COVID-19: HHS Should Clarify Agency Roles for Emergency Return of U.S. Citizens during a Pandemic
Fast Facts
When the COVID-19 pandemic began, the U.S. repatriated about 1,100 U.S. citizens from abroad and quarantined them domestically to prevent the spread of the virus.
But coordination and safety issues among Department of Health and Human Services' personnel put repatriates, HHS personnel, and nearby communities at risk. HHS agencies didn't follow plans delineating their roles for repatriations during a pandemic. For example, there was confusion about which agency was in charge of health and safety protocols at the first quarantine site.
We recommended that HHS revise or develop and test repatriation response plans to clarify agency roles.
Department of State personnel aboard the first repatriation flight out of Wuhan, China, in January 2020.
Highlights
What GAO Found
At the beginning of the COVID-19 pandemic, the U.S. returned, or repatriated, about 1,100 U.S. citizens from abroad and quarantined them domestically to prevent the spread of COVID-19. The Department of Health and Human Services (HHS) experienced coordination and safety issues that put repatriates, HHS personnel, and nearby communities at risk. This occurred because HHS component agencies—the Administration for Children and Families, the Office of the Assistant Secretary for Preparedness and Response, and the Centers for Disease Control and Prevention—did not follow plans or guidance delineating their roles and responsibilities for repatriating individuals during a pandemic—an event these agencies had never experienced. While they had general repatriation plans, there was disagreement as to whether the effort was in fact a repatriation. This led to fundamental problems for HHS agencies and their federal partners, including at the March Air Reserve Base quarantine facility in California where the first repatriated individuals were quarantined prior to widespread transmission of COVID-19 in the U.S. These problems included the following:
- Lack of clarity as to which agency was in charge when the first repatriation flight from Wuhan, China, arrived at the quarantine facility, which caused confusion among the HHS component agencies.
- Coordination issues among HHS component agencies resulted in component agencies operating independently of each other, and led to frustration and complications.
- HHS's delay in issuing its federal quarantine order, during which time a repatriate tried to leave the quarantine facility.
- HHS personnel's inconsistent use of personal protective equipment (PPE), and HHS officials' disagreement on which agency was responsible for managing infection prevention and control. An HHS official also directed personnel to remove their PPE as it created “bad optics,” according to an HHS report that examined the repatriation effort.
The National Response Framework, a guide to how the U.S. responds to disasters and emergencies, instructs agencies to understand their respective roles and responsibilities, know what plans apply, and develop appropriate guidance for emergency responses. Until HHS revises or develops new plans that clarify agency roles and responsibilities during a repatriation in response to a pandemic, it will be unable to prevent the coordination and health and safety issues it experienced during the COVID-19 repatriation response in future pandemic emergencies.
HHS also did not include repatriation in its pandemic planning exercises. As a result, agencies lacked experience deploying together to test repatriation plans during a pandemic, which contributed to serious coordination issues. GAO has previously reported that exercises play an important role in preparing for an incident by providing opportunities to test response plans and assess the clarity of roles and responsibilities. Until HHS conducts such exercises, it will be unable to test its repatriation plans during a pandemic and identify areas for improvement.
Why GAO Did This Study
HHS provides temporary assistance to U.S. citizens repatriated by the Department of State (State) from a foreign country because of destitution, illness, threat of war, or similar crises through the U.S. Repatriation Program. In January and February 2020, HHS assisted State in repatriating individuals from Wuhan, China, and the Diamond Princess cruise ship in Yokohama, Japan, to the U.S. HHS quarantined repatriates at five Department of Defense (DOD) installations to ensure they did not infect others with COVID-19.
GAO was asked to examine HHS's COVID-19 repatriation efforts to ensure the health and safety of those involved in the response. This report examines HHS's coordination and management of its COVID-19 repatriation response.
GAO reviewed relevant documentation from HHS, State, and DOD related to repatriation planning, including documentation on pandemic planning exercises. GAO also interviewed officials from HHS, State, and DOD.
Recommendations
GAO is making two recommendations to the Secretary of Health and Human Services: (1) revise or develop new emergency repatriation response plans to clarify agency roles and responsibilities during a pandemic; and (2) plan and conduct repatriation exercises with relevant stakeholders—including federal partners and state, local, and territorial governments—to test repatriation plans in response to a pandemic. HHS agreed with our recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | The Secretary of Health and Human Services should revise or develop new emergency repatriation response plans that clarify agency roles and responsibilities, including those for an evacuation and quarantine, during a pandemic. (Recommendation 1) |
HHS agreed with the recommendation. The Administration for Children and Families (ACF) provided documentation showing that beginning in March 2023, they started a series of bi-monthly workgroup meetings with relevant stakeholders with the goal of developing the following documents: 1) an updated National Emergency Repatriation Framework; 2) a Federal Emergency Repatriation Operations Plan; and 3) a Highly Infectious Disease Annex. As part of this effort, ACF stated it will engage individual agencies in a discussion of their role for an emergency repatriation. In April 2024, ACF stated it plans to have drafts of all documents finalized in early summer 2024. To close the recommendation, HHS and its component agencies will have to demonstrate that they have agreed upon a plan that outlines agency roles and responsibilities, including those for an evacuation and quarantine, in the event of a pandemic.
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| Department of Health and Human Services | The Secretary of Health and Human Services should plan and conduct regular exercises with relevant stakeholders—including federal partners, state, local, and territorial governments—to test repatriation plans in response to a pandemic and update relevant plans based on lessons learned. (Recommendation 2) |
HHS agreed with this recommendation and, as of April 2024, has taken steps to implement it. Specifically, the Administration for Children and Families (ACF) conducted a repatriation exercise in May 2022 involving ACF, the Centers for Disease Control and Prevention, the Office of the Assistant Secretary for Preparedness and Response (now the Administration for Strategic Preparedness and Response), the Department of State, Customs and Border Protection, and the State of Arizona, based on a repatriation event in response to political unrest resulting from an earthquake in South America. The exercise included COVID-19 concerns, including a masking requirement. In August and September 2021, ACF included COVID-19 testing as part of the Afghanistan emergency repatriation response, Operation Allies Welcome. These are both positive steps. However, GAO has previously stated we are monitoring for HHS to conduct exercises with all relevant stakeholders, including other federal agencies based on agreed upon repatriation plans in response to a pandemic. In April 2024, ACF stated it is finalizing plans that will clarify roles and responsibilities in response to our first recommendation in early summer 2024. To close this recommendation, HHS and its component agencies will need to conduct exercises with relevant stakeholders based on agreed upon guidance that outlines agency roles and responsibilities in response to a pandemic.
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