Influenza Pandemic: DOD Has Taken Important Actions to Prepare,  
but Accountability, Funding, and Communications Need to be	 
Clearer and Focused Departmentwide (21-SEP-06, GAO-06-1042).	 
                                                                 
An influenza pandemic would be of global and national		 
significance and could affect large numbers of Department of	 
Defense (DOD) personnel, seriously challenging DOD's readiness.  
GAO was asked to examine DOD's pandemic influenza preparedness	 
efforts. This report focuses on DOD's planning for its workforce,
specifically (1) actions DOD has taken to prepare and (2)	 
challenges DOD faces going forward. GAO analyzed guidance,	 
contracts, and plans, and met with DOD officials.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-1042					        
    ACCNO:   A61248						        
  TITLE:     Influenza Pandemic: DOD Has Taken Important Actions to   
Prepare, but Accountability, Funding, and Communications Need to 
be Clearer and Focused Departmentwide				 
     DATE:   09/21/2006 
  SUBJECT:   Accountability					 
	     Avian influenza					 
	     Defense communications				 
	     Defense contingency planning			 
	     Defense operations 				 
	     Emergency preparedness				 
	     Health care planning				 
	     Immunization programs				 
	     Infectious diseases				 
	     Influenza						 
	     Pandemic						 
	     Performance measures				 
	     Program evaluation 				 
	     Strategic planning 				 
	     Vaccination					 
	     Program goals or objectives			 

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GAO-06-1042

     

     * Results in Brief
     * Background
     * DOD Had Taken Actions to Prepare for an Influenza Pandemic
          * Certain DOD Offices Established Pandemic Influenza Working G
          * Some Offices and Components Issued Guidance on and Developed
          * DOD Established Web Sites for Pandemic and Avian Influenza I
          * DOD Procured Antiviral Medications and Vaccines
          * DOD Initiated Projects to Assist Other Nations' Preparedness
     * Going Forward, DOD Faces Four Key Management Challenges in I
          * DOD Had Not Yet Fully Defined Departmentwide Lead and Suppor
          * DOD Had Not Yet Identified an Appropriate Funding Mechanism
          * DOD Had Not Yet Defined the Types of Personnel Included in I
          * Although a Communications Strategy Was under Development, DO
     * Conclusions
     * Recommendations for Executive Action
     * Agency Comments and Our Evaluation
     * Appendix I: Scope and Methodology
     * Appendix II: Summary of DOD's Guidance for Pandemic Influenz
     * Appendix III: Comments from the Department of Defense
     * Appendix IV: GAO Contact and Staff Acknowledgments
          * GAO Contact
          * Staff Acknowledgments
     * Related GAO Products
          * Order by Mail or Phone

Report to the Committee on Government Reform, House of Representatives

United States Government Accountability Office

GAO

September 2006

INFLUENZA PANDEMIC

DOD Has Taken Important Actions to Prepare, but Accountability, Funding,
and Communications Need to be Clearer and Focused Departmentwide

GAO-06-1042

Contents

Letter 1

Results in Brief 6
Background 11
DOD Had Taken Actions to Prepare for an Influenza Pandemic 13
Going Forward, DOD Faces Four Key Management Challenges in Its Pandemic
Influenza Planning and Preparedness Efforts for Its Workforce
Departmentwide 22
Conclusions 33
Recommendations for Executive Action 34
Agency Comments and Our Evaluation 35
Appendix I Scope and Methodology 39
Appendix II Summary of DOD's Guidance for Pandemic Influenza and Related
Force Health Protection Policies 41
Appendix III Comments from the Department of Defense 43
Appendix IV GAO Contact and Staff Acknowledgments 47
Related GAO Products 48

Table

Table 1: DOD's Current Priorities for Vaccine and Antiviral Distribution
17

Figures

Figure 1: Issues to Be Addressed in DOD's Pandemic Influenza
Implementation Plan 3
Figure 2: Comparison of WHO Pandemic Phases and U.S. Government Stages 4
Figure 3: Timeline of Actions DOD Has Taken to Prepare for an Influenza
Pandemic Compared to Key Homeland Security Council Plans 14

Abbreviations

ASD Assistant Secretary of Defense

DOD Department of Defense

HHS Department of Health and Human Services

WHO World Health Organization

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separately.

