy
lays out high-level goals to prepare for and respond to an influenza
pandemic, while 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 the goals. The
Plan includes 324 action items, a majority of which have measures of
performance and associated time frames. Both the Strategy and Plan are
based on a scenario that assumes a severe pandemic originating outside
the United States, spreading first among animal populations and then
transmitted to humans. While the current pandemic does not share these
characteristics, according to the Director of Medical Preparedness
Policy for the White House National Security Staff (NSS), which
supports the HSC in the current administration,[Footnote 2] the
Strategy and Plan provide the foundation for an additional planning
document, the National Framework for 2009-H1N1 Influenza Preparedness
and Response, that was developed this year to respond to the H1N1
pandemic. The framework for the 2009 H1N1 pandemic has not yet been
made publicly available.
In August 2007, we reported that while the development of the Strategy
and Plan were an important first step in guiding national preparedness,
the Plan lacked a prescribed process for monitoring and reporting on
progress, which is one element of the six desirable characteristics of
a national strategy.[Footnote 3] To address this and other areas that
we had identified, we recommended that the HSC establish a specific
process and time frame for updating the Plan, including lessons learned
from exercises and other events, such as the 2009 H1N1 pandemic. For
this report, you asked us to focus on the progress in implementing the
action items in the Plan, specifically (1) determining how the HSC and
the responsible federal agencies are monitoring the progress and
completion of the Plan's action items; and (2) assessing the extent to
which selected action items have been completed, whether activity has
continued on the selected action items reported as complete, and the
nature of that work. We did not assess the response to the 2009 H1N1
pandemic in this report, but we are continuing to monitor the outbreak
and the federal government's response.
To address these objectives, we conducted an in-depth analysis of a
random sample of 60 action items in the Plan. These 60 action items are
listed in appendix II. We drew a random sample from the 286 action
items involving six federal agencies with primary responsibility for
ensuring completion of the large majority (88 percent) of the 324
action items. These six agencies include the Department of Defense
(DOD), Department of Health and Human Services (HHS), Department of
Homeland Security (DHS), Department of State (DOS), Department of
Transportation (DOT), and the Department of Agriculture (USDA).
[Footnote 4] We do not generalize the results of our analysis because
the particular analytical steps we took across the selected action
items varied, and as a result there was no common underlying measure on
which to generalize the results to all of the action items in the Plan.
In addition, we did not review all of the action items in the Plan in
depth because our analyses involved multiple assessments for each
action item, including the review of large volumes of agency
documentation in determining the level of evidence for completion of
the action item. See appendix I for a more detailed discussion of our
scope and methodology.
For both objectives, we interviewed officials and obtained
documentation from the six agencies. We also reviewed the HSC's 6-
month, 1-year, and 2-year progress reports, and the HSC's 1-year
summary report on the implementation of the action items in the Plan.
In addition, we interviewed a senior HSC official in the previous
administration and the Director of Medical Preparedness Policy for the
NSS in the current administration, who is responsible for overseeing
the implementation of the Plan. We also relied on our prior pandemic
work, including a review of whether the Strategy and Plan contained all
the characteristics of an effective national strategy, to inform our
analysis.[Footnote 5] To address the first objective, we assessed
information from interviews and documentation on how the HSC and the
selected agencies monitored the progress and completion of all action
items. We also interviewed representatives from nonfederal entities
that agency officials had identified as working on specific action
items, such as the World Organisation for Animal Health (OIE) and the
Denver Health Medical Center, to determine whether they had been
consulted on the status of those action items. To address the second
objective, we analyzed the 49 action items designated as complete in
the HSC's 2-year progress report from the random sample of 60 action
items, along with collected documentation and interviews with selected
agency officials and a senior HSC official from the prior
administration. To describe the extent to which action items had been
completed, we analyzed information on the 49 selected action items in
the Plan, the HSC progress reports, and documentation on each of the 49
action items. To evaluate the extent of work that has continued on the
49 action items in our sample designated as complete and the nature of
that work, we asked all selected agencies with primary responsibility
if they had performed additional work and, if so, to provide a brief
description of the nature of that work. In addition, for the 34
selected action items designated as complete in the HSC's 1-year
progress report, we analyzed each action item's summary in the HSC's 1-
and 2-year progress reports for any new information on work conducted
in that period.
We conducted this performance audit from July 2008 to November 2009 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives. Detailed information on our
scope and methodology appears in appendix I. A list of related GAO
products is also included at the end of this report.
Background:
An influenza pandemic is caused by a novel strain of influenza virus
for which there is little resistance and which therefore is highly
transmissible among humans. Unlike incidents that are discretely
bounded in space or time (e.g., most natural or man-made disasters), an
influenza pandemic is not a singular event, but is likely to come in
waves, each lasting weeks or months, and pass through communities of
all sizes across the nation and the world simultaneously. While a
pandemic will not directly damage physical infrastructure such as power
lines or computer systems, it threatens the operation of critical
systems by potentially removing the essential personnel needed to
operate them from the workplace for weeks or months.
On June 11, 2009, the World Health Organization (WHO) declared a
pandemic based on the novel influenza A (H1N1) virus currently in wide
circulation by raising the worldwide pandemic alert level to Phase 6--
the highest level.[Footnote 6] Figure 1 shows the WHO phases of a
pandemic, characterizing Phase 6 as community-level outbreaks in at
least one country in a different WHO region in addition to the criteria
defined in Phase 5.[Footnote 7] This action was a reflection of the
spread of the new H1N1 virus, not the severity of illness caused by the
virus. At that time, more than 70 countries had reported cases of 2009
H1N1 and there were ongoing community-level outbreaks in multiple parts
of the world. As of November 8, 2009, WHO reported over 503,536
confirmed cases and at least 6,260 deaths, acknowledging, however, that
the number of cases was actually understated since it is no longer
requiring affected countries to count individual cases and confirm them
through laboratory testing.
Figure 1: WHO Pandemic Influenza Phases:
[Refer to PDF for image: illustration]
Phases 1-3:
Predominantly animal injections; few human injections.
Phase 4:
Sustained human to human transmission.
Phase 5-6/pandemic (circled):
Widespread human infection.
Post peak:
Possibility of recurrent events.
Pons pandemic:
Disease activity at seasonal levels.
Source: WHO.
Note: Circle indicates WHO assessment of current global phase.
[End of figure]
Similar to the seasonal influenza, the 2009 H1N1 influenza can vary
from mild to severe. Given ongoing H1N1 activity to date, the Centers
for Disease Control and Prevention (CDC) stated that it anticipates
that there will be more cases, more hospitalizations, and more deaths
associated with this pandemic in the United States in the fall and
winter. The novel H1N1 virus, in conjunction with regular seasonal
influenza viruses, poses the potential to cause significant illness
with associated hospitalizations and deaths during the U.S. influenza
season. The United States continues to report the largest number of
2009 H1N1 cases of any country worldwide, although most people who have
become ill have recovered without requiring medical treatment. The 2009
H1N1 influenza has been reported in all 50 states, the District of
Columbia, Guam, American Samoa, the Commonwealth of the Northern
Mariana Islands, Puerto Rico, and the U.S. Virgin Islands.
National Planning Efforts for an Influenza Pandemic:
As shown in figure 2, the Strategy lays out three high-level goals to
prepare for and respond to an influenza: (1) stop, slow, or otherwise
limit the spread of a pandemic to the United States; (2) limit the
domestic spread of a pandemic and mitigate disease, suffering, and
death; and (3) sustain infrastructure and mitigate impact on the
economy and the functioning of society. These goals are underpinned by
three pillars that are intended to guide the federal government's
approach to a pandemic threat, including: (1) preparedness and
communication, (2) surveillance and detection, and (3) response and
containment. Each pillar describes domestic and international efforts,
animal and human health efforts, and efforts that would need to be
undertaken at all levels of government and in communities. The Plan
outlines steps for federal entities and also provides expectations for
nonfederal entities--including state, local, and tribal governments;
the private sector; international partners; and individuals--to prepare
themselves and their communities.
Figure 2: Elements of the Strategy and Plan:
[Refer to PDF for image: illustration]
Illustration depicts three pillars supporting three goals:
Goal 1:
Stop, slow, and limit spread to United States.
Goal 2:
Limit the domestic spread and mitigate disease, suffering, and death.
Goal 3:
Sustain infrastructure and mitigate impact on economy and functioning
of society.
Pillar 1: Preparedness and communication;
Number of action items within each functional area:
International efforts: 31;
Transportation and borders: 17;
Protecting human health: 57;
Protecting animal health: 16;
Law enforcement, public safety, and security: 14;
Institutions protecting personnel, ensuring continuity of operations:
9.
Pillar 2: Surveillance and detection;
Number of action items within each functional area:
International efforts: 33;
Transportation and borders: 19;
Protecting human health: 25;
Protecting animal health: 9;
Law enforcement, public safety, and security: 0;
Institutions protecting personnel, ensuring continuity of operations:
0.
Pillar 3: Response and containment;
Number of action items within each functional area:
International efforts: 20;
Transportation and borders: 27;
Protecting human health: 31;
Protecting animal health: 10;
Law enforcement, public safety, and security: 3;
Institutions protecting personnel, ensuring continuity of operations:
3.
Source: GAO analysis of HSC data.
Note: Data are from the National Strategy for Pandemic Influenza and
the Implementation Plan for the National Strategy for Pandemic
Influenza.
[End of figure]
Of the 324 action items in the Plan, 144 are related to pillar 1 on
preparedness and communication; 86 are related to pillar 2 on
surveillance and detection; and the remaining 94 are related to pillar
3 on response and containment. Nearly all of the action items (307 of
324) have a measure of performance, and most (287 of 324) of the action
items have a time frame identified either in the action item's
description, measure of performance, or both. Most of the action items
in the Plan--those that were not tied to response--were expected to
have been completed in 3 years, by May 2009. Since the issuance of the
Plan in May 2006, the HSC publicly reported on the status of the action
items at 6 months, 1 year, and 2 years in December 2006, July 2007, and
October 2008, respectively. Although this administration has not yet
publicly reported on the 3-year status of implementing the Plan's
action items, an NSS official stated that the 3-year progress report
had been in development prior to the 2009 H1N1 pandemic, and may be
released shortly.
The HSC Monitors Agencies' Progress on Most Action Items:
The HSC monitors the status of action items in the Plan tasked to
federal agencies by convening regular interagency meetings and
requesting summaries of progress from agencies.[Footnote 8] According
to a former HSC official who was involved with monitoring the Plan in
the prior administration and officials from all of the six agencies,
following the development of the Plan, the HSC officials convened
interagency meetings at the Sub-Policy Coordination Committee level
(deputy assistant secretary or his or her representative) that included
discussions on the implementation of action items. The former HSC
official stated that these meetings are a forum for monitoring the
status of the Plan's action items. These meetings were held weekly
after the release of the Plan and biweekly after the spring of 2008,
according to the former HSC official. Officials from several of the
selected agencies stated that the interagency meetings facilitate
interagency cooperation and coordination on the action items in the
Plan. Officials also said that these meetings provide a venue to raise
and address concerns relating to how to implement particular action
items, and enable them to build relationships with their colleagues in
other agencies. In addition, the HSC requested that agencies provide
the Council with periodic summaries of their progress on the action
items in preparation for the HSC's progress reports, according to
officials from all of the selected agencies.
Officials from the six selected agencies informed us that, in this
administration, the NSS continues to lead the interagency process used
to monitor progress of the Plan. Officials from several of the selected
agencies stated that the NSS continues to hold meetings at the Sub-
Interagency Policy Committee level to monitor efforts related to
influenza pandemic, with a primary focus on the 2009 H1N1 response.
According to an NSS official, the NSS has also requested periodic
summaries of progress from agencies on the action items.
For action items that involve multiple federal agencies, the six
agencies monitor the action items assigned to them by designating one
or two agencies to report one consolidated summary of progress for each
action item to the HSC, according to agency officials. Some action
items task additional federal agencies with a support role as well.
According to agency officials, all agencies tasked with responsibility
for an action item have to approve its summary of progress before it is
provided to the HSC. The HSC's 6-month, 1-year, and 2-year progress
reports state that the action items' summaries in the reports were
prepared by relevant agencies and departments. Officials from all six
agencies said that the HSC does not always require them to submit
supporting documentation along with their summary of progress to
determine if an action item is complete. For instance, officials at
three of the agencies said that the HSC does not require them to submit
supporting documentation, while officials from two other agencies said
that additional information is required by the HSC if it is not
convinced about the completeness of an action item, or if it is unclear
that the respective measure of performance was met based on the summary
of progress.
For the 112 action items in the Plan that include both federal agencies
and nonfederal entities, the responsible federal agencies determined
how they would work with and monitor the nonfederal entities. According
to the former HSC official, the responsible agencies determined how
these action items would be implemented, including deciding which
nonfederal entities they would work with and in what manner they would
work with them. Among the six agencies we reviewed, five said that they
worked with nonfederal entities to implement some of the action items
in the Plan. For example, DOT officials stated that they worked with
professional associations to develop guidelines and recommendations for
Emergency Medical Services (EMS) and 9-1-1 call centers, and HHS
officials told us that they worked with medical experts to develop
guidance on mass casualty care. We interviewed representatives of nine
of these nonfederal entities and all of them confirmed that the status
of the action items with which they were associated had been accurately
reported. However, they also told us that they had not been asked for
input into the summaries of progress for the action items with which
they were associated and had therefore been unable to check the
accuracy of the summaries before they were reported.
The HSC Uses Information Provided by Agencies to Determine Action Item
Status:
The HSC makes the final determination as to whether the Plan's action
items are completed, according to the former HSC official and officials
from the selected agencies. The HSC bases its determination on
information from federal agencies, and uses the measure of performance
associated with the action items as criteria for completion, as stated
in the HSC's 6-month, 1-year, and 2-year progress reports. Officials
from three of the selected agencies stated that their agencies advise
the HSC as to whether they believe an action item is complete when they
provide summaries of progress to the HSC, while officials from two
selected agencies stated that they provide summaries of progress to the
HSC, and the HSC ultimately determines if an action item is complete.
An interagency group led by the HSC reviews the agencies' summaries of
progress to help determine if action items are complete. The former HSC
official told us that the HSC's method of assessing whether an action
item was complete depends on the specific action item. For some action
items, the former HSC official stated that the summary of progress is
reviewed by both an interagency group and a technical working group
consisting of subject-matter experts.
Neither the HSC nor Agencies Monitor Action Items Intended for
Nonfederal Entities:
As we reported in August 2007, 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, even though it relies on
these stakeholders' efforts.[Footnote 9] 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. Moreover, the Plan states that in the event
of an influenza pandemic, the distributed nature and sheer burden of
disease across the nation would mean that the federal government's
support to any particular community is likely to be limited, with the
primary response to a pandemic coming from state governments and local
communities. In our June 2008 report on states' influenza pandemic
planning and exercising, officials from selected states and localities
confirmed that they were not directly involved in developing the Plan.
[Footnote 10] Further, HHS officials confirmed that the Plan was
developed by the federal government without any state input.
Although the Plan calls for 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. While the HSC reported on progress on
all of the action items involving both federal and nonfederal entities
that are included in the 2-year progress report, the 17 action items
that are intended for nonfederal entities are not monitored or reported
on by the HSC or the six federal agencies we reviewed. According to the
former HSC official in the prior administration and an NSS official in
the current administration, the HSC is not in a position to assess
progress on these action items because the federal government cannot
direct nonfederal entities to complete them. Therefore, these 17 action
items do not contain measures of performance against which to measure
progress. Although the HSC's 1-and 2-year progress reports stated that
the HSC intended to continue and intensify its work with nonfederal
entities, the 2-year progress report does not have any information on
work conducted on these 17 action items nor is their status reported.
Examples of the 17 action items intended for nonfederal entities
include the following:
* State, local, and tribal pandemic preparedness plans should address
the implementation and enforcement of isolation and quarantine, the
conduct of mass immunization programs, and provisions for release or
exception.[Footnote 11]
* States should ensure that pandemic response plans adequately address
law enforcement and public safety preparedness across the range of
response actions that may be implemented, and that these plans are
integrated with authorities that may be exercised by federal agencies
and other state, local, and tribal governments.[Footnote 12]
Although there is no information on these two action items in the HSC's
2-year progress report, we reported in June 2008 that HHS had led a
multi-department effort to review pertinent parts of states' influenza
pandemic plans in 22 priority areas,[Footnote 13] and had provided
feedback to states in November 2007.[Footnote 14] These priority areas
included mass vaccination, law enforcement, and community containment,
which includes community-level interventions designed to limit the
transmission of a pandemic virus with emphasis on isolation and
quarantine, closing schools, and discouragement of large public
gatherings, at a minimum. This HHS-led review found major gaps in these
three areas, which are activities cited in the two action items noted
above. Since our 2008 report, HHS led a second interagency assessment
of state influenza pandemic plans,[Footnote 15] which found that
although states have made important progress toward preparing for
combating an influenza pandemic, most states still have major gaps in
their pandemic plans.[Footnote 16] So, for these two action items, HHS
had gathered information on their status for other purposes and made it
publicly available on [hyperlink, http://www.flu.gov], but this
information was not reported in the HSC's progress reports.
The Plan Lacks a Description of the Information Needed to Carry Out
Response-Related Action Items:
The Plan includes response-related action items that have a measure of
performance or time frame associated with a pandemic or animal
outbreak. In a response-related section in the HSC's 2-year progress
report, the report states that although neither a pandemic nor animal
outbreak had occurred in the United States as of October 2008, the
federal government had exercised many of the capabilities called for in
these action items.
We found that the Plan does not describe the specific circumstances,
such as the type or severity of an outbreak or pandemic, under which
the response-related action items would be undertaken. In addition, for
response-related action items in which the trigger is not an outbreak
or pandemic, the Plan does not describe the types of information that
would be needed in order to make a decision to implement the action
items. For example, one of the action items, shown in table 1 below,
calls for DOS and DHS to impose restrictions on travel into the United
States as appropriate.[Footnote 17] However, a senior DOS official told
us that the agency does not have triggers for when these travel
restrictions would be implemented. As we have previously reported, in
preparing for, responding to, and recovering from any catastrophic
disaster, roles and responsibilities must be clearly defined,
effectively communicated, and well understood in order to facilitate
rapid and effective decision making.[Footnote 18] In an August 2009
report on U.S. preparations for the 2009 H1N1 pandemic, the President's
Council of Advisors on Science and Technology highlighted the need for
quantitative triggers and recommended that federal agencies adopt
structured frameworks for key decision making by incorporating
scenarios and specific trigger points for action.[Footnote 19]
Table 1: The 10 Response-Related Action Items in Our Sample:
Action item number: 4.3.6.3.;
Description: USDA, in coordination with DHS, the United States Trade
Representative (USTR), and DOS, shall ensure that clear and coordinated
messages are provided to international trading partners regarding
animal disease outbreak response activities in the United States;
Measure of performance: Within 24 hours of an outbreak, appropriate
messages will be shared with key animal/animal product trading
partners.
Action item number: 5.3.1.1.;
Description: DOS and DHS, in coordination with DOT, Department of
Commerce (DOC), HHS, Department of the Treasury (Treasury), and USDA,
shall work with foreign counterparts to limit or restrict travel from
affected regions to the United States, as appropriate, and notify host
government(s) and the traveling public;
Measure of performance: Measures imposed within 24 hours of the
decision to do so, after appropriate notifications made.
Action item number: 5.3.4.3.;
Description: DHS, if needed, will implement contingency plans to
maintain border control during a period of pandemic influenza induced
mass migration;
Measure of performance: Contingency plan activated within 24 hours of
notification.
Action item number: 5.3.4.5.;
Description: DOT shall issue safety-related waivers as needed, to
facilitate efficient movement of goods and people during an emergency,
balancing the need to expedite services with safety, and states should
consider waiving state-specific regulatory requirements, such as size
and weight limits and convoy registration;
Measure of performance: All regulatory waivers as needed balance need
to expedite services with safety.
Action item number: 5.3.5.3.;
Description: DOT, in coordination with DHS;
state, local, and tribal governments;
and the private sector, shall monitor system closures, assess effects
on the transportation system, and implement contingency plans;
Measure of performance: Timely reports transmitted to DHS and other
appropriate entities, containing relevant, current, and accurate
information on the status of the transportation sector and impacts
resulting from the pandemic;
when appropriate, contingency plans implemented within no more than 24
hours of a report of a transportation sector impact or issue.
Action item number: 5.3.5.4.;
Description: DOT, in support of DHS and in coordination with other
emergency support function (ESF) #1 support agencies, shall work
closely with the private sector and state, local, and tribal entities
to restore the transportation system, including decontamination and
reprioritization of essential commodity shipments;
Measure of performance: Backlogs or shortages of essential commodities
and goods quickly eliminated, returning production and consumption to
prepandemic levels.
Action item number: 5.3.1.4.;
Description: DHS, in coordination with DOS, USDA, and the Department of
the Interior (DOI), shall provide countries with guidance to increase
scrutiny of cargo and other imported items through existing programs,
such as the Container Security Initiative, and impose country-based
restrictions or item-specific embargoes;
Measure of performance: Guidance, which may include information on
restrictions, is provided for increased scrutiny of cargo and other
imported items, within 24 hours upon notification of an outbreak.
Action item number: 5.3.2.3.;
Description: DHS, in coordination with USDA, DOS, DOC, DOI, and
shippers, shall rapidly implement and enforce cargo restrictions for
export or import of potentially contaminated cargo, including embargo
of live birds, and notify international partners/shippers;
Measure of performance: Measures implemented within 6 hours of decision
to do so.
Action item number: 7.3.1.2.;
Description: USDA shall coordinate with DHS and other federal, state,
local, and tribal officials, animal industry, and other affected
stakeholders during an outbreak in commercial or other domestic birds
and animals to apply and enforce appropriate movement controls on
animals and animal products to limit or prevent spread of influenza
virus;
Measure of performance: Initial movement controls in place within 24
hours of detection of an outbreak.
Action item number: 7.3.2.1.;
Description: USDA shall activate plans to distribute veterinary medical
countermeasures and materiel from the National Veterinary Stockpile
(NVS) to federal, state, local, and tribal influenza outbreak
responders within 24 hours of confirmation of an outbreak in animals of
influenza with human pandemic potential, within 9 months;
Measure of performance: NVS materiel distributed within 24 hours of
confirmation of an outbreak.
Source: HSC.
Note: Data are from the HSC's 2-year progress report.
[End of table]
As of late May 2009, an official from only one of the four selected
agencies responsible for the 10 response-related action items in our
sample, the Deputy Associate Director for Security Policy at DOT,
stated that the 2009 H1N1 outbreak had triggered an action item from
this group (5.3.5.3) for which the agency was responsible. For the
remaining nine action items, officials from all four agencies noted
that none of the action items for which their agency had responsibility
were relevant to the H1N1 outbreak at that time.
