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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 administrationís 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 Planís 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 agenciesí progress in implementing the Planís 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 Planís 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, GAOís 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 HSCís progress summaries 
sometimes corrected for this by either referring to activities in the 
action itemís 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 itemsí 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 GAOís 
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 ó 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 ó 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] 

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[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] 

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