United States Government Accountability Office

Washington, DC 20548

September 21, 2006 September 21, 2006

The Honorable Tom Davis Chairman The Honorable Henry A. Waxman Ranking
Minority Member Committee on Government Reform House of Representatives
The Honorable Tom Davis Chairman The Honorable Henry A. Waxman Ranking
Minority Member Committee on Government Reform House of Representatives

An influenza pandemic-a novel strain of influenza virus to which humans
have little or no immunity that has the ability to infect and be passed
efficiently between humans worldwide-would be of global and national
significance. A large number of Department of Defense (DOD) personnel
potentially could be affected by an influenza pandemic, which could
adversely affect the military's readiness, jeopardize ongoing military
operations overseas, and threaten the day-to-day functioning of the
department and maintenance of its critical infrastructure. For example,
approximately one-half of all of the deaths of U.S. servicemembers from
World War I, at least 43,000 deaths, were due to influenza or
influenza-related complications, and another 1 million servicemembers were
hospitalized, limiting the military's resources to continue ongoing
missions. An influenza pandemic outbreak not only would be a medical
problem, but also a human capital and national security problem. The
federal government anticipates an influenza pandemic would occur in
multiple waves over a period of time, rather than as a discrete event.
During the peak weeks of an outbreak of a severe influenza pandemic, an
estimated 40 percent of the U.S. workforce may not be at work due to
illness, the need to care for family members, or fear of infection. An
influenza pandemic-a novel strain of influenza virus to which humans have
little or no immunity that has the ability to infect and be passed
efficiently between humans worldwide-would be of global and national
significance. A large number of Department of Defense (DOD) personnel
potentially could be affected by an influenza pandemic, which could
adversely affect the military's readiness, jeopardize ongoing military
operations overseas, and threaten the day-to-day functioning of the
department and maintenance of its critical infrastructure. For example,
approximately one-half of all of the deaths of U.S. servicemembers from
World War I, at least 43,000 deaths, were due to influenza or
influenza-related complications, and another 1 million servicemembers were
hospitalized, limiting the military's resources to continue ongoing
missions. An influenza pandemic outbreak not only would be a medical
problem, but also a human capital and national security problem. The
federal government anticipates an influenza pandemic would occur in
multiple waves over a period of time, rather than as a discrete event.
During the peak weeks of an outbreak of a severe influenza pandemic, an
estimated 40 percent of the U.S. workforce may not be at work due to
illness, the need to care for family members, or fear of infection.

Planning for an influenza pandemic is a difficult and daunting task,
particularly because so much is currently unknown about a potential
pandemic. While some scientists and public health experts believe that the
next influenza pandemic could be spawned by the H5N1 strain of avian
influenza (also known as "bird flu") that is currently circulating in
parts of Asia, the Middle East, Europe, and Africa, it is unknown when an
influenza pandemic will occur, where it will begin, or whether a variant
of the H5N1 strain or some other strain would be the cause. Moreover, the
severity of an influenza pandemic, as well as the groups of people most at
risk for infection, cannot be accurately predicted. Additionally,
responding to an influenza pandemic would be more challenging than dealing
with annual influenza in several ways. Each year, annual influenza causes
Planning for an influenza pandemic is a difficult and daunting task,
particularly because so much is currently unknown about a potential
pandemic. While some scientists and public health experts believe that the
next influenza pandemic could be spawned by the H5N1 strain of avian
influenza (also known as "bird flu") that is currently circulating in
parts of Asia, the Middle East, Europe, and Africa, it is unknown when an
influenza pandemic will occur, where it will begin, or whether a variant
of the H5N1 strain or some other strain would be the cause. Moreover, the
severity of an influenza pandemic, as well as the groups of people most at
risk for infection, cannot be accurately predicted. Additionally,
responding to an influenza pandemic would be more challenging than dealing
with annual influenza in several ways. Each year, annual influenza causes
approximately 226,000 hospitalizations and 36,000 deaths in the United
States. According to the World Health Organization (WHO), an influenza
pandemic would spread throughout the world very quickly, usually in less
than a year, and could sicken more than a quarter of the global
population, including young, healthy individuals who are not normally as
affected by the annual influenza. However, despite all of these
uncertainties, sound planning and preparedness could lessen the impact of
any influenza pandemic.

To address the potential threat of an influenza pandemic, the Homeland
Security Council issued its National Strategy for Pandemic Influenza in
November 2005.1 The Implementation Plan for the National Strategy for
Pandemic Influenza,2 which was released in May 2006, proposes actions for
federal departments-including DOD-in support of the national strategy and
describes expectations for nonfederal entities, including state, local,
and tribal governments; the private sector; international partners; and
individuals. The national implementation plan tasked each federal agency
to develop an implementation plan that addresses two issues, as shown in
figure 1. First, each federal department was to detail how it would carry
out the department's responsibilities in the national implementation plan.
For example, of the more than 300 actions in the national implementation
plan, