This is the accessible text file for GAO report number GAO-09-909T 
entitled 'Influenza Pandemic: Gaps in Pandemic Planning and 
Preparedness Need to Be Addressed' which was released on July 29, 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. 

Testimony: 

Before the Chairman, Committee on Homeland Security, House of 
Representatives: 

United States Government Accountability Office: 
GAO: 

For Release on Delivery: 
Expected at 2:00 p.m. EST:
Wednesday, July 29, 2009: 

Influenza Pandemic: 

Gaps in Pandemic Planning and Preparedness Need to Be Addressed: 

Statement of Bernice Steinhardt: 
Director, Strategic Issues: 

GAO-09-909T: 

GAO Highlights: 

Highlights of GAO-09-909T, a testimony before the Chairman, Committee 
on Homeland Security, House of Representatives. 

Wht GAO Did This Study: 

As the current H1N1 outbreak underscores, an influenza pandemic remains 
a real threat to our nation. Over the past 3 years, GAO conducted a 
body of work, consisting of 12 reports and 4 testimonies, to help the 
nation better prepare for a possible pandemic. In February 2009, GAO 
synthesized the results of most of this work and, in June 2009, GAO 
issued an additional report on agency accountability for protecting the 
federal workforce in the event of a pandemic. GAOís work points out 
that while a number of actions have been taken to plan for a pandemic, 
including developing a national strategy and implementation plan, many 
gaps in pandemic planning and preparedness still remain. 

This statement covers six thematic areas: (1) leadership, authority, 
and coordination; (2) detecting threats and managing risks; (3) 
planning, training, and exercising; (4) capacity to respond and 
recover; (5) information sharing and communication; and (6) performance 
and accountability. 

What GAO Found: 

* Leadership roles and responsibilities for an influenza pandemic need 
to be clarified, tested, and exercised, and existing coordination 
mechanisms, such as critical infrastructure coordinating councils, 
could be better utilized to address challenges in coordination between 
the federal, state, and local governments and the private sector in 
preparing for a pandemic. 

* Efforts are underway to improve the surveillance and detection of 
pandemic-related threats, but targeting assistance to countries at the 
greatest risk has been based on incomplete information, particularly 
from developing countries. 

* Pandemic planning and exercising has occurred at the federal, state, 
and local government levels, but important planning gaps remain at all 
levels of government. At the federal level, agency planning to maintain 
essential operations and services while protecting their employees in 
the event of a pandemic is uneven. 

* Further actions are needed to address the capacity to respond to and 
recover from an influenza pandemic, which will require additional 
capacity in patient treatment space, and the acquisition and 
distribution of medical and other critical supplies, such as antivirals 
and vaccines. 

* Federal agencies have provided considerable guidance and pandemic-
related information to state and local governments, but could augment 
their efforts with additional information on school closures, state 
border closures, and other topics. 

* Performance monitoring and accountability for pandemic preparedness 
needs strengthening. For example, the May 2006 National Strategy for 
Pandemic Influenza Implementation Plan does not establish priorities 
among its 324 action items and does not provide information on the 
financial resources needed to implement them. Also, greater agency 
accountability is needed to protect federal workers in the event of a 
pandemic because there is no mechanism in place to monitor and report 
on agenciesí progress in developing workforce pandemic plans. 

The current H1N1 pandemic should serve as a powerful reminder that the 
threat of a pandemic influenza, which seemed to fade from public 
awareness in recent years, never really disappeared. While federal 
agencies have taken action on 13 of GAOís 24 recommendations, 11 of the 
recommendations that GAO has made over the past 3 years have not been 
fully implemented. With the possibility that the H1N1 virus could 
become more virulent this fall or winter, the administration and 
federal agencies should use this time to turn their attention to 
filling in the planning and preparedness gaps GAOís work has pointed 
out. 

What GAO Recommends: 

This statement discusses the status of GAOís prior recommendations on 
the nationís planning and preparedness for a pandemic. Key open 
recommendations concern the need to exercise the shared federal 
leadership roles for a pandemic, address planning gaps at all levels of 
government and in the private sector, and monitor and report on 
agenciesí plans to protect their workers. 

View [hyperlink, http://www.gao.gov/products/GAO-09-909T] or key 
components. For more information, contact Bernice Steinhardt at (202) 
512-6543 or steinhardtb@gao.gov. 

[End of section] 

Mr. Chairman and Members of the Committee: 

I am pleased to be here today to discuss key themes from the body of 
work GAO has developed over the past several years to help the nation 
better prepare for, respond to, and recover from a possible influenza 
pandemic. An influenza pandemic remains a real threat to our nation and 
to the world, as we are witnessing during the current H1N1 pandemic. 
The previous administration took a number of actions to plan for a 
pandemic, including developing a national strategy and implementation 
plan. However, much more needs to be done, and many gaps in planning 
and preparedness still remain. Strengthening preparedness for large- 
scale public health emergencies, such as an influenza pandemic, is one 
of 13 urgent issues that we identified earlier this year as among those 
needing the immediate attention of the new administration and Congress. 
[Footnote 1] 

In the past 3 years, GAO has issued 12 reports and 4 testimonies on 
influenza pandemic planning.[Footnote 2] We synthesized the results of 
most of our work in a February 2009 report, which I will discuss in 
more detail today.[Footnote 3] In addition, I will discuss key results 
from our recent report on protecting the federal workforce in the event 
of a pandemic.[Footnote 4] We have made 24 recommendations based on the 
findings from these reports, 13 of which have been acted upon by the 
responsible federal agencies. The responsible federal agencies have 
generally agreed with our recommendations and some actions are underway 
to address them. However, 11 recommendations have not yet been fully 
implemented. While our February 2009 report made no new 
recommendations, it reflects the status of those recommendations that 
were made prior to our June 2009 report that had not yet been 
implemented. Many of the recommendations that remain unimplemented have 
become even more pressing in light of the very real possibility of the 
return of a more severe form of the H1N1 virus later this year. Lists 
of our open recommendations and related GAO products that are 
referenced throughout this statement are located in attachments I and 
II. 

In summary, my statement will address the following issues which were 
drawn from the key themes of GAO's pandemic work: 

* Leadership roles and responsibilities for an influenza pandemic need 
to be clarified, tested, and exercised, and existing coordination 
mechanisms, such as critical infrastructure coordinating councils, 
could be better utilized to address challenges in coordination between 
the federal, state, and local governments and the private sector in 
preparing for a pandemic. 

* Efforts are underway to improve the surveillance and detection of 
pandemic-related threats in humans and animals, but targeting 
assistance to countries at the greatest risk has been based on 
incomplete information, particularly from developing countries. 

* Pandemic planning and exercising have occurred at the federal, state, 
and local government levels, but important planning gaps remain at all 
levels of government. At the federal level, agency planning to maintain 
essential operations and services while protecting their employees in 
the event of a pandemic is uneven. 