The Plan states that the operational details on how to carry out
actions in support of the Strategy will be included in departmental
pandemic plans.[Footnote 20] Federal agencies may have operational
plans or other existing guidance that would specify the information
needed to determine whether to undertake the response-related action
items during a pandemic. However, the Plan itself gives no indication
of whether these plans or guidance actually contain such information,
or whether the information that would be needed has been determined in
advance.
Status of Some Selected Action Items Considered Complete Was Difficult
to Determine:
The HSC reported in October 2008 that about 75 percent of the 324
action items in the Plan were designated as complete based on its
criteria of whether the measures of performance were achieved.[Footnote
21] Among the 60 action items in our sample, 49 had been designated as
complete, 3 designated as in-progress, and 8 had no reported status.
[Footnote 22] For a number of reasons, as stated in the following
sections, it was difficult to determine the actual status of some of
the 49 selected action items that were designated complete.
Measures of Performance Used to Determine Status Do Not Always Fully
Reflect the Descriptions of the Action Items:
As discussed earlier, according to the HSC's progress reports, a
determination that an action item is complete is based on whether the
action item's measure of performance is achieved. Our review found,
however, that for more than half of the action items considered
complete, the measures of performance did not fully address all the
activities contained in their descriptions. In some instances, the HSC
used information other than the measures of performance to report
progress.
All of the 49 action items designated as complete that we reviewed have
both a description of activities to be carried out, and a measure of
performance, which generally is used as an indicator to measure
progress of completion by responsible parties in carrying out what is
specified in its respective description. We found that the types of
performance measures for selected action items varied widely. For
instance, measures of performance may call for processes to be
developed and implemented, changes to be effected in foreign countries,
or products such as guidance or a vaccine to be developed.
As we reported in 2007, most of the Plan's measures of performance for
action items 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. In these cases, it is difficult to determine
whether the goals and objectives have been achieved.[Footnote 23] We
found that the selected action items' measures of performance addressed
the descriptions of their respective action items to varying degrees.
[Footnote 24] Examples can be seen in table 2.
Table 2: Examples of Selected Action Items Where Measures of
Performance Fully or Partially Addressed the Plan's Respective
Descriptions:
Action item number: 4.2.3.9.;
Plan's description: DOD, in coordination with HHS, shall prioritize
international DOD laboratory research efforts to develop, refine, and
validate diagnostic methods to rapidly identify pathogens, within 18
months;
Plan's measure of performance: Completion of prioritized research plan,
resources identified, and tasks assigned across DOD medical research
facilities;
GAO analysis of relationship between Plan's description and measure of
performance: Fully addressed--measure of performance includes all
components specified in its respective description.
Action item number: 6.1.13.6.;
Plan's description: DOT, in coordination with HHS; DHS; state, local,
and tribal officials; and other EMS stakeholders, shall develop
suggested EMS pandemic influenza guidelines for statewide adoption that
address: clinical standards, education, treatment protocols,
decontamination procedures, medical direction, scope of practice, legal
parameters, and other issues, within 12 months;
Plan's measure of performance: EMS pandemic influenza guidelines
completed;
GAO analysis of relationship between Plan's description and measure of
performance: Fully addressed--measure of performance includes all
components specified in its respective description.
Action item number: 5.1.1.5.;
Plan's description: DOD, in coordination with DHS, DOT, the Department
of Justice (DOJ), and DOS, shall conduct an assessment of military
support related to transportation and borders that may be requested
during a pandemic and develop a comprehensive contingency plan for
Defense Support to Civil Authorities, within 18 months;
Plan's measure of performance: Defense Support to Civil Authorities
plan in place that addresses emergency transportation and border
support;
GAO analysis of relationship between Plan's description and measure of
performance: Partially addressed--measure of performance excludes a
reference to an assessment of military support related to
transportation and borders, as specified in its respective description.
Action item number: 9.1.2.2.[A];
Plan's description: DHS, in coordination with states, localities, and
tribal entities, shall support private sector preparedness with
education, exercise, training, and information-sharing outreach
programs, within 6 months;
Plan's measure of performance: Preparedness exercises established with
private sector partners in all states and U.S. territories;
GAO analysis of relationship between Plan's description and measure of
performance: Partially addressed--measure of performance excludes a
reference to education, training, and information-sharing outreach
programs for private sector preparedness, as specified in its
respective description.
Source: GAO analysis of HSC data.
Data are from the Implementation Plan for the National Strategy for
Pandemic Influenza.
Notes: "Fully addressed" means that the measure of performance
contained all of the activities specified in the respective
description. "Partially addressed" means that the measure of
performance contained some of the activities specified in the
respective description. "Did not address" means that the measure of
performance did not contain any of the activities specified in the
respective description.
[A] For action item 9.1.2.2., although the measure of performance
partially addressed the respective description, the HSC's 2-year
progress summary addressed all of the components identified in the
description. However, the progress summary did not fully address the
measure of performance as it excluded a reference to whether the
preparedness exercises were established with private sector partners in
all states and U.S. territories.
[End of table]
All of the 49 selected action items' measures of performance either
fully or partially addressed their respective descriptions. In 23 of
the 49 selected action items that were designated as complete in the
HSC's 2-year progress report, we found that the measures of performance
fully addressed the respective descriptions for the action items. For
the remaining 26 action items, the measures of performance partially
addressed their respective descriptions. For example, as noted in table
2, the description for one of the action items calls for DOD to conduct
an assessment of military support related to transportation and borders
that could be requested during a pandemic. While the measure of
performance did not include this activity, the HSC nevertheless
designated the action item as complete.
Our review also found that for 22 of the 49 selected action items
designated as complete in the HSC's 2-year progress report, the
progress summaries fully addressed how the measures of performance were
achieved, thereby supporting the HSC's designation of complete for
these action items. However, for the other 27 selected action items
designated as complete, the progress summaries did not fully address
how the measures of performance were achieved.[Footnote 25]
Specifically, in 18 of the 27 selected action items, the HSC's
summaries addressed some but not all of the activities specified in the
respective measures of performance, and for the remaining 9 action
items, the summaries did not address at all how the measures of
performance were achieved.[Footnote 26] In these instances, we found
that the HSC either used the action item's description, or used
information that was not reflected in either the description or measure
of performance, to assess completion. Table 3 below includes two
examples where the HSC summaries partially addressed or did not address
the action item's measure of performance.
Table 3: Examples of Selected Action Items Where the HSC's 2-Year
Progress Report Summaries Partially Addressed or Did Not Address the
Plan's Respective Measures of Performance:
Action item number: 4.2.3.10.;
Plan's description: DOD shall work with priority nations' military
forces to assess existing laboratory capacity, rapid response teams,
and portable field assay testing equipment, and fund essential
commodities and training necessary to achieve an effective national
military diagnostic capability, within 18 months;
Plan's measure of performance: Assessments completed, proposals
accepted, and funding made available to priority countries;
Summaries of status of action items in the HSC's 2-year progress report
(as of October 2008): The Department of Defense performed assessments
in all priority countries with the exception of those where the
nations' Ministry of Defense, Ministry of Health, or political
limitations would not allow. DOD has worked with and conducted training
with other nations to enhance their lab capability. Combatant commands
have worked with our partners to develop and improve infection control
programs and develop training and exercise programs. In addition, the
military laboratories assist regional partner nations with testing and
diagnosis;
GAO analysis of relationship between the HSC's summary and Plan's
measure of performance: Partially addressed--The HSC's summary
partially addressed the measure of performance for this action item as
it did not explicitly state that proposals were accepted, and funding
was made available to priority countries.
Action item number: 8.1.1.2.;
Plan's description: DHS, in coordination with DOJ, HHS, the Department
of Labor (DOL), and DOD, shall develop a pandemic influenza tabletop
exercise for state, local, and tribal law enforcement/public safety
officials that they can conduct in concert with public health and
medical partners, and ensure it is distributed nationwide within 4
months;
Plan's measure of performance: Percent of state, local, and tribal law
enforcement/public safety agencies that have received the pandemic
influenza tabletop exercise;
Summaries of status of action items in the HSC's 2-year progress report
(as of October 2008): A tabletop exercise template has been developed
for use by public health authorities. DHS is continuing to work with
federal partners to develop pandemic influenza tabletop exercises for
state, local, and tribal law enforcement/public safety officials that
can be conducted in concert with medical and public health entities;
GAO analysis of relationship between the HSC's summary and Plan's
measure of performance: Did not address--The HSC's summary did not
address how the measure of performance was achieved because it did not
include information on the percentage of various law enforcement and
public safety agencies that received the tabletop exercises.
Source: GAO analysis of HSC data.
Data are from the Implementation Plan for the National Strategy for
Pandemic Influenza and HSC's Two-Year Progress Report.
Notes: "Fully addressed" means that the HSC's progress summary
contained all of the activities specified in the action item's measure
of performance. "Partially addressed" means that the HSC's progress
summary contained some of the activities specified in the action item's
measure of performance. "Did not address" means that the HSC's progress
summary did not contain any of the activities specified in action
item's measure of performance.
[End of table]
Some Selected Action Items Were Designated as Complete Despite
Requiring Actions outside the Authority of the Responsible Entities:
Of the 49 selected action items designated as complete, 11 have
measures of performance that cannot be accomplished solely by
responsible entities tasked to work on these action items. Five of
these require other countries' assistance while the remaining six
require nondesignated entities' participation in order for the action
items to be completed. For these 11 action items, the responsible
federal agencies are not able to achieve the measures of performance
for these action items on their own, but can provide assistance, such
as funding and guidance, to encourage completion of these action items
by others. For example, one of the action items below calls for DOS to
promote, among other things, rapid reporting of influenza cases by
other nations; the measure of performance is that all high-risk
countries improve their capacity for rapid reporting.[Footnote 27] Even
though this outcome is beyond DOS's ability to achieve on its own, the
action item was considered complete, and no explanation was provided.
Some examples of the measures of performance that cannot be entirely
fulfilled by the agencies and organizations in the United States
include the following:
* DOS, in coordination with other agencies, shall work on a continuing
basis through the Partnership and through bilateral and multilateral
diplomatic contacts to promote transparency, scientific cooperation,
and rapid reporting of avian and human influenza cases by other nations
within 12 months. Measure of performance: All high-risk countries
actively cooperating in improving capacity for transparent, rapid
reporting of outbreaks.[Footnote 28]
* USDA shall provide technical assistance to priority countries to
increase safety of animal products by identifying potentially
contaminated animal products, developing screening protocols,
regulations, and enforcement capacities that conform to the World
Organisation for Animal Health (OIE) avian influenza standards for
transboundary movement of animal products, within 36 months. Measure of
performance: All priority countries have protocols and regulations in
place or in process.[Footnote 29]
We previously reported in June 2007 that DOS officials confirmed that
the following action item, which was designated as complete in the
HSC's 2-year progress report, had a measure of performance that was
difficult to address because the agency did not have the means to
accurately estimate the effective reach or impact of their efforts on
target audiences.[Footnote 30] As a result, this action item could only
be achieved with the participation from nondesignated entities.