* Further actions are needed to address the capacity to respond to and 
recover from an influenza pandemic, which will require additional 
capacity in patient treatment space, and the acquisition and 
distribution of medical and other critical supplies, such as antivirals 
and vaccines. 

* Federal agencies have provided considerable guidance and pandemic- 
related information to state and local governments, but could augment 
their efforts with additional information on school closures, state 
border closures, and other topics. 

* Performance monitoring and accountability for pandemic preparedness 
needs strengthening. For example, the May 2006 National Strategy for 
Pandemic Influenza Implementation Plan (National Pandemic 
Implementation Plan) does not establish priorities among its 324 action 
items and does not provide information on the financial resources 
needed to implement them. Also, greater agency accountability is needed 
to protect federal workers in the event of a pandemic because there is 
no mechanism in place to monitor and report on agencies' progress in 
developing workforce pandemic plans that provide the operational 
details of how agencies will protect their employees and maintain 
essential operations and services. 

As noted earlier, this statement is based on our prior work, which was 
conducted in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

Background: 

Given the consequences of a severe influenza pandemic, in 2006, GAO 
developed a strategy for our work that would help support Congress's 
decision making and oversight related to pandemic planning. Our 
strategy was built on a large body of work spanning two decades, 
including reviews of government responses to prior disasters such as 
Hurricanes Andrew and Katrina, the devastation caused by the 9/11 
terror attacks, efforts to address the Year 2000 (Y2K) computer 
challenges, and assessments of public health capacities in the face of 
bioterrorism and emerging infectious diseases such as Severe Acute 
Respiratory Syndrome (SARS). The strategy was built around six key 
themes as shown in figure 1. While all of these themes are 
interrelated, our earlier work underscored the importance of 
leadership, authority, and coordination, a theme that touches on all 
aspects of preparing for, responding to, and recovering from an 
influenza pandemic. 

Figure 1: Key Themes of GAO's Pandemic Strategy: 

[Refer to PDF for image: illustration] 

Performance and accountability; 
Information sharing and communication; 
Leadership, authority, and coordination; 
Capacity to respond and recover; 
Planning, training, and exercising; 
Detecting threats and managing risks. 

Source: GAO. 

[End of figure] 

Influenza pandemic--caused by a novel strain of influenza virus for 
which there is little resistance and which therefore is highly 
transmissible among humans--continues to be a real and significant 
threat facing the United States and the world. Unlike incidents that 
are discretely bounded in space or time (e.g., most natural or man-made 
disasters), an influenza pandemic is not a singular event, but is 
likely to come in waves, each lasting weeks or months, and pass through 
communities of all sizes across the nation and the world 
simultaneously. However, the current H1N1 pandemic seems to be 
relatively mild, although widespread. The history of an influenza 
pandemic suggests it could return in a second wave this fall or winter 
in a more virulent form.[Footnote 5] While a pandemic will not directly 
damage physical infrastructure such as power lines or computer systems, 
it threatens the operation of critical systems by potentially removing 
the essential personnel needed to operate them from the workplace for 
weeks or months. In a severe pandemic, absences attributable to 
illnesses, the need to care for ill family members, and fear of 
infection may, according to the Centers for Disease Control and 
Prevention (CDC), reach a projected 40 percent during the peak weeks of 
a community outbreak, with lower rates of absence during the weeks 
before and after the peak.[Footnote 6] In addition, an influenza 
pandemic could result in 200,000 to 2 million deaths in the United 
States, depending on its severity. 

The President's Homeland Security Council (HSC) took an active approach 
to this potential disaster by, among other things, issuing the National 
Strategy for Pandemic Influenza (National Pandemic Strategy) in 
November 2005, and the National Pandemic Implementation Plan in May 
2006.[Footnote 7] The National Pandemic Strategy is intended to provide 
a high-level overview of the approach that the federal government will 
take to prepare for and respond to an influenza pandemic. It also 
provides expectations for nonfederal entities--including state, local, 
and tribal governments; the private sector; international partners; and 
individuals--to prepare themselves and their communities. The National 
Pandemic Implementation Plan is intended to lay out broad 
implementation requirements and responsibilities among the appropriate 
federal agencies and clearly define expectations for nonfederal 
entities. The Plan contains 324 action items related to these 
requirements, responsibilities, and expectations, most of which were to 
be completed before or by May 2009. HSC publicly reported on the status 
of the action items that were to be completed by 6 months, 1 year, and 
2 years in December 2006, July 2007, and October 2008 respectively. HSC 
indicated in its October 2008 progress report that 75 percent of the 
action items have been completed. We have ongoing work for this 
committee assessing the status of implementing this plan which we 
expect to report on in the fall of 2009. 

Leadership Roles and Responsibilities Need to Be Clarified and Tested, 
and Coordination Mechanisms Could Be Better Utilized: 

Federal government leadership roles and responsibilities for pandemic 
preparedness and response are evolving, and will require further 
testing before the relationships among the many federal leadership 
positions are well understood. Such clarity in leadership is even more 
crucial now, given the change in administration and the associated 
transition of senior federal officials. Most of these federal 
leadership roles involve shared responsibilities between the Department 
of Health and Human Services (HHS) and the Department of Homeland 
Security (DHS), and it is not clear how these would work in practice. 
According to the National Pandemic Strategy and Plan, the Secretary of 
Health and Human Services is to lead the federal medical response to a 
pandemic, and the Secretary of Homeland Security will lead the overall 
domestic incident management and federal coordination. In addition, 
under the Post-Katrina Emergency Management Reform Act of 2006, the 
Administrator of the Federal Emergency Management Agency (FEMA) was 
designated as the principal domestic emergency management advisor to 
the President, the HSC, and the Secretary of Homeland Security, adding 
further complexity to the leadership structure in the case of a 
pandemic.[Footnote 8] To assist in planning and coordinating efforts to 
respond to a pandemic, in December 2006 the Secretary of Homeland 
Security predesignated a national Principal Federal Official (PFO) for 
influenza pandemic and established five pandemic regions each with a 
regional PFO and Federal Coordinating Officers (FCO) for influenza 
pandemic. PFOs are responsible for facilitating federal domestic 
incident planning and coordination, and FCOs are responsible for 
coordinating federal resources support in a presidentially declared 
major disaster or emergency. 

However, the relationship of these roles to each other as well as with 
other leadership roles in a pandemic is unclear. Moreover, as we 
testified in July 2007, state and local first responders were still 
uncertain about the need for both FCOs and PFOs and how they would work 
together in disaster response.[Footnote 9] Accordingly, we recommended 
in our August 2007 report on federal leadership roles and the National 
Pandemic Strategy that DHS and HHS develop rigorous testing, training, 
and exercises for influenza pandemic to ensure that federal leadership 
roles and responsibilities for a pandemic are clearly defined and 
understood and that leaders are able to effectively execute shared 
responsibilities to address emerging challenges.[Footnote 10] In 
response to our recommendation, HHS and DHS officials stated in January 
2009 that several influenza pandemic exercises had been conducted since 
November 2007 that involved both agencies and other federal officials, 
but it is unclear whether these exercises rigorously tested federal 
leadership roles in a pandemic. 

In addition to concerns about clarifying federal roles and 
responsibilities for a pandemic and how shared leadership roles would 
work in practice, private sector officials told us that they are 
unclear about the respective roles and responsibilities of the federal 
and state governments during a pandemic emergency. The National 
Pandemic Implementation Plan states that in the event of an influenza 
pandemic, the distributed nature and sheer burden of the disease across 
the nation would mean that the federal government's support to any 
particular community is likely to be limited, with the primary response 
to a pandemic coming from states and local communities. Further, 
federal and private sector representatives we interviewed at the time 
of our October 2007 report identified several key challenges they face 
in coordinating federal and private sector efforts to protect the 
nation's critical infrastructure in the event of an influenza 
pandemic.[Footnote 11] One of these was a lack of clarity regarding the 
roles and responsibilities of federal and state governments on issues 
such as state border closures and influenza pandemic vaccine 
distribution. 

Coordination Mechanisms: 

Mechanisms and networks for collaboration and coordination on pandemic 
preparedness between federal and state governments and the private 
sector exist, but they could be better utilized. In some instances, the 
federal and private sectors are working together through a set of 
coordinating councils, including sector-specific and cross-sector 
councils. To help protect the nation's critical infrastructure, DHS 
created these coordinating councils as the primary means of 
coordinating government and private sector efforts for industry sectors 
such as energy, food and agriculture, telecommunications, 
transportation, and water.[Footnote 12] Our October 2007 report found 
that DHS has used these critical infrastructure coordinating councils 
primarily to share pandemic information across sectors and government 
levels rather than to address many of the challenges identified by 
sector representatives, such as clarifying the roles and 
responsibilities between federal and state governments.[Footnote 13] We 
recommended in the October 2007 report that DHS encourage the councils 
to consider and address the range of coordination challenges in a 
potential influenza pandemic between the public and private sectors for 
critical infrastructure. DHS concurred with our recommendation and DHS 
officials informed us at the time of our February 2009 report that the 
department was working on initiatives to address it, such as developing 
pandemic contingency plan guidance tailored to each of the critical 
infrastructure sectors, and holding a series of "webinars" with a 
number of the sectors. 

Federal executive boards (FEB) bring together federal agency and 
community leaders in major metropolitan areas outside of Washington, 
D.C., to discuss issues of common interest, including an influenza 
pandemic. The Office of Personnel Management (OPM), which provides 
direction to the FEBs, and the FEBs have designated emergency 
preparedness, security, and safety as an FEB core function. The FEB's 
emergency support role with its regional focus may make the boards a 
valuable asset in pandemic preparedness and response. As a natural 
outgrowth of their general civic activities and through activities such 
as hosting emergency preparedness training, some of the boards have 
established relationships with, for example, federal, state, and local 
governments; emergency management officials; first responders; and 
health officials in their communities. In a May 2007 report on the 
FEBs' ability to contribute to emergency operations, we found that many 
of the selected FEBs included in our review were building capacity for 
influenza pandemic response within their member agencies and community 
organizations by hosting influenza pandemic training and exercises. 
[Footnote 14] We recommended that, since FEBs are well positioned 
within local communities to bring together federal agency and community 
leaders, the Director of OPM work with FEMA to formally define the 
FEBs' role in emergency planning and response. As a result of our 
recommendation, FEBs were included in the National Response Framework 
(NRF)[Footnote 15] in January 2008 as one of the regional support 
structures that have the potential to contribute to development of 
situational awareness during an emergency. OPM and FEMA also signed a 
memorandum of understanding in August 2008 in which FEBs and FEMA 
agreed to work collaboratively in carrying out their respective roles 
in the promotion of the national emergency response system. 

Efforts Are Underway to Improve the Surveillance and Detection Of 
Pandemic-Related Threats, but Targeting Assistance to Countries at the 
Greatest Risk Has Been Based on Incomplete Information: 

International disease surveillance and detection efforts serve as an 
early warning system that could prevent the spread of an influenza 
pandemic outbreak. The United States and its international partners are 
involved in efforts to improve pandemic surveillance, including 
diagnostic capabilities, so that outbreaks can be quickly detected. 
Yet, as reported in 2007, international capacity for surveillance has 
many weaknesses, particularly in developing countries.[Footnote 16] As 
a result, assessments of the risks of the emergence of influenza 
pandemic by U.S. agencies and international organizations, which were 
used to target assistance to countries at risk, were based on 
insufficiently detailed or incomplete information, limiting their value 
for comprehensive comparisons of risk levels by country. 

Pandemic Planning and Exercising Has Occurred, but Planning Gaps 
Remain: 

The National Pandemic Strategy and National Pandemic Implementation 
Plan are important first steps in guiding national preparedness. 
However, important gaps exist that could hinder the ability of key 
stakeholders to effectively execute their responsibilities. In our 
August 2007 report on the National Pandemic Strategy and Implementation 
Plan, we found that while these documents are an important first step 
in guiding national preparedness, they do not fully address all six 
characteristics of an effective national strategy, as identified in our 
work.[Footnote 17] The documents fully address only one of the six 
characteristics, by reflecting a clear description and understanding of 
problems to be addressed. Further, the National Pandemic Strategy and 
Implementation Plan do not address one characteristic at all, 
containing no discussion of what it will cost, where resources will be 
targeted to achieve the maximum benefits, and how it will balance 
benefits, risks, and costs. Moreover, the documents do not provide a 
picture of priorities or how adjustments might be made in view of 
resource constraints. Although the remaining four characteristics are 
partially addressed, important gaps exist that could hinder the ability 
of key stakeholders to effectively execute their responsibilities. For 
example, state and local jurisdictions that will play crucial roles in 
preparing for and responding to a pandemic were not directly involved 
in developing the National Pandemic Implementation Plan, even though it 
relies on these stakeholders' efforts. Stakeholder involvement during 
the planning process is important to ensure that the federal 
government's and nonfederal entities' responsibilities are clearly 
understood and agreed upon. Further, relationships and priorities among 
actions were not clearly described, performance measures were not 
always linked to results, and insufficient information was provided 
about how the documents are integrated with other response-related 
plans, such as the NRF. We recommended that the HSC establish a process 
for updating the National Pandemic Implementation Plan and that the 
updated plan should address these and other gaps. HSC did not comment 
on our recommendation and has not indicated if it plans to implement 
it. 

Federal Workforce Pandemic Planning: 

The National Pandemic Implementation Plan required federal agencies to 
develop operational plans for protecting their employees and 
maintaining essential operations and services in the event of a 
pandemic. In our June 2009 report, we found that federal agency 
progress in pandemic planning is uneven.[Footnote 18] We surveyed the 
pandemic coordinators from the 24 agencies covered by the Chief 
Financial Officers Act of 1990, which we supplemented with a case study 
approach of 3 agencies.[Footnote 19] We used the survey to get an 
overview of governmentwide pandemic influenza preparedness efforts. The 
survey questions asked about pandemic plans; essential functions other 
than first response that employees cannot perform remotely; protective 
measures, such as procuring pharmaceutical interventions; social 
distancing strategies;[Footnote 20] information technology testing; and 
communication of human capital pandemic policies. Although all of the 
surveyed agencies reported being engaged in planning for pandemic 
influenza to some degree, several agencies reported that they were 
still in the early stages of developing their pandemic plans and their 
measures to protect their workforce. For example, several agencies 
responded that they had yet to identify essential functions during a 
pandemic that cannot be performed remotely. And, although many of the 
agencies' pandemic plans rely on telework to carry out their functions, 
5 agencies reported testing their information technology capability to 
little or no extent. 

The three case study agencies also showed differences in the degree to 
which their individual facilities had operational pandemic plans. The 
Bureau of Prisons' correctional workers had only recently been required 
to develop pandemic plans for their correctional facilities. The 
Department of Treasury's Financial Management Service, which has 
production staff involved in disbursing federal payments such as Social 
Security checks, had pandemic plans for its four regional centers and 
had stockpiled personal protective equipment. By contrast, the Federal 
Aviation Administration's air traffic control management facilities, 
where air traffic controllers work, had not yet developed facility 
pandemic plans or incorporated pandemic plans into their all-hazards 
contingency plans. 

State and Local Pandemic Planning: 

We reported in June 2008 that, according to CDC, all 50 states and the 
3 localities that received federal pandemic funds have developed 
influenza pandemic plans and conducted pandemic exercises in accordance 
with federal funding guidance.[Footnote 21] A portion of the $5.62 
billion that Congress appropriated in supplemental funding to HHS for 
pandemic preparedness in 2006--$600 million--was specifically provided 
for state and local planning and exercising. All 10 localities that we 
reviewed in depth had also developed plans and conducted exercises, and 
had incorporated lessons learned from pandemic exercises into their 
planning.[Footnote 22] However, an HHS-led interagency assessment of 
states' plans found on average that states had "many major gaps" in 
their influenza pandemic plans in 16 of 22 priority areas, such as 
school closure policies and community containment, which are community- 
level interventions designed to reduce the transmission of a pandemic 
virus. The remaining 6 priority areas were rated as having "a few major 
gaps." Subsequently, HHS led another interagency assessment of state 
influenza pandemic plans and reported in January 2009 that although 
they had made important progress, most states still had major gaps in 
their pandemic plans.[Footnote 23] 

As we had reported in June 2008, HHS, in coordination with DHS and 
other federal agencies, had convened a series of regional workshops for 
states in five influenza pandemic regions across the country.[Footnote 
24] Because these workshops could be a useful model for sharing 
information and building relationships, we recommended that HHS and 
DHS, in coordination with other federal agencies, convene additional 
meetings with states to address the gaps in the states' pandemic plans. 
As reported in February 2009, HHS and DHS generally concurred with our 
recommendation, but have not yet held these additional meetings. 
[Footnote 25] HHS and DHS indicated at the time of our February 2009 
report that while no additional meetings had been planned, states will 
have to continuously update their pandemic plans and submit them for 
review. 

We have also reported on the need for more guidance from the federal 
government to help states and localities in their planning. In June 
2008, we reported that although the federal government has provided a 
variety of guidance, officials of the states and localities we reviewed 
told us that they would welcome additional guidance from the federal 
government in a number of areas, such as community containment, to help 
them to better plan and exercise for an influenza pandemic.[Footnote 
26] Other state and local officials have identified similar concerns. 
According to the National Governors Association's (NGA) September 2008 
issue brief on states' pandemic preparedness, states are concerned 
about a wide range of school-related issues, including when to close 
schools or dismiss students, how to maintain curriculum continuity 
during closures, and how to identify the appropriate time at which 
classes could resume.[Footnote 27] NGA also reported that states 
generally have very little awareness of the status of disease 
outbreaks, either in real time or in near real time, to allow them to 
know precisely when to recommend a school closure or reopening in a 
particular area. NGA reported that states wanted more guidance in the 
following areas: (1) workforce policies for the health care, public 
safety, and private sectors; (2) schools; (3) situational awareness 
such as information on the arrival or departure of a disease in a 
particular state, county, or community; (4) public involvement; and (5) 
public-private sector engagement. 

Private Sector Pandemic Planning: 

The private sector has also been planning for an influenza pandemic, 
but many challenges remain. To better protect critical infrastructure, 
federal agencies and the private sector have worked together across a 
number of sectors to plan for a pandemic, including developing general 
pandemic preparedness guidance, such as checklists for continuity of 
business operations during a pandemic. However, federal and private 
sector representatives have acknowledged that sustaining preparedness 
and readiness efforts for an influenza pandemic is a major challenge, 
primarily because of the uncertainty associated with a pandemic, 
limited financial and human resources, and the need to balance pandemic 
preparedness with other, more immediate, priorities, such as responding 
to outbreaks of foodborne illnesses in the food sector and, now, the 
effects of the financial crisis. 

In our March 2007 report on preparedness for an influenza pandemic in 
one of these critical infrastructure sectors--financial markets--we 
found that despite significant progress in preparing markets to 
withstand potential disease pandemics, securities and banking 
regulators could take additional steps to improve the readiness of the 
securities markets.[Footnote 28] The seven organizations that we 
reviewed--which included exchanges, clearing organizations, and payment-
system processors--were working on planning and preparation efforts to 
reduce the likelihood that a worldwide influenza pandemic would disrupt 
their critical operations. However, only one of the seven had completed 
a formal plan. To increase the likelihood that the securities markets 
will be able to function during a pandemic, we recommended that the 
Chairman, Federal Reserve; the Comptroller of the Currency; and the 
Chairman, Securities and Exchange Commission (SEC), consider taking 
additional actions to ensure that market participants adequately 
prepare for a pandemic outbreak. In response to our recommendation, the 
Federal Reserve and the Office of the Comptroller of the Currency, in 
conjunction with the Federal Financial Institutions Examination Council 
and the SEC directed all banking organizations under their supervision 
to ensure that the pandemic plans the financial institutions have in 
place are adequate to maintain critical operations during a severe 
outbreak. SEC issued similar requirements to the major securities 
industry market organizations. 

Further Actions Are Needed to Address the Capacity to Respond to and 
Recover from an Influenza Pandemic: 

Improving the nation's response capability to catastrophic disasters, 
such as an influenza pandemic, is essential. Following a mass casualty 
event, health care systems would need the ability to adequately care 
for a large number of patients or patients with unusual or highly 
specialized medical needs. The ability of local or regional health care 
systems to deliver services could be compromised, at least in the short 
term, because the volume of patients would far exceed the available 
hospital beds, medical personnel, pharmaceuticals, equipment, and 
supplies. Further, in natural and man-made disasters, assistance from 
other states may be used to increase capacity, but in a pandemic, 
states would likely be reluctant to provide assistance to each other 
due to scarce resources and fears of infection. 

Over the last few years, Congress has provided over $13 billion in 
supplemental funding for pandemic preparedness. The $5.62 billion that 
Congress provided in supplemental funding to HHS in 2006 was for, among 
other things, (1) monitoring disease spread to support rapid response, 
(2) developing vaccines and vaccine production capacity, (3) 
stockpiling antivirals and other countermeasures, (4) upgrading state 
and local capacity, and (5) upgrading laboratories and research at 
CDC.[Footnote 29] The majority of this supplemental funding--about 77 
percent--was allocated for developing antivirals and vaccines for a 
pandemic, and purchasing medical supplies. Also, a portion of the 
funding that went to states and localities for preparedness activities--
$170 million--was allocated for state antiviral purchases for their 
state stockpiles. In June 2009, Congress approved and the President 
signed a supplemental appropriations act that included $7.7 billion for 
pandemic flu preparedness, including the development and purchase of 
vaccine, antivirals, necessary medical supplies, diagnostics, and other 
surveillance tools and to assist international efforts and respond to 
international needs relating to the 2009-H1N1 influenza outbreak. 
[Footnote 30] This amount included $1.85 billion to be available 
immediately and $5.8 billion to be available subsequently in the 
amounts designated by the President as emergency funding requirements. 
On July 10, 2009, HHS announced its plans to use the $350 million 
designated for upgrading state and local capacity for additional grants 
to states and territories to prepare for the H1N1 pandemic and seasonal 
influenza. State public health departments will receive $260 million, 
and hospitals will receive $90 million of these grant funds. 

An outbreak will require additional capacity in many areas, including 
the procurement of additional patient treatment space and the 
acquisition and distribution of medical and other critical supplies, 
such as antivirals and vaccines for an influenza pandemic.[Footnote 31] 
In a severe pandemic, the demand would exceed the available hospital 
bed capacity, which would be further challenged by the existing 
shortages of health care providers and their potential high rates of 
absenteeism. In addition, the availability of antivirals and vaccines 
could be inadequate to meet demand due to limited production, 
distribution, and administration capacity. 

The federal government has provided some guidance in addition to 
funding to help states plan for additional capacity. For example, the 
federal government provided guidance for states to use when preparing 
for medical surge and on prioritizing target groups for an influenza 
pandemic vaccine. Some state officials reported, however, that they had 
not begun work on altered standards of care guidelines, that is, for 
providing care while allocating scarce equipment, supplies, and 
personnel in a way that saves the largest number of lives in mass 
casualty event, or had not completed drafting guidelines, because of 
the difficulty of addressing the medical, ethical, and legal issues 
involved. We recommended that HHS serve as a clearinghouse for sharing 
among the states altered standards of care guidelines developed by 
individual states or medical experts. HHS did not comment on the 
recommendation, and it has not indicated if it plans to implement 
it.[Footnote 32] Further, in our June 2008 report on state and local 
planning and exercising efforts for an influenza pandemic, we found 
that state and local officials reported that they wanted federal 
influenza pandemic guidance on facilitating medical surge, which was 
also one of the areas that the HHS-led assessment rated as having "many 
major gaps" nationally among states' influenza pandemic plans.[Footnote 
33] 

Federal Agencies Have Provided Considerable Guidance and Pandemic- 
Related Information, but Could Augment Their Efforts: 

The National Pandemic Implementation Plan emphasizes that government 
and public health officials must communicate clearly and continuously 
with the public throughout a pandemic. Accordingly, HHS, DHS, and other 
federal agencies have shared pandemic-related information in a number 
of ways, such as through Web sites, guidance, and state summits and 
meetings, and are using established networks, including coordinating 
councils for critical infrastructure protection, to share information 
about pandemic preparedness, response, and recovery. Federal agencies 
have established an influenza pandemic Web site [hyperlink, 
http://www.pandemicflu.gov] and disseminated pandemic preparedness 
checklists for workplaces, individuals and families, schools, health 
care, community organizations, and state and local governments. 

However, state and local officials from all of the states and 
localities we interviewed for our June 2008 report on state and local 
pandemic planning and exercising, wanted additional influenza pandemic 
guidance from the federal government on specific topics, on how to 
implement community interventions such as closing schools, fatality 
management, and facilitating medical surge. Although the federal 
government had issued some guidance at the time of our review, it may 
not have reached state and local officials or may not have addressed 
the particular concerns or circumstances of the state and local 
officials we interviewed. More recently, CDC has issued additional 
guidance on a number of topics related to responding to the H1N1 
outbreak. CDC issued interim guidance on school closures which 
originally recommended that schools with confirmed H1N1 influenza 
close. Once it became more clear that the disease severity of H1N1 was 
similar to that of seasonal influenza and that the virus had already 
spread within communities, CDC determined that school closure would be 
less effective as a measure of control and issued updated guidance 
recommending that schools not close for suspected or confirmed cases of 
influenza.[Footnote 34] However, the change in guidance caused 
confusion, underscoring the importance of clear and continuous 
communication with the public throughout a pandemic. In addition, 
private sector officials have told us that they would like 
clarification about the respective roles and responsibilities of the 
federal and state governments during an influenza pandemic emergency, 
such as in state border closures and influenza pandemic vaccine 
distribution. 

Performance Monitoring and Accountability for Pandemic Preparedness 
Needs Strengthening: 

While the National Pandemic Strategy and Implementation Plan identify 
overarching goals and objectives for pandemic planning, the documents 
are not altogether clear on the roles, responsibilities, and 
requirements to carry out the plan. Some of the action items in the 
National Pandemic Implementation Plan, particularly those that are to 
be completed by state, local, and tribal governments or the private 
sector, do not identify an entity responsible for carrying out the 
action. Most of the implementation plan's performance measures consist 
of actions to be completed, such as disseminating guidance, but the 
measures are not always clearly linked with intended results. 