* DOS, in coordination with HHS, the United States Agency for
International Development (USAID), USDA, DOD, and DHS, shall lead an
interagency public diplomacy group to develop a coordinated,
integrated, and prioritized plan to communicate U.S. foreign policy
objectives relating to our international engagement on avian and
pandemic influenza to key stakeholders (e.g., the American people, the
foreign public, nongovernmental organizations, international
businesses), within 3 months. Measure of performance: Number and range
of target audiences reached with core public affairs and public
diplomacy messages, and impact of these messages on public responses to
avian and pandemic influenza.[Footnote 31]
Additional Work Was Conducted on Some Selected Action Items Designated
as Complete:
We found that work has continued on some of the selected action items
the HSC designated as complete, including providing additional
guidance, training and exercises. In some instances, continued efforts
may be warranted--for example, when new information or circumstances
might require an update of guidance. In addition, according to the
HSC's progress reports, a determination of "complete" indicates that
the measure of performance has been achieved but does not necessarily
mean that work on the action items has ended; the work is ongoing in
many cases.
Our analysis of the 1-year and 2-year progress reports confirmed that
there was additional work conducted for 20 of the 34 selected action
items initially designated complete as of the 1-year report[Footnote
32]. For example, one of the action items called for national
spokespersons to coordinate and communicate messages to the
public.[Footnote 33] The HSC's 1-year report stated that for this
action item, which was designated as complete, the federal government
had engaged various spokespersons by providing training for risk
communications and supporting community and individual actions to
reduce illness and death. In the HSC's 2-year report, the HSC provided
new information on an influenza pandemic communications plan, which
included messaging and spokesperson development components and numerous
regional and local crisis and emergency risk communications trainings.
In another example, an action item required all hospitals and health
facilities funded by HHS, DOD, and the Department of Veterans Affairs
(VA) to develop and publicly disseminate guidance materials on
infection control.[Footnote 34] In its 1-year report, the HSC provided
information on guidance documents issued by HHS on hospital infection
control and VA's national infection prevention campaign, whereas in its
2-year report, the HSC reported on new information related to two DOD
guidance documents on preparation and response health policy and
clinical and public health guidelines for the military health system.
In addition to the supplementary information provided in the HSC's 2-
year progress report, the selected agencies informed us that they had
conducted additional work for 27 of the 49 selected action items that
had earlier been designated as complete, which included providing
additional guidance, training, and exercises for an influenza
pandemic.[Footnote 35] For example, the selected agencies that had
primary responsibility for three different action items reported that
they were continuing to either provide funding or conduct additional
influenza pandemic exercises with states and local governments and the
private sector to help them better prepare for an outbreak.[Footnote
36] Officials from HHS also informed us that they were conducting
additional training to help improve surveillance and laboratory
diagnostics in priority countries.[Footnote 37] Further, USDA officials
stated that they continued to provide guidance and training materials
to countries in the implementation of a national animal vaccination
program.[Footnote 38] An official from the Food and Agriculture
Organization (FAO) also confirmed that additional work had continued
for this action item in conjunction with the World Organisation for
Animal Health (OIE) in developing joint strategies for highly
pathogenic avian influenza.
Conclusions:
In 2007, we recommended that the HSC establish a specific process and
time frame for updating the Plan to include a number of features we
identified as important elements of a national strategy, including a
process for monitoring and reporting on progress. While the Plan's
assumptions are not matched to the 2009 H1N1 pandemic, making some of
the action items less relevant to current circumstances, the process
for monitoring and reporting on the status of pandemic plans is not
particular to any one type of pandemic scenario. The lessons learned
from developing and monitoring the 2006 Plan should be relevant to all
future pandemic planning efforts.
In particular, although the HSC, which is supported by the NSS, has
monitored progress on the Plan, it has not yet established a process
for updating the Plan, as previously reported, and we have found
additional areas for improvement in how the Plan has been monitored and
the status of action items assessed. For one thing, the NSS and the
responsible federal agencies have not been monitoring or reporting on
action items in the Plan intended for state and local governments and
other nonfederal entities, even though, in some instances, they have
information available that would allow them to do so, such as the
interagency assessment of state pandemic plans led by HHS. Given that
the Plan states that in a pandemic the primary response will come from
states and communities, this information should be in the progress
reports, notwithstanding that it may be available in other sources.
Similarly, while agency operational plans or guidance may provide the
information under which the response-related action items would be
undertaken, the Plan itself contains no such information. As a result,
it is unclear whether the information that would be needed to activate
the response-related action items in the Plan has been identified or
worked out in advance.
The HSC designated about 75 percent of the action items in the Plan as
completed, as of October 2008. However, based on our review of 49 of
the 245 action items designated as complete, it is difficult to
determine the actual status of some of the selected action items
designated as complete. The HSC and the responsible federal agencies
generally relied on the measures of performance to assess progress in
completing the selected action items. However, for more than half of
the selected action items, we found that the measures of performance
did not fully reflect all of the activities called for in the action
items' descriptions. While the HSC's progress summaries sometimes
corrected for this by referring to activities in the action item's
description omitted from the measures of performance, future progress
reports would benefit from using measures of performance that are more
consistent with the action items' descriptions. This would, in turn,
provide a more consistent and complete basis for describing progress in
implementing the Plan.
Finally, although the administration has prepared an additional
planning document tailored specifically to the 2009 H1N1 pandemic, the
Strategy and Plan will still be needed for future events. Because most
of the action items were to be completed by May 2009, the Plan should
be updated, as we earlier recommended, to include all the elements
identified in our 2007 report and to take into account the lessons
learned from the 2009 H1N1 pandemic. As part of the process for
monitoring the progress made in preparing the nation for an influenza
pandemic, the Plan should address the monitoring and assessment
improvements we identified in this report.
Recommendations for Executive Action:
To improve how progress is monitored and completion is assessed under
the Plan and in future updates of the Plan, the HSC should instruct the
NSS to work with responsible federal agencies to:
* develop a monitoring and reporting process for action items that are
intended for nonfederal entities, such as state and local governments;
* identify the types of information needed to decide whether to carry
out the response-related action items; and:
* develop measures of performance that are more consistent with the
descriptions of the action items.
Agency Comments and Our Evaluation:
We provided a draft of this report to the Homeland Security Council
(HSC), and to the Secretaries of Agriculture, Defense, Health and Human
Services, Homeland Security, State, and Transportation for their review
and comment.
In written comments on our draft report, the Principal Deputy Counsel
to the President, on behalf of the administration, stated that our
report is one notable source of suggestions for improving national
pandemic planning, and that the administration would give consideration
to our findings and recommendations as it continues its work in this
area. The HSC also provided us with technical comments, which we
incorporated as appropriate.
HHS noted in its comments that important questions and analysis that
underpin our findings and recommendations were not presented or
addressed in this report, including whether (1) the original Plan was
adequate, (2) the priorities selected were appropriate, (3) the
measures selected for monitoring progress were appropriate, and (4) the
monitoring parameters selected were measurable or even achievable. We
agree that these are important questions. However, the objectives of
this report were to (1) determine how the HSC and responsible federal
agencies monitor the progress and completion of the Plan's action items
and (2) assess the extent to which selected action items have been
completed. As such, we believe that we have in fact addressed the
issues raised by HHS in this report in our examination of action items
and related measures of performance, as well as in our prior
recommendation that has not yet been implemented to incorporate into
future updates of the Plan the lessons learned from exercises and other
events, such as the H1N1 pandemic.
HHS also provided two other general comments. First, regarding our
discussion related to the lack of details in the Plan on the
information that would be used to activate the response-related action
items, HHS stated that it would be inappropriate to set specific
trigger points to activate specific responses because an influenza
virus has an infinite range of potential characteristics, which are not
predictable, and that flexibility is necessary. HHS further stated that
it would be more appropriate to discuss the "types" of circumstances
and responses that should be planned for. We agree that flexibility is
necessary to assess the specific circumstances under which to implement
the response-related action items in the Plan, given the changing
nature of an influenza virus. We agree with HHS that the Plan should
discuss the types of circumstances that should be planned for in a
pandemic. We have made changes to the report to clarify this point.
Second, with respect to our discussion of additional work conducted on
selected action items designated as complete, HHS noted that
preparedness is a continuous and iterative improvement process based on
lessons learned, and that ongoing training and exercises should be
iterative and adapt to lessons learned. We agree. As we noted in this
report, in some instances, continued efforts on action items may be
warranted--for example, when new information or circumstances might
require an update of guidance. Our concern, however, is that it is
unclear what additional work or progress had been made on these action
items, since the HSC had designated them as complete.
DHS stated that the information in our report is generally accurate and
had no substantive comments on the content of the report. DHS further
stated that while improvements can be made in the Plan as we outlined
in our report, there has been significant work accomplished in pandemic
preparedness as a direct result of the Plan. For example, DHS noted
that significant collaboration at all levels of government and the
private sector has occurred, which enabled a more efficient and
coordinated response for the 2009 H1N1 pandemic.
DOT provided us with technical comments, which we incorporated. DOD,
DOS, and USDA informed us that they did not have any comments on the
draft report. The White House, HHS, and DHS provided written comments
on a draft of this report, which are reprinted in appendixes III, IV,
and V, respectively.
As agreed with your office, we plan no further distribution of this
report until 30 days from its date, unless you publicly announce its
contents earlier. At that time we will send copies to the HSC,
Secretary of Agriculture, Secretary of Defense, Secretary of Health and
Human Services, Secretary of Homeland Security, Secretary of State,
Secretary of Transportation, and other interested parties. In addition,
this report will be available at no charge on GAO's Web site at
[hyperlink, http://www.gao.gov].
If you or your staff have any further questions about this report,
please contact me at (202) 512-6543 or steinhardtb@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix VI.
Sincerely yours,
Signed by:
Bernice Steinhardt:
Director, Strategic Issues:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
The objectives of this study were to (1) determine how the Homeland
Security Council (HSC) and the responsible federal agencies are
monitoring the progress and completion of the Implementation Plan for
the National Strategy for Pandemic Influenza (Plan) action items, and
(2) assess the extent to which selected action items have been
completed, whether activity has continued on the selected action items
reported as complete, and the nature of that work. We did not assess
the response efforts for the 2009 H1N1 pandemic in this report, but we
continue to monitor the outbreak and the federal government's response.
To address these objectives, we conducted an in-depth analysis of a
random sample of 60 action items in the Plan. We drew a random sample
from the 286 action items involving six federal agencies with primary
responsibility for ensuring completion of the large majority (88
percent) of the 324 action items.[Footnote 39] These six agencies are
the Department of Defense (DOD), Department of Health and Human
Services (HHS), Department of Homeland Security (DHS), Department of
State (DOS), Department of Transportation (DOT), and the Department of
Agriculture (USDA). Of the 60 action items selected for our sample, the
HSC reported that 49 were completed, 3 were in progress, and 8 had no
status updates in its 2-year progress report. The purpose of this
random sampling was not to be able to generalize our findings to the
entire population of 286; rather, it was to produce a sample that had a
distribution of items generally mirroring that of the overall
population of 286 using the following variables so that the sample
would include action items that represented (1) the six agencies with
primary responsibility for implementing the Plan, (2) the three pillars
in the Plan,[Footnote 40] (3) the presence of collaboration between
federal agencies and nonfederal entities (i.e. state, local, and tribal
entities, the private sector, international organizations, and
nongovernmental organizations), and (4) various time frames of when
they should be completed, which range from within 24 hours of an
outbreak to 60 months from the release of the Plan in May 2006, among
other time frames. We do not generalize the results of our analysis
because the particular analytical steps we took across the selected
action items varied and as a result there was no common underlying
measure on which to generalize results to all of the action items in
the Plan. In addition, we did not review all of the action items in the
Plan in depth because our analyses involved multiple assessments for
each action item, including the review of large volumes of agency
documentation in determining the level of evidence for completion of
the action item.[Footnote 41]
For both objectives, we interviewed officials and obtained
documentation from the six federal agencies. We reviewed the HSC's 6-
month, 1-year, and 2-year progress reports and the HSC's 1-year summary
report on the implementation of the action items in the Plan. In
addition, we interviewed a senior HSC official from the previous
administration and the Director of Medical Preparedness Policy for the
White House National Security Staff (NSS) in the current administration
responsible for overseeing the implementation of the Plan. [Footnote
42] We also relied on our prior pandemic work to inform our analysis.
To address the first objective on how the HSC and responsible federal
agencies are monitoring the progress and completion of the Plan's
action items, we assessed information from interviews and
documentation, such as the HSC's progress reports, on how the HSC and
the selected agencies monitored the progress and completion of all
action items. We also requested information from the six agencies on
how the NSS is currently overseeing the interagency process used for
monitoring the implementation of action items in the Plan. We also
interviewed representatives from nine nonfederal entities, such as the
World Organisation for Animal Health (OIE) and the Denver Health
Medical Center, which agency officials had identified as working
collaboratively with them on four action items in our sample, and asked
these representatives whether the agencies asked for information on the
progress of implementing these action items. In addition, we reviewed
the Plan and the HSC's 2-year progress report to identify specific
circumstances that would trigger the response-related action items that
are activated by an animal outbreak or pandemic. We also collected
information from the four selected agencies that had primary
responsibility for the 10 response-related action items in our sample
regarding criteria that would trigger these action items.[Footnote 43]
To address the second objective, we analyzed the 49 action items in our
random sample that the HSC's 2-year progress report designated as
complete. We also collected documentation and conducted interviews with
selected agency officials from the six agencies and a senior HSC
official from the prior administration. To describe the extent to which
action items had been completed, we analyzed information on the 49
selected action items in the Plan, the HSC progress reports, and
supporting documentation provided by the six agencies with primary
responsibility for each of the 49 action items to demonstrate how the
measures of performance were achieved based on the HSC's criteria for
completion. Specifically, we analyzed the 49 selected action items
designated as complete to assess whether:
1. the measures of performance fully addressed, partially addressed, or
did not address their respective action item description;[Footnote 44]
2. the summaries contained in the HSC's 2-year progress report fully
addressed, partially addressed, or did not address how the measures of
performance were achieved;[Footnote 45] and:
3. the measures of performance could be accomplished solely by
responsible entities that are tasked to work on the action items.
[Footnote 46]
To evaluate the extent of work that has continued on the 49 action
items in our sample that were designated as complete, and the nature of
that work, we gathered information in two ways. First, we compared the
HSC's 1-year and 2-year progress reports for 34 selected action items
initially designated as complete as of the 1-year report by analyzing
each action item's summary in the HSC's 1-and 2-year progress reports
for any new information on work conducted. Second, we asked the six
agencies with primary responsibility if they had performed additional
work after action items were designated as complete and, if so, to
provide a brief description of the nature of that work. For 27 of the
49 action items designated as complete, the agencies indicated that
they had performed additional work after the action items were
designated as complete. For 22 of those 27 action items, the agencies
also specified the nature of the additional work. To ensure consistency
and accuracy of our analysis, at least two GAO analysts independently
analyzed the data we received for the 49 selected action items in our
sample designated as complete and then compared their results. In cases
where there were discrepancies, the two analysts reconciled their
differences for a final response. Additionally, methodologists in GAO's
Applied Research and Methods team conducted an independent analysis and
verification of our assessment by reviewing whether the measures of
performance addressed its respective description and whether the HSC
summaries addressed how the measures of performance were achieved for
all 49 action items designated as complete. In cases where there were
discrepancies between the analysts' and methodologists' teams, a joint
reconciliation was conducted for a final response.
We conducted this performance audit from July 2008 to November 2009 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
[End of section]
Appendix II: Sample of 60 Selected Action Items in the Implementation
Plan for the National Strategy for Pandemic Influenza:
Action item number: 4.1.2.1.;
Actions and expectations: The Department of State (DOS) shall ensure
strong U.S. government engagement in and follow-up on bilateral and
multilateral initiatives to build cooperation and capacity to fight
pandemic influenza internationally, including the Asia-Pacific Economic
Cooperation initiatives (inventory of resources and regional expertise
to fight pandemic influenza, a regionwide tabletop exercise, a
Symposium on Emerging Infectious Diseases to be held in Beijing in
April 2006 and the Regional Emerging Disease Intervention (REDI) Center
in Singapore), the U.S.-China Joint Initiative on Avian Influenza, and
the U.S.-Indonesia-Singapore Joint Avian Influenza Demonstration
Project; and should develop a strategy to expand the number of
countries fully cooperating with U.S. and/or international technical
agencies in the fight against pandemic influenza, within 6 months;
Measure of performance: Finalized action plans that outline goals to be
achieved and timeframes in which they will be achieved.
Action item number: 4.1.2.2.;
Actions and expectations: The Department of Health and Human Services
(HHS) shall staff the REDI Center in Singapore within 3 months;
Measure of performance: U.S. government staff provided to REDI Center.
Action item number: 4.1.2.3.;
Actions and expectations: The United States Department of Agriculture
(USDA), working with the United States Agency for International
Development (USAID) and the Partnership, shall support the Food and
Agriculture Organization (FAO) and the World Organisation for Animal
Health (OIE) to implement an instrument to assess priority countries'
veterinary infrastructure for prevention, surveillance, and control of
animal influenza and increase veterinary rapid response capacity by
supporting national capacities for animal surveillance, diagnostics,
training, and containment in at-risk countries, within 9 months;
Measure of performance: Per the OIE's Performance, Vision and Strategy
Instrument, assessment tools exercised and results communicated to the
Partnership, and priority countries are developing, or have in place,
an infrastructure capable of supporting their national prevention and
response plans for avian or other animal influenza.
Action item number: 4.1.4.2.;
Actions and expectations: DOS and HHS, in coordination with other
agencies, shall implement programs within 3 months to inform U.S.
citizens, including businesses, nongovernmental organization (NGO)
personnel, the Department of Defense (DOD) personnel, and military
family members residing and traveling abroad, where they may obtain
accurate, timely information, including risk level assessments, to
enable them to make informed decisions and take appropriate personal
measures;
Measure of performance: Majority of registered U.S. citizens abroad
have access to accurate and current information on influenza.
Action item number: 4.1.4.3.;
Actions and expectations: DOS and HHS shall ensure that adequate
guidance is provided to federal, state, tribal, and local authorities
regarding the inviolability of diplomatic personnel and facilities and
shall work with such authorities to develop methods of obtaining
voluntary cooperation from the foreign diplomatic community within the
United States consistent with U.S. government treaty obligations within
6 months;
Measure of performance: Briefing materials and an action plan in place
for engaging with relevant federal, state, tribal, and local
authorities.
Action item number: 4.1.5.3.;
Actions and expectations: HHS shall provide technical expertise,
information, and guidelines for stockpiling and use of pandemic
influenza vaccines within 6 months;
Measure of performance: All priority countries and partner
organizations have received relevant information on influenza vaccines
and application strategies.
Action item number: 4.1.7.2.;
Actions and expectations: The Department of Justice (DOJ) and DOS, in
coordination with HHS, shall consider whether the U.S. Government, in
order to benefit from the protections of the Defense Appropriations
Act, should seek to negotiate liability-limiting treaties or
arrangements covering U.S. contributions to an international stockpile
of vaccine and other medical countermeasures, within 6 months;
Measure of performance: Review initiated and decision rendered.
Action item number: 4.1.7.3.;
Actions and expectations: USDA, in collaboration with FAO and OIE,
shall develop and provide best-practice guidelines and technical
expertise to countries that express interest in obtaining aid in the
implementation of a national animal vaccination program, within 4
months;
Measure of performance: Interested countries receive guidelines and
other assistance within 3 months of their request.
Action item number: 4.2.1.1.;
Actions and expectations: DOS, in coordination with other agencies,
shall work on a continuing basis through the Partnership and through
bilateral and multilateral diplomatic contacts to promote transparency,
scientific cooperation, and rapid reporting of avian and human
influenza cases by other nations within 12 months;
Measure of performance: All high-risk countries actively cooperating in
improving capacity for transparent, rapid reporting of outbreaks.
Action item number: 4.2.1.5.;
Actions and expectations: HHS shall support the World Health
Organization (WHO) Secretariat to enhance the early detection,
identification and reporting of infectious disease outbreaks through
the WHO's Influenza Network and Global Outbreak and Alert Response
Network within 12 months;
Measure of performance: Expansion of the network to regions not
currently part of the network.
Action item number: 4.2.2.4.;
Actions and expectations: HHS shall enhance surveillance and response
to high priority infectious disease, including influenza with pandemic
potential, by training physicians and public health workers in disease
surveillance, applied epidemiology and outbreak response at its Global
Disease Detection Response Centers in Thailand and China and at the
U.S.-China Collaborative Program on Emerging and Re-Emerging Infectious
Diseases, within 12 months;
Measure of performance: 50 physicians and public health workers living
in priority countries receive training in disease surveillance applied
epidemiology and outbreak response.
Action item number: 4.2.2.7.;
Actions and expectations: DOD, in coordination with DOS and with the
cooperation of the host nation, shall assist with influenza
surveillance of host nation populations in accordance with existing
treaties and international agreements, within 24 months;
Measure of performance: Medical surveillance "watchboard" expanded to
include host nations.
Action item number: 4.2.3.1.;
Actions and expectations: HHS shall develop and implement laboratory
diagnostics training programs in basic laboratory techniques related to
influenza sample preparation and diagnostics in priority countries
within 9 months;
Measure of performance: 25 laboratory scientists trained in influenza
sample preparation and diagnostics.
Action item number: 4.2.3.5.;
Actions and expectations: HHS and USAID shall work with the WHO
Secretariat and private sector partners, through existing bilateral
agreements, to provide support for human health diagnostic laboratories
by developing and giving assistance in implementing rapid international
laboratory diagnostics protocols and standards in priority countries,
within 12 months;
Measure of performance: 75 percent of priority countries have improved
human diagnostic laboratory capacity.
Action item number: 4.2.3.9.;
Actions and expectations: DOD, in coordination with HHS, shall
prioritize international DOD laboratory research efforts to develop,
refine, and validate diagnostic methods to rapidly identify pathogens,
within 18 months;
Measure of performance: Completion of prioritized research plan,
resources identified, and tasks assigned across DOD medical research
facilities.
Action item number: 4.2.3.10.;
Actions and expectations: DOD shall work with priority nations'
military forces to assess existing laboratory capacity, rapid response
teams, and portable field assay testing equipment, and fund essential
commodities and training necessary to achieve an effective national
military diagnostic capability, within 18 months;
Measure of performance: Assessments completed, proposals accepted, and
funding made available to priority countries.
Action item number: 4.2.5.1.;
Actions and expectations: HHS and USAID shall develop, in coordination
with the WHO Secretariat and other donor countries, rapid response
protocols for use in responding quickly to credible reports of human-to-
human transmission that may indicate the beginnings of an influenza
pandemic, within 12 months;
Measure of performance: Adoption of protocols by WHO and other
stakeholders.
Action item number: 4.2.7.2.;
Actions and expectations: USDA shall provide technical assistance to
priority countries to increase safety of animal products by identifying
potentially contaminated animal products, developing screening
protocols, regulations, and enforcement capacities that conform to OIE
avian influenza standards for transboundary movement of animal
products, within 36 months;
Measure of performance: All priority countries have protocols and
regulations in place or in process.
Action item number: 4.3.6.1.;
Actions and expectations: DOS, in coordination with HHS, USAID, USDA,
DOD, and the Department of Homeland Security (DHS), shall lead an
interagency public diplomacy group to develop a coordinated,
integrated, and prioritized plan to communicate U.S. foreign policy
objectives relating to our international engagement on avian and
pandemic influenza to key stakeholders (e.g., the American people, the
foreign public, NGOs, international businesses),within 3 months;
Measure of performance: Number and range of target audiences reached
with core public affairs and public diplomacy messages, and impact of
these messages on public responses to avian and pandemic influenza.
Action item number: 4.3.6.3.;
Actions and expectations: USDA, in coordination with DHS, the United
States Trade Representative (USTR), and DOS, shall ensure that clear
and coordinated messages are provided to international trading partners
regarding animal disease outbreak response activities in the United
States;
Measure of performance: Within 24 hours of an outbreak, appropriate
messages will be shared with key animal/animal product trading
partners.
Action item number: 5.1.1.5.;
Actions and expectations: DOD, in coordination with DHS, the Department
of Transportation (DOT), DOJ, and DOS, shall conduct an assessment of
military support related to transportation and borders that may be
requested during a pandemic and develop a comprehensive contingency
plan for Defense Support to Civil Authorities, within 18 months;
Measure of performance: Defense Support to Civil Authorities plan in
place that addresses emergency transportation and border support.
Action item number: 5.1.4.2.;
Actions and expectations: DHS, in coordination with DOT, the Department
of Labor (DOL), the Office of Personnel Management, and DOS, shall
disseminate workforce protection information to stakeholders, conduct
outreach with stakeholders, and implement a comprehensive program for
all Federal transportation and border staff within 12 months;
Measure of performance: 100 percent of workforce has or has access to
information on pandemic influenza risk and appropriate protective
measures.
Action item number: 5.2.4.7.;
Actions and expectations: DHS, DOT, and HHS, in coordination with
transportation and border stakeholders, and appropriate state and local
health authorities, shall develop aviation, land border, and maritime
entry and exit protocols and/or screening protocols, and education
materials for non-medical, front-line screeners and officers to
identify potentially infected persons or cargo, within 10 months;
Measure of performance: Protocols and training materials developed and
disseminated.
Action item number: 5.2.4.8.;
Actions and expectations: DHS and HHS, in coordination with DOT, DOJ,
and appropriate State and local health authorities, shall develop
detection, diagnosis, quarantine, isolation, emergency medical services
(EMS) transport, reporting, and enforcement protocols and education
materials for travelers, and undocumented aliens apprehended at and
between ports of entry, who have signs or symptoms of pandemic
influenza or who may have been exposed to influenza, within 10 months;
Measure of performance: Protocols developed and distributed to all
ports of entry.
Action item number: 5.2.5.2.;
Actions and expectations: USDA, in coordination with DHS, the
Department of the Interior (DOI), and HHS, shall review the process for
withdrawing permits for importation of live avian species or products
and identify ways to increase timeliness, improve detection of high-
risk importers, and increase outreach to importers and their
distributors, within 6 months;
Measure of performance: Revised process for withdrawing permits of high-
risk importers.
Action item number: 5.2.5.3.;
Actions and expectations: USDA, in coordination with DOI, DHS, shall
enhance protocols at air, land, and sea ports of entry to identify and
contain animals, animal products, and/or cargo that may harbor viruses
with pandemic potential and review procedures to quickly impose
restrictions, within 6 months;
Measure of performance: Risk based protocols established and in use.
Action item number: 5.2.5.6.;
Actions and expectations: USDA, DHS, and DOI, in coordination with DOS,
HHS, and the Department of Commerce (DOC), shall conduct outreach and
expand education campaigns for the public, agricultural stakeholders,
wildlife trade community, and cargo and animal importers/exporters on
import and export regulations and influenza disease risks, within 12
months;
Measure of performance: 100 percent of key stakeholders are aware of
current import and export regulations and penalties for non-compliance.
Action item number: 5.3.1.1.;
Actions and expectations: DOS and DHS, in coordination with DOT, DOC,
HHS, the Department of the Treasury (Treasury), and USDA, shall work
with foreign counterparts to limit or restrict travel from affected
regions to the United States, as appropriate, and notify host
government(s) and the traveling public;
Measure of performance: Measures imposed within 24 hours of the
decision to do so, after appropriate notifications made.
Action item number: 5.3.1.4.;
Actions and expectations: DHS, in coordination with DOS, USDA and DOI,
shall provide countries with guidance to increase scrutiny of cargo and
other imported items through existing programs, such as the Container
Security Initiative, and impose country-based restrictions or item-
specific embargoes;
Measure of performance: Guidance, which may include information on
restrictions, is provided for increased scrutiny of cargo and other
imported items, within 24 hours upon notification of an outbreak.
Action item number: 5.3.2.3.;
Actions and expectations: DHS, in coordination with USDA, DOS, DOC,
DOI, and shippers, shall rapidly implement and enforce cargo
restrictions for export or import of potentially contaminated cargo,
including embargo of live birds, and notify international
partners/shippers;
Measure of performance: Measures implemented within 6 hours of decision
to do so.
Action item number: 5.3.4.3.;
Actions and expectations: DHS, if needed, will implement contingency
plans to maintain border control during a period of pandemic influenza
induced mass migration;
Measure of performance: Contingency plan activated within 24 hours of
notification.
Action item number: 5.3.4.5.;
Actions and expectations: DOT shall issue safety-related waivers as
needed, to facilitate efficient movement of goods and people during an
emergency, balancing the need to expedite services with safety, and
states should consider waiving state-specific regulatory requirements,
such as size and weight limits and convoy registration;
Measure of performance: All regulatory waivers as needed balance need
to expedite services with safety.
Action item number: 5.3.5.3.;
Actions and expectations: DOT, in coordination with DHS, state, local,
and tribal governments, and the private sector, shall monitor system
closures, assess effects on the transportation system, and implement
contingency plans;
Measure of performance: Timely reports transmitted to DHS and other
appropriate entities, containing relevant, current, and accurate
information on the status of the transportation sector and impacts
resulting from the pandemic; when appropriate, contingency plans
implemented within no more than 24 hours of a report of a
transportation sector impact or issue.
Action item number: 5.3.5.4.;
Actions and expectations: DOT, in support of DHS and in coordination
with other emergency support function (ESF) #1 support agencies, shall
work closely with the private sector and state, local, and tribal
entities to restore the transportation system, including
decontamination and reprioritization of essential commodity shipments;
Measure of performance: Backlogs or shortages of essential commodities
and goods quickly eliminated, returning production and consumption to
prepandemic levels.
Action item number: 6.1.1.3.;
Actions and expectations: DHS, in coordination with HHS, DOJ, DOT, and
DOD, shall be prepared to provide emergency response element training
(e.g., incident management, triage, security, and communications) and
exercise assistance upon request of state, local, and tribal
communities and public health entities within 6 months;
Measure of performance: Percentage of requests for training and
assistance fulfilled.
Action item number: 6.1.2.2.;
Actions and expectations: HHS, in coordination with DHS, DOD, and the
Department of Veterans Affairs (VA), shall develop a joint strategy
defining the objectives, conditions, and mechanisms for deployment
under which the National Disaster Medical System assets, U.S. Public
Health Service Commissioned Corps, Epidemic Intelligence Service
officers, and DOD/VA health care personnel and public health officers
would be deployed during a pandemic, within 9 months;
Measure of performance: Interagency strategy completed and tested for
the deployment of federal medical personnel during a pandemic.
Action item number: 6.1.3.1.;
Actions and expectations: HHS, in coordination with DHS, DOS, DOD, VA,
and other federal partners, shall develop, test, and implement a
federal government public health emergency communications plan
(describing the government's strategy for responding to a pandemic,
outlining U.S. international commitments and intentions, and reviewing
containment measures that the government believes will be effective as
well as those it regards as likely to be ineffective, excessively
costly, or harmful) within 6 months;
Measure of performance: Containment strategy and emergency response
materials completed and published on www.pandemicflu.gov;
communications plan implemented.
Action item number: 6.1.3.3.;
Actions and expectations: HHS, in coordination with DHS, DOD, and the
VA, and in collaboration with state, local, and tribal health agencies
and the academic community, shall select and retain opinion leaders and
medical experts to serve as credible spokespersons to coordinate and
effectively communicate important and informative messages to the
public, within 6 months;
Measure of performance: National spokespersons engaged in
communications campaign.
Action item number: 6.1.4.2.;
Actions and expectations: DOT, in cooperation with HHS, DHS, and DOC,
shall develop model protocols for 9-1-1 call centers and public safety
answering points that address the provision of information to the
public, facilitate caller screening, and assist with priority dispatch
of limited emergency medical services, within 12 months;
Measure of performance: Model protocols developed and disseminated to 9-
1-1call centers and public safety answering points.
Action item number: 6.1.8.1.;
Actions and expectations: HHS shall work with the pharmaceutical
industry toward the goal of developing, within 60 months, domestic
vaccine production capacity sufficient to provide vaccine for the
entire U.S. population within 6 months after the development of a
vaccine reference strain;
Measure of performance: Domestic vaccine manufacturing capacity in
place to produce 300 million courses of vaccine within 6 months of
development of a vaccine reference strain during a pandemic.
Action item number: 6.1.13.6.;
Actions and expectations: DOT, in coordination with HHS, DHS, state,
local, and tribal officials and other EMS stakeholders, shall develop
suggested EMS pandemic influenza guidelines for statewide adoption that
address: clinical standards, education, treatment protocols,
decontamination procedures, medical direction, scope of practice, legal
parameters, and other issues, within 12 months;
Measure of performance: EMS pandemic influenza guidelines completed.
Action item number: 6.1.13.9.;
Actions and expectations: HHS, in coordination with DOD, VA, and in
collaboration with state, territorial, tribal, and local partners,
shall develop/refine mechanisms to: (1) track adverse events following
vaccine and antiviral administration; (2) ensure that individuals
obtain additional doses of vaccine, if necessary; and (3) define
protocols for conducting vaccine- and antiviral-effectiveness studies
during a pandemic, within 18 months;
Measure of performance: Mechanism(s) to track vaccine and antiviral
medication coverage and adverse events developed; vaccine-and antiviral-
effectiveness study protocols developed.
Action item number: 6.1.14.3.;
Actions and expectations: HHS, in coordination with DHS and sector-
specific agencies, DOS, DOD, DOL, and VA, shall establish a strategy
for shifting priorities based on at-risk populations, supplies and
efficacy of countermeasures against the circulating pandemic strain,
and characteristics of the virus within 9 months;
Measure of performance: Clearly articulated process in place for
evaluating and adjusting prepandemic recommendations of groups
receiving priority access to medical countermeasures.
Action item number: 6.1.16.2.;
Actions and expectations: HHS shall support the renovation of existing
U.S. manufacturing facilities that produce other Food and Drug
Administration licensed cell-based vaccines or biologics and the
establishment of new domestic cell-based influenza vaccine
manufacturing facilities, within 36 months;
Measure of performance: Contracts awarded for renovation or
establishment of domestic cell-based influenza vaccine manufacturing
capacity.
Action item number: 6.1.17.3.;
Actions and expectations: HHS, in coordination with DHS, shall develop
and test new point-of-care and laboratory-based rapid influenza
diagnostics for screening and surveillance, within 18 months;
Measure of performance: New grants and contracts awarded to researchers
to develop and evaluate new diagnostics.
Action item number: 6.2.1.1.;
Actions and expectations: HHS shall provide guidance to public health
and clinical laboratories on the different types of diagnostic tests
and the case definitions to use for influenza at the time of each
pandemic phase. Guidelines for the current pandemic alert phase will be
disseminated within 3 months;
Measure of performance: Dissemination on www.pandemicflu.gov and
through other channels of guidance on the use of diagnostic tests for
H5N1 and other potential pandemic influenza subtypes.
Action item number: 6.2.2.8.;
Actions and expectations: HHS, in coordination with DHS, DOD, and VA,
and in collaboration with state, local, and tribal authorities, shall
be prepared to collect, analyze, integrate, and report information
about the status of hospitals and health care systems, healthcare
critical infrastructure, and medical materiel requirements, within 12
months;
Measure of performance: Guidance provided to states and tribal entities
on the use and modification of the components of the National Hospital
Available Beds for Emergencies and Disasters system for implementation
at the local level.
Action item number: 6.3.2.5.;
Actions and expectations: All HHS-, DOD- , and VA-funded hospitals and
health facilities shall develop, test, and be prepared to implement
infection control campaigns for pandemic influenza, within 3 months;
Measure of performance: Guidance materials on infection control
developed and disseminated on www.pandemicflu.gov and through other
channels.
Action item number: 6.3.3.1.;
Actions and expectations: HHS, in coordination with DHS, VA, and DOD,
shall develop and disseminate guidance that explains steps individuals
can take to decrease their risk of acquiring or transmitting influenza
infection during a pandemic, within 3 months;
Measure of performance: Guidance disseminated on www.pandemicflu.gov
and through VA and DOD channels.
Action item number: 7.1.5.1.;
Actions and expectations: USDA and DOI shall perform research to
understand better how avian influenza viruses circulate and are
transmitted in nature, in order to improve information on biosecurity
distributed to local animal owners, producers, processors, markets,
auctions, wholesalers, distributors, retailers, and dealers, as well as
wildlife management agencies, rehabilitators, and zoos, within 18
months;
Measure of performance: Completed research studies provide new
information, or validate current information, on the most useful
biosecurity measures to be taken to effectively prevent introduction,
and limit or prevent spread, of avian influenza viruses in domestic and
captive animal populations.
Action item number: 7.1.5.4.;
Actions and expectations: USDA shall perform research to improve
vaccines and mass immunization techniques for use against influenza in
domestic birds within 36 months;
Measure of performance: An effective avian influenza vaccine that can
be delivered simultaneously to multiple birds ready for commercial
development.
Action item number: 7.2.1.1.;
Actions and expectations: DOI and USDA shall collaborate with state
wildlife agencies, universities, and others to increase surveillance of
wild birds, particularly migratory water birds and shore birds, in
Alaska and other appropriate locations elsewhere in the United States
and its territories, to detect influenza viruses with pandemic
potential, including highly pathogenic avian influenza H5N1, and
establish baseline data for wild birds, within 12 months;
Measure of performance: Reports detailing geographically appropriate
wild bird samples collected and influenza virus testing results.
Action item number: 7.2.1.2.;
Actions and expectations: USDA and DOI shall collaborate to develop and
distribute information to state and tribal entities on the detection,
identification, and reporting of influenza viruses in wild bird
populations, within 6 months;
Measure of performance: Information distributed and a report available
describing the type, amount, and audiences for the information.
Action item number: 7.2.1.3.;
Actions and expectations: USDA shall work with state and tribal
entities, and industry groups, to perform surveys of game birds and
waterfowl raised in captivity, and implement surveillance of birds at
auctions, swap meets, flea markets, and public exhibitions, within 12
months;
Measure of performance: Samples collected at 50 percent of the largest
auctions, swap meets, flea markets, and public exhibitions held in at
least five states or tribal entities believed to be at highest risk for
an avian influenza introduction.
Action item number: 7.3.1.2.;
Actions and expectations: USDA shall coordinate with DHS and other
federal, state, local, and tribal officials, animal industry, and other
affected stakeholders during an outbreak in commercial or other
domestic birds and animals to apply and enforce appropriate movement
controls on animals and animal products to limit or prevent spread of
influenza virus;
Measure of performance: Initial movement controls in place within 24
hours of detection of an outbreak.
Action item number: 7.3.2.1.;
Actions and expectations: USDA shall activate plans to distribute
veterinary medical countermeasures and materiel from the National
Veterinary Stockpile (NVS) to federal, state, local, and tribal
influenza outbreak responders within 24 hours of confirmation of an
outbreak in animals of influenza with human pandemic potential, within
9 months;
Measure of performance: NVS materiel distributed within 24 hours of
confirmation of an outbreak.
Action item number: 8.1.1.2.;
Actions and expectations: DHS, in coordination with DOJ, HHS, DOL, and
DOD, shall develop a pandemic influenza tabletop exercise for state,
local, and tribal law enforcement/public safety officials that they can
conduct in concert with public health and medical partners, and ensure
it is distributed nationwide within 4 months;
Measure of performance: Percent of state, local, and tribal law
enforcement/public safety agencies that have received the pandemic
influenza tabletop exercise.
Action item number: 8.3.2.2.;
Actions and expectations: DHS, in coordination with DOJ, DOD, DOT, HHS,
and other appropriate federal sector-specific agencies, shall engage in
contingency planning and related exercises to ensure they are prepared
to sustain EMS, fire, emergency management, public works, and other
emergency response functions during a pandemic, within 6 months;
Measure of performance: Completed plans (validated by exercise(s)) for
supporting EMS, fire, emergency management, public works, and other
emergency response functions.
Action item number: 9.1.2.2.;
Actions and expectations: DHS, in coordination with states, localities
and tribal entities, shall support private sector preparedness with
education, exercise, training, and information sharing outreach
programs, within 6 months;
Measure of performance: Preparedness exercises established with private
sector partners in all states and U.S. territories.
Action item number: 9.3.1.2.;
Actions and expectations: DHS shall develop and operate a national-
level monitoring and information sharing system for core essential
services to provide status updates to critical infrastructure dependent
on these essential services, and aid in sharing real-time impact
information, monitoring actions, and prioritizing national support
efforts for preparedness, response, and recovery of critical
infrastructure sectors within 12 months;
Measure of performance: National-level critical infrastructure
monitoring and information-sharing system established and operational.
Source: HSC.
Data are from the Implementation Plan for the National Strategy for
Pandemic Influenza.
Notes: As stated earlier, we reviewed 60 of the 324 action items, of
which the Homeland Security Council (HSC) designated 49 as complete, 3
as in progress, and 8 with no reported status. As we pointed out, our
analysis highlighted a number of reasons why it was difficult to
determine the actual status for some of the 49 selected action items
that were designated as complete.
[End of table]
[End of section]
Appendix III: Comments from the White House:
The White House:
Washington:
November 18, 2009:
Ms. Bernice Steinhardt:
Director, Strategic Issues:
Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548-0001:
Dear Ms. Steinhardt:
Thank you for providing the White House National Security Staff, which
supports the Homeland Security Council, the opportunity to comment on
the Government Accountability Office's report entitled, "Influenza
Pandemic: Monitoring and Assessing Status of the National Pandemic Plan
Needs Improvement" (GAO-10-73).
We appreciate GAO's attention to the important and timely area of
pandemic influenza planning. As the report notes, the previous
Administration issued the National Strategy for Pandemic Influenza in
2005 and the Implementation Plan for the National Strategy far Pandemic
Influenza in 2006; it also issued progress reports on the
Implementation Plan in 2006, 2007, and 2008. Through these efforts, the
Federal government has made important strides in improving its ability
to respond to a pandemic, and it has formed crucial lines of
collaboration and cooperation with state, local, and non-governmental
entities on pandemic issues.
This Administration is committed to building on this prior work in
order to improve national pandemic preparedness and to further
strengthen cooperation with our non-federal partners. Your report is
one notable source of suggestions for improving national pandemic
planning. The Administration will give consideration to GAO's findings
and recommendations as it continues its work in this important area.
Thank you for your work on this set of issues.
Sincerely,
Signed by:
Daniel Meltzer:
Principal Deputy Counsel to the President:
[End of section]
Appendix IV: Comments from the Department of Health and Human Services:
Note: Page numbers in the draft report may differ from those in this
report.
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
October 30, 2009:
Bernice Steinhardt:
Director, Strategic Issues:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Ms. Steinhardt:
Enclosed are comments on the U.S. Government Accountability Office's
(GAO) report entitled: Influenza Pandemic: Gaps in Monitoring and
Assessing Status of the National Pandemic Implementation Plan Need to
be Addressed (GAO-10-73).
The Department appreciates the opportunity to review this report before
its publication.
Sincerely,
Signed by:
Andrea Palm:
Acting Assistant Secretary for Legislation:
Enclosure:
[End of letter]
General Comments Of The Department Of Health And Human Services (HHS)
On The Government Accountability Office's (GAO) Draft Report Entitled:
Pandemic Influenza: Gaps In Monitoring And Assessing Status Of The
National Pandemic Implementation Plan Needs To Be Addressed (GAO-19-
73):
GAO was asked to examine (1) how implementation of the HSC items is
monitored and (2) whether selected HSC items have been completed and
whether activity has continued on items reported as complete. The GAO
report identifies difficulties in the HSC monitoring process and
confirms that many activities continue, despite being considered as
"complete" in terms of the HSC reporting requirements.
To resolve these issues, GAO makes three recommendations to HSC to
improve use of the 324 HSC items as a monitoring tool:
* Developing a monitoring and reporting process for actions tasked
exclusively to nonfederal entities such as state and local governments;
* Defining information and circumstances that would trigger response-
related action items.
* Improving how completion of individual HSC items is assessed.
There are several scientific and technical inaccuracies in the
statements and text that could affect the interpretation of the
findings and recommendations in the Report. Important questions and
analysis are not presented or addressed in the Report, that underpin
GAO's findings and recommendations. For example: Was the original
National Pandemic Implementation Plan adequate? Were the priorities
selected appropriate? Were the measures selected for monitoring
progress appropriate? Were the monitoring parameters selected
measurable or even achievable? We believe that these predicate
questions need to be addressed as part of any evaluation of the reports
of progress and/or completion on the planned action items.
Two conclusions of the Report do not adequately take into account the
realities of an influenza pandemic or important concepts of pandemic
preparedness:
1) Page 15 ” Discussion of lack of specific triggers and criteria to
activate responses.
From a scientific and epidemiology Perspective, setting of specific
trigger points to activate specific responses is inappropriate because
the influenza virus has an infinite range of potential behaviors,
transmissibility, virulence, severity, attack rates, etc. that are
defined by its genetic makeup. It is not possible, nor realistic to
attempt to predict all the possible permutations and combinations of
circumstances and appropriate responses. It is more appropriate to
speak in terms of the "types" of circumstances and "types" of responses
that should be planned for Flexibility is necessary to assess the
specific circumstances that arise and apply the specific and most
appropriate response from the various available of options.
2) Page 26 ” Discussion of additional work conducted on selected items
designated as complete.
Preparedness is a continuous, ongoing, iterative, improvement process
based on lessons learned. As indicated above, due to the inherent
nature of influenza virus, preparedness is not a fixed endpoint.
Guidance needs to be updated based on new scientific discovery and on
information obtained from ongoing surveillance of the mutations of the
influenza virus (pre-pandemic or during a pandemic) as it continues to
circulate around the globe. Training and exercises should not be
considered a one-time activity. There is considerable scientific
evidence that refreshing knowledge and skills improves performance when
the knowledge and skills are actually needed, particularly if the
events do not occur often. The health and public health workforces are
not static entities. People move in and out of the workforce and
between categories of responsibilities fluidly. Ongoing training is
necessary and exercises should-be iterative and adapt to lessons
learned and from new scientific discovery and information obtained
froth ongoing surveillance of the influenza virus.
[End of section]
Appendix V: Comments from the Department of Homeland Security:
Department of Homeland Security:
Washington, DC 20528:
October 23, 2009:
Ms. Bernice Steinhardt:
Director, Strategic Issues:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Ms. Steinhardt:
RE: Draft Report GAO 10-73 (Reference # 450696) National Pandemic
Implementation Plan Action Items:
Thank you for the opportunity to review the draft report concerning the
National Pandemic Implementation action items. While there were no
recommendations for the Department of Homeland Security (DHS) in the
draft report, we would like to respectfully offer the following
comments:
DHS has reviewed the report and has no substantive comments on the
content of the report. The information in the report is generally
accurate and DHS recognizes that while improvements can be made in the
National Implementation Plan as outlined in the GAO report, it is
important to recognize that over the past 3 years, there has been a
great deal of significant work accomplished in many different areas of
pandemic preparedness and response that are directly related to work
completed as outlined in the 2006 National Implementation Plan.
As a direct result of the National Implementation Plan, significant
collaboration has occurred at all levels of government and the private
sector that has effectively built a strong base for pandemic
preparedness and response that enabled a much more efficient and
coordinated response for the 2009 H1N1 events that continues today.
While the National Implementation Plan was written to specifically
address a severe pandemic, much of the work completed has been vitally
important and beneficial in responding to the 2009 H1N1 pandemic, which
continues to be a mild to moderate pandemic. The collaboration networks
that were established and the significant training and exercises that
had already been established as required in the National Implementation
Plan, positioned our nation to be in a much better position to respond
efficiently to the 2009 H1N1 events and thereby greatly reduced the
impact of the current pandemic.
Thank you for the opportunity to comment on this Draft Report and we
look forward to working with you on future homeland security issues.
Sincerely,
Signed by:
Peggy Mayfield, for:
Jerald E. Levine:
Director:
Departmental GAO/OIG Liaison Office:
[End of section]
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
Bernice Steinhardt, (202) 512-6543 or steinhardtb@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Sarah Veale, Assistant
Director; Maya Chakko; Susan Sato; David Fox; Melissa Kornblau; Kara
Marshall; Mark Ryan; David Dornisch; Andrew Stavisky; and members of
GAO's Pandemic Working Group made key contributions to this report.
[End of section]
Related GAO Products:
Influenza Pandemic: Key Securities Market Participants Are Making
Progress, but Agencies Could Do More to Address Internet Congestion and
Encourage Readiness. [hyperlink, http://www.gao.gov/products/GAO-10-8].
Washington, D.C.: October 26, 2009.
Influenza Pandemic: Gaps in Pandemic Planning and Preparedness Need to
Be Addressed. [hyperlink, http://www.gao.gov/products/GAO-09-909T].
Washington, D.C.: July 29, 2009.
Influenza Pandemic: Greater Agency Accountability Needed to Protect
Federal Workers in the Event of a Pandemic. [hyperlink,
http://www.gao.gov/products/GAO-09-783T]. Washington, D.C.: June 16,
2009.
Influenza Pandemic: Increased Agency Accountability Could Help Protect
Federal Employees Serving the Public in the Event of a Pandemic.
[hyperlink, http://www.gao.gov/products/GAO-09-404]. Washington, D.C.:
June 12, 2009.
Influenza Pandemic: Continued Focus on the Nation's Planning and
Preparedness Efforts Remains Essential. [hyperlink,
http://www.gao.gov/products/GAO-09-760T]. Washington, D.C.: June 3,
2009.
Influenza Pandemic: Sustaining Focus on the Nation's Planning and
Preparedness Efforts. [hyperlink,
http://www.gao.gov/products/GAO-09-334]. Washington, D.C.: February 26,
2009.
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] The HSC was established in 2001 pursuant to Executive Order 13228
to serve as a mechanism for ensuring coordination of homeland security-
related activities of executive departments and agencies and effective
development and implementation of homeland security policies. Congress
subsequently established the HSC for the purpose of more effectively
coordinating the policies and functions of the federal government
relating to homeland security in the Homeland Security Act of 2002.
Pub. L. No. 107-296 (Nov. 25, 2002).
[2] 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 influenza pandemic.
[3] 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, Influenza Pandemic: Further
Efforts Are Needed to Ensure Clearer Federal Leadership Roles and an
Effective National Strategy, GAO-07-781 (Washington, D.C.: Aug. 14,
2007).
[4] HHS, DHS, and USDA have primary responsibility in implementing a
majority of the action items in the Plan.
[5] [hyperlink, http://www.gao.gov/products/GAO-07-781].
[6] On April 25, 2009, WHO convened a meeting of the Emergency
Committee, which is composed of international experts in a variety of
disciplines, to assess the H1N1 influenza cases reported in Mexico and
in the United States and declared the 2009 H1N1 a public health
emergency of international concern.
[7] Phase 5 is characterized by human-to-human spread of the virus into
at least two countries in one WHO region.
[8] As discussed later, the HSC does not monitor action items intended
for nonfederal entities.
[9] [hyperlink, http://www.gao.gov/products/GAO-07-781].
[10] GAO, 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).
[11] Action item 6.3.1.1.
[12] Action item 8.1.1.1.
[13] Stage 1 of the HHS-led interagency review of state pandemic plans
spanned from August 2006 to January 2007.
[14] [hyperlink, http://www.gao.gov/products/GAO-08-539].
[15] Stage 2 of the HHS-led interagency review of state pandemic plans
spanned from January 2007 to December 2008.
[16] 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) and Departments of Health and Human Services and Homeland
Security and other agencies, Assessment of States' Operating Plans to
Combat Pandemic Influenza: Report to Homeland Security Council,
(Washington, D.C.: January 2009).
[17] Action item 5.3.1.1.
[18] GAO, 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.: Sept. 6,
2006).
[19] Executive Office of the President, President's Council of Advisors
on Science and Technology, Report to the President on U.S. Preparations
for 2009-H1N1 Influenza (Washington, D.C.: Aug. 7, 2009).
[20] HSC, Implementation Plan for the National Strategy for Pandemic
Influenza, (Washington, D.C.: May 2006).
[21] As of October 2008, the HSC reported that of the 324 action items,
245 were complete, 21 were in progress, and 58 had no status reported.
Of the 58 action items that had no status reported, 34 had measures of
performance and time frames associated with a pandemic or animal
outbreak in the United States, 17 were intended for nonfederal
entities, 3 were directed to the federal government or to agencies and
nonfederal entities, 2 had deadlines beyond the 2-year reporting time
frame, and the remaining 2--action items 5.2.4.10. and 6.1.6.3.--were
not included in the report.
[22] Action items with no reported status were either response-related
or had time frames greater than 24 months.
[23] [hyperlink, http://www.gao.gov/products/GAO-07-781].
[24] For this analysis, we reviewed the action item's measure of
performance relative to the respective description as written in the
Plan, and therefore we could not determine the intent of the measure or
of the description.
[25] For this analysis, we reviewed the summaries of the status of
selected action items in the HSC's 2-year progress report and the
action item's measure of performance in the Plan as written.
[26] For these nine action items, we analyzed the HSC's summaries from
its 2-year progress report to determine whether the HSC used the action
item's descriptions to make its determination that they were complete.
Our analysis found that the HSC's summaries from its 2-year progress
report fully or partially addressed five of the respective action
item's descriptions and did not address the four remaining action
items' descriptions. In these four cases, it is unclear on what basis
the HSC made its determination since the summaries did not address
either the respective measures of performance or their descriptions.
[27] Action item 4.2.1.1.
[28] Action item 4.2.1.1.
[29] Action item 4.2.7.2.
[30] GAO, 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).
[31] Action item 4.3.6.1.
[32] Our sample included 49 action items designated as complete as of
the HSC's 2-year report. However, we only reviewed the 34 of 49 action
items designated as complete as of the HSC's 1-year report. The
remaining 15 of the 49 action items were not reviewed as they had time
frames beyond 12 months.
[33] Action item 6.1.3.3.
[34] Action item 6.3.2.5.
[35] Fifteen of these 27 action items were designated complete as of
the HSC's 1-year report and also contained new information that was not
highlighted in the HSC's 2-year report.
[36] Action items 6.1.1.3., 7.3.2.1., and 9.1.2.2.
[37] Action items 4.2.2.4., 4.2.3.1., and 4.2.3.5.
[38] Action item 4.1.7.3.
[39] The Plan includes a total of 324 action items. As noted, we drew a
random sample using 286 of the 324 action items.
[40] As noted earlier, the National Strategy for Pandemic Influenza has
three high-level goals, which are underpinned by three pillars that are
intended to guide the federal government's approach to a pandemic
threat, including: (1) preparedness and communication, (2) surveillance
and detection, and (3) response and containment.
[41] In addition, we randomly sampled 11 action items from our sample
of 60 that called for joint collaboration with nonfederal entities. We
interviewed nonfederal entities that federal agencies told us they had
worked with for 4 of the 11 action items. However, we only report this
information anecdotally in the report. Additionally, we did not request
documentation attesting to the presence of collaboration with the
federal agencies with primary responsibility or the completion of the
action item with the nonfederal entities.
[42] As noted earlier in the report, 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 influenza pandemic.
[43] Of the 10 response-related action items, the HSC designated 4 as
complete and 6 had no status reported. As stated earlier in the report,
according to the HSC's 2-year progress report, 4 action items were
designated as complete because the agencies with primary responsibility
had previously responded to animal outbreaks in other countries and
within the United States.
[44] "Fully addressed" means that the measure of performance contained
all of the activities specified in the respective description.
"Partially addressed" means that the measure of performance contained
some of the activities specified in the respective description. "Did
not address" means that the measure of performance did not contain any
of the activities specified in the respective description.
[45] "Fully addressed" means that the HSC's progress summary contained
all of the activities specified in the action item's measure of
performance. "Partially addressed" means that the HSC's progress
summary contained some of the activities specified in the action item's
measure of performance. "Did not address" means that the HSC's progress
summary did not contain any of the activities specified in action
item's measure of performance.
[46] We conducted this analysis by reviewing whether the responsible
entities, such as federal agencies, tasked to the 49 action items
designated as complete could achieve the respective measures of
performance without the assistance of nondesignated entities, such as
other countries.
[End of section]
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "E-mail Updates."
Order by Phone:
The price of each GAO publication reflects GAO‘s actual cost of
production and distribution and depends on the number of pages in the
publication and whether the publication is printed in color or black and
white. Pricing and ordering information is posted on GAO‘s Web site,
[hyperlink, http://www.gao.gov/ordering.htm].
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card,
MasterCard, Visa, check, or money order. Call for additional
information.
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Ralph Dawn, Managing Director, dawnr@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