For example, one action item asked that all HHS-, Department of 
Defense- and Veterans Administration-funded hospitals and health 
facilities develop, test, and be prepared to implement infection 
control campaigns for pandemic influenza within 3 months. However, the 
associated performance measure is not clearly linked to the intended 
result. This performance measure states that infection control guidance 
should be developed and disseminated on [hyperlink, 
http://www.pandemicflu.gov] and other channels.[Footnote 35] This 
action would not directly result in developing, testing, and preparing 
to implement infection control campaigns. This lack of clear linkage 
makes it difficult to ascertain whether progress has in fact been made 
toward achieving the national goals and objectives described in the 
National Pandemic Strategy and Implementation Plan. Without a clear 
linkage to anticipated results, these measures of activities do not 
give an indication of whether the purpose of the activity is achieved. 
In addition, as discussed earlier, the National Pandemic Implementation 
Plan does not establish priorities among its 324 action items, which 
becomes especially important as agencies and other parties strive to 
effectively manage scarce resources and ensure that the most important 
steps are accomplished. Moreover, the National Pandemic Strategy and 
its Implementation Plan do not provide information on the financial 
resources needed to implement them, which is one of six characteristics 
of an effective national strategy that we have identified. As a result, 
the documents do not provide a picture of priorities or how adjustments 
might be made in view of resource constraints. 

As discussed earlier, the National Pandemic Implementation Plan also 
required federal agencies to develop operational pandemic plans to 
describe, among other requirements, how each agency will protect its 
workforce and maintain essential operations and services in the event 
of a pandemic. [Footnote 36] We recently reported, however, that there 
is no mechanism in place to monitor and report on agencies' progress in 
developing these plans. Under the Implementation Plan, DHS was charged 
with this responsibility, but instead the HSC simply requested that 
agencies certify to the council that they were addressing in their 
plans the applicable elements of a pandemic checklist. The 
certification process did not provide for monitoring and reporting on 
agencies' abilities to continue operations in the event of a pandemic 
while protecting their employees. Moreover, even as envisioned under 
the Implementation Plan, the report was to be directed to the Executive 
Office of the President with no provision for the report to be made 
available to Congress. 

As noted earlier, given agencies' uneven progress in developing their 
pandemic plans, monitoring and reporting would enhance agencies' 
accountability to protect their employees during a pandemic. We 
therefore recommended that the HSC request that the Secretary of 
Homeland Security monitor and report to the Executive Office of the 
President on the readiness of agencies to continue their operations 
while protecting their employees in the event of a pandemic. We also 
suggested that to help support its oversight responsibilities, Congress 
may want to consider requiring DHS to report to it on agencies' 
progress in developing and implementing their plans, including any key 
challenges and gaps in the plans. The HSC noted that it will give 
serious consideration to the report findings and recommendations, and 
DHS said the report findings and recommendations will contribute to its 
efforts to ensure that government entities are well prepared for what 
may come next. 

Concluding Observations: 

The current H1N1 influenza pandemic should serve as a powerful reminder 
that the threat of a more virulent pandemic, which seemed to fade from 
public awareness in recent years, never really disappeared. While 
federal agencies have taken action on many of our recommendations, 
about half the recommendations that we have made over the past 3 years 
are still not fully implemented. It is essential, given the change in 
administration and the associated transition of senior federal 
officials, that the shared leadership roles that have been established 
between HHS and DHS, along with other responsible federal officials, 
are tested in rigorous tests and exercises. Likewise, DHS should 
continue to work with other federal agencies and private sector members 
of the critical infrastructure coordinating councils to help address 
the challenges of coordination and clarify roles and responsibilities 
of federal and state governments. DHS and HHS should also, in 
coordination with other federal agencies, continue to work with states 
and local governments to help them address identified gaps in their 
pandemic planning. Moreover, the 3-year period covered by the National 
Pandemic Implementation Plan is now over and it will be important for 
HSC to establish a process for updating the National Pandemic 
Implementation Plan so that the updated plan can address the gaps we 
have identified, as well as lessons learned from the current H1N1 
outbreak. Finally, greater monitoring and reporting of agencies' 
progress in plans to protect their workers during a pandemic are needed 
to insure the readiness of agencies to continue operations while 
protecting their employees in the event of a pandemic. 

Pandemic influenzas, as I noted earlier, differ from other types of 
disasters in that they are not necessarily discrete events. While the 
current H1N1 pandemic seems to be relatively mild, the virus could 
become more virulent this fall or winter. Given this risk, the 
administration and federal agencies should use this opportunity to turn 
their attention to filling in some of the planning and preparedness 
gaps our work has pointed out, while time is still on our side. 

Chairman Thompson and Members of the Committee, this concludes my 
prepared statement. I would be happy to respond to any questions you 
may have. 

Contacts and Staff Acknowledgements: 

For further information regarding this statement, please contact 
Bernice Steinhardt, Director, Strategic Issues, at (202) 512-6543 or 
steinhardtb@gao.gov. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
statement. Individuals making key contributions to this testimony 
include Sarah Veale, (Assistant Director), Maya Chakko, David Fox, Bill 
Doherty, Ellen Grady, Karin Fangman, and members of GAO's Pandemic 
Working Group. 

[End of section] 

Attachment I: Open Recommendations from GAO's Work on an Influenza 
Pandemic: 

Title and GAO product number: 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], June 12, 2009; 
Summary of open recommendations: The Homeland Security Council should 
request that the Secretary of Homeland Security monitor and report to 
the Executive Office of the President on the readiness of agencies to 
continue their operations while protecting their employees in the event 
of an influenza pandemic; 
Status: The Homeland Security Council commented that the council will 
give serious consideration to the report's findings and 
recommendations. DHS commented that the report's findings and 
recommendations will contribute to its efforts to ensure that 
government entities are well prepared for what may come next. 

Title and GAO product number: Influenza Pandemic: HHS Needs to Continue 
Its Actions and Finalize Guidance for Pharmaceutical Interventions, 
[hyperlink, http://www.gao.gov/products/GAO-08-671], September 30, 
2008; 
Summary of open recommendations: The Secretary of Health and Human 
Services should expeditiously finalize guidance to assist state and 
local jurisdictions to determine how to effectively use limited 
supplies of antivirals and pre-pandemic vaccine in a pandemic, 
including prioritizing target groups for pre-pandemic vaccine; 
Status: In December 2008, HHS released final guidance on antiviral drug 
use during an influenza pandemic. HHS officials informed us that they 
are drafting the guidance on pre-pandemic influenza vaccination. 

Title and GAO product number: Influenza Pandemic: Federal Agencies 
Should Continue to Assist States to Address Gaps in Pandemic Planning, 
[hyperlink, http://www.gao.gov/products/GAO-08-539], June 19, 2008; 
Summary of open recommendations: The Secretaries of Health and Human 
Services and Homeland Security should, in coordination with other 
federal agencies, convene additional meetings of the states in the five 
federal influenza pandemic regions to help them address identified gaps 
in their planning; 
Status: HHS and DHS officials indicated that while no additional 
meetings are planned at this time, states will have to continuously 
update their pandemic plans and submit them for review. 

Title and GAO product number: Influenza Pandemic: Opportunities Exist 
to Address Critical Infrastructure Protection Challenges That Require 
Federal and Private Sector Coordination, [hyperlink, 
http://www.gao.gov/products/GAO-08-36], October 31, 2007; 
Summary of open recommendations: The Secretary of Homeland Security 
should work with sector-specific agencies and lead efforts to encourage 
the government and private sector members of the councils to consider 
and help address the challenges that will require coordination between 
the federal and private sectors involved with critical infrastructure 
and within the various sectors, in advance of, as well as during, a 
pandemic; 
Status: DHS officials informed us that the department is working on 
initiatives, such as developing pandemic contingency plan guidance 
tailored to each of the critical infrastructure sectors, and holding a 
series of webinars with a number of the sectors. 

Title and GAO product number: Influenza Pandemic: Further Efforts Are 
Needed to Ensure Clearer Federal Leadership Roles and an Effective 
National Strategy, [hyperlink, http://www.gao.gov/products/GAO-07-781], 
August 14, 2007; 
Summary of open recommendations: (1) The Secretaries of Homeland 
Security and Health and Human Services should work together to develop 
and conduct rigorous testing, training, and exercises for an influenza 
pandemic to ensure that the federal leadership roles are clearly 
defined and understood and that leaders are able to effectively execute 
shared responsibilities to address emerging challenges. Once the 
leadership roles have been clarified through testing, training, and 
exercising, the Secretaries of Homeland Security and Health and Human 
Services should ensure that these roles are clearly understood by 
state, local, and tribal governments; the private and nonprofit 
sectors; and the international community; 
Status: (1) HHS and DHS officials stated that several influenza 
pandemic exercises had been conducted since November 2007 that involved 
both agencies and other federal officials, but it is unclear whether 
these exercises rigorously tested federal leadership roles in a 
pandemic. 

Title and GAO product number: Influenza Pandemic: Opportunities Exist 
to Clarify Federal Leadership Roles and Improve Pandemic Planning, 
[hyperlink, http://www.gao.gov/products/GAO-07-1257T], September 26, 
2007; 
Summary of open recommendations: (2) The Homeland Security Council 
should establish a specific process and time frame for updating the 
National Pandemic Implementation Plan. The process should involve key 
nonfederal stakeholders and incorporate lessons learned from exercises 
and other sources. The National Pandemic Implementation Plan should 
also be improved by including the following information in the next 
update: (a) resources and investments needed to complete the action 
items and where they should be targeted, (b) a process and schedule for 
monitoring and publicly reporting on progress made on completing the 
action items, (c) clearer linkages with other strategies and plans, and 
(d) clearer descriptions of relationships or priorities among action 
items and greater use of outcome-focused performance measures; 
Status: (2) HSC did not comment on the recommendation and has not 
indicated if it plans to implement it. 

Title and GAO product number: Avian Influenza: USDA Has Taken Important 
Steps to Prepare for Outbreaks, but Better Planning Could Improve 
Response, [hyperlink, http://www.gao.gov/products/GAO-07-652], June 11, 
2007; 
Summary of open recommendations: (1) The Secretaries of Agriculture and 
Homeland Security should develop a memorandum of understanding that 
describes how USDA and DHS will work together in the event of a 
declared presidential emergency or major disaster, or an Incident of 
National Significance, and test the effectiveness of this coordination 
during exercises; 
Status: (1) Both USDA and DHS officials told us that they have taken 
preliminary steps to develop additional clarity and better define their 
coordination roles. For example, the two agencies meet on a regular 
basis to discuss such coordination. 
Summary of open recommendations: (2) The Secretary of Agriculture 
should, in consultation with other federal agencies, states, and the 
poultry industry identify the capabilities necessary to respond to a 
probable scenario or scenarios for an outbreak of highly pathogenic 
avian influenza. The Secretary of Agriculture should also use this 
information to develop a response plan that identifies the critical 
tasks for responding to the selected outbreak scenario and, for each 
task, identifies the responsible entities, the location of resources 
needed, time frames, and completion status. Finally, the Secretary of 
Agriculture should test these capabilities in ongoing exercises to 
identify gaps and ways to overcome those gaps; 
Status: (2) USDA officials told us that it has created a draft 
preparedness and response plan that identifies federal, state, and 
local actions, timelines, and responsibilities for responding to highly 
pathogenic avian influenza, but the plan has not been issued yet.
Summary of open recommendations: (3) The Secretary of Agriculture 
should develop standard criteria for the components of state response 
plans for highly pathogenic avian influenza, enabling states to develop 
more complete plans and enabling USDA officials to more effectively 
review them; 
Status: (3) USDA told us that it has drafted large volumes of guidance 
documents that are available on a secure Web site. However, the 
guidance is still under review and it is not clear what standard 
criteria from these documents USDA officials and states should apply 
when developing and reviewing plans;
Summary of open recommendations: (4) The Secretary of Agriculture 
should focus additional work with states on how to overcome potential 
problems associated with unresolved issues, such as the difficulty in 
locating backyard birds and disposing of carcasses and materials; 
Status: (4) USDA officials have told us that the agency has developed 
online tools to help states make effective decisions about carcass 
disposal. In addition, USDA has created a secure Internet site that 
contains draft guidance for disease response, including highly 
pathogenic avian influenza, and it includes a discussion about many of 
the unresolved issues; 
Summary of open recommendations: (5) The Secretary of Agriculture 
should determine the amount of antiviral medication USDA would need in 
order to protect animal health responders, given various highly 
pathogenic avian influenza scenarios. The Secretary of Agriculture 
should also determine how to obtain and provide supplies within 24 
hours of an outbreak; 
Status: (5) USDA officials told us that the National Veterinary 
Stockpile contains enough antiviral medication to protect 3,000 animal 
health responders for 40 days. However, USDA has yet to determine the 
number of individuals who would need medicine based on a calculation of 
those exposed to the virus under a specific scenario. Further, USDA 
officials told us that a contract for additional medication for the 
stockpile has not yet been secured, which would better ensure that 
medications are available in the event of an outbreak of highly 
pathogenic avian influenza. 

Source: GAO. 

[End of table] 

[End of section] 

Attachment II: Related GAO Products: 

Influenza Pandemic: 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] GAO's 2009 Congressional and Presidential Transition Web site: 
[hyperlink, http://www.gao.gov/transition_2009]. 

[2] We also have two pandemic-related reviews underway on the following 
topics: (1) the status of implementing the National Strategy for 
Pandemic Influenza Implementation Plan (National Pandemic 
Implementation Plan); and (2) the effect of a pandemic on the 
telecommunications capacity needed to sustain critical financial market 
activities. 

[3] GAO, Influenza Pandemic: Sustaining Focus on the Nation's Planning 
and Preparedness Efforts, [hyperlink, 
http://www.gao.gov/products/GAO-09-334] (Washington, D.C.: Feb. 26, 
2009). 

[4] GAO, Influenza Pandemic: 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). 

[5] On June 11, 2009, the World Health Organization (WHO) raised its 
influenza pandemic alert level from phase 5 to the highest phase, phase 
6, signaling the widespread human infection associated with a pandemic 
for the H1N1 virus. 

[6] GAO, Influenza Pandemic: Further Efforts Are Needed to Ensure 
Clearer Federal Leadership Roles and an Effective National Strategy, 
[hyperlink, http://www.gao.gov/products/GAO-07-781] (Washington, D.C.: 
Aug. 14, 2007). 

[7] On May 26, 2009, the President announced the full integration of 
White House staff supporting national security and homeland security. 
The Homeland Security Council will be maintained as the principal venue 
for interagency deliberations on issues that affect the security of the 
homeland, such as influenza pandemic. 

[8] Pub. L. No. 109-295, Title VI. 

[9] GAO, Homeland Security: Observations on DHS and FEMA Efforts to 
Prepare for and Respond to Major and Catastrophic Disasters and Address 
Related Recommendations and Legislation, [hyperlink, 
http://www.gao.gov/products/GAO-07-1142T] (Washington, D.C.: July 31, 
2007). 

[10] [hyperlink, http://www.gao.gov/products/GAO-07-781]. 

[11] GAO, Influenza Pandemic: Opportunities Exist to Address Critical 
Infrastructure Protection Challenges That Require Federal and Private 
Sector Coordination, [hyperlink, http://www.gao.gov/products/GAO-08-36] 
(Washington, D.C.: Oct. 31, 2007). 

[12] The 18 critical infrastructure and key resource sectors are: food 
and agriculture; banking and finance; chemical; commercial facilities; 
commercial nuclear reactors, materials, and water; dams; defense 
industrial base; drinking water and water treatment systems; emergency 
services; energy; governmental facilities; information technology; 
national monuments and icons; postal and shipping; public health and 
healthcare; telecommunications; transportation systems; and critical 
manufacturing. Critical infrastructure are systems and assets, whether 
physical or virtual, so vital to the United States that their 
incapacity or destruction would have a debilitating effect on national 
security, national economic security, and national public health or 
safety, or any combination of those matters. Key resources are publicly 
or privately controlled resources essential to minimal operations of 
the economy or government, including individual targets whose 
destruction would not endanger vital systems but could create a local 
disaster or profoundly damage the nation's morale or confidence. 

[13] [hyperlink, http://www.gao.gov/products/GAO-08-36]. 

[14] GAO, The Federal Workforce: Additional Steps Needed to Take 
Advantage of Federal Executive Boards' Ability to Contribute to 
Emergency Operations, [hyperlink, 
http://www.gao.gov/products/GAO-07-515] (Washington, D.C.: May 4, 
2007). 

[15] Issued in January 2008 by DHS and effective in March 2008, the NRF 
is a guide to how the nation conducts all-hazards incident response and 
replaces the National Response Plan. It focuses on how the federal 
government is organized to support communities and states in 
catastrophic incidents. The NRF builds upon the National Incident 
Management System, which provides a national template for managing 
incidents. 

[16] GAO, Influenza Pandemic: Efforts Under Way to Address Constraints 
on Using Antivirals and Vaccines to Forestall a Pandemic, [hyperlink, 
http://www.gao.gov/products/GAO-08-92] (Washington, D.C.: Dec. 21, 
2007). 

[17] The six characteristics of an effective national strategy include: 
(1) purpose, scope, and methodology; (2) problem definition and risk 
assessment; (3) goals, subordinate objectives, activities, and 
performance measures; (4) resources, investments, and risk management; 
(5) organizational roles, responsibilities, and coordination; and (6) 
integration and implementation. GAO, Combating Terrorism: Evaluation of 
Selected Characteristics in National Strategies Related to Terrorism, 
[hyperlink, http://www.gao.gov/products/GAO-04-408T] (Washington, D.C.: 
Feb. 3, 2004). 

[18] [hyperlink, http://www.gao.gov/products/GAO-09-404]. 

[19] The survey was conducted from May through July 2008, and the 
results were confirmed or updated in early 2009. 

[20] Social distancing is a technique used to minimize close contact 
among persons in public places, such as work sites and public areas. 

[21] 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, DC: June 19, 
2008). 

[22] We conducted site visits to the five most populous states 
including California, Florida, Illinois, New York, and Texas for a 
number of reasons, including that these states constituted over one- 
third of the U.S. population, received over one-third of the total 
funding from HHS and DHS that could be used for planning and exercising 
efforts, and were likely entry points for individuals coming from 
another country given that the states either bordered Mexico or Canada 
or contained major ports, or both. Within each state, we also 
interviewed officials at 10 localities, which consisted of 5 urban 
areas and 5 rural counties. 

[23] DHS and HHS and other agencies, Assessment of States' Operating 
Plans to Combat Pandemic Influenza: Report to Homeland Security Council 
(Washington, D.C.: January 2009). 

[24] [hyperlink, http://www.gao.gov/products/GAO-08-539]. 

[25] [hyperlink, http://www.gao.gov/products/GAO-09-334]. 

[26] [hyperlink, http://www.gao.gov/products/GAO-08-539]. 

[27] National Governors Association Center for Best Practices, Issue 
Brief: Pandemic Preparedness in the States--An Assessment of Progress 
and Opportunity (September 2008). 

[28] GAO, Financial Market Preparedness: Significant Progress Has Been 
Made, but Pandemic Planning and Other Challenges Remain, [hyperlink, 
http://www.gao.gov/products/GAO-07-399] (Washington, D.C.: Mar. 29, 
2007). 

[29] Pub. L. No. 109-148 and Pub. L. No. 109-234. 

[30] Pub. L. No. 111-32. 

[31] Antivirals can prevent or reduce the severity of a viral 
infection, such as influenza. Vaccines are used to stimulate the 
production of an immune system response to protect the body from 
disease. 

[32] GAO, Emergency Preparedness: States Are Planning for Medical 
Surge, but Could Benefit from Shared Guidance for Allocating Scarce 
Medical Resources, [hyperlink, http://www.gao.gov/products/GAO-08-668], 
(Washington, DC: June 13, 2008). 

[33] [hyperlink, http://www.gao.gov/products/GAO-08-539]. 

[34] Centers for Disease Control and Prevention,Update on School (K - 
12) and Child Care Programs: Interim CDC Guidance in Response to Human 
Infections with the Novel Influenza A (H1N1) Virus (Updated May 22, 
2009). 

[35] Homeland Security Council, National Strategy for Pandemic 
Influenza Implementation Plan (Washington,D.C.: May 2006). 

[36] [hyperlink, http://www.gao.gov/products/GAO-09-404]. 

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 GAOís 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 GAOís 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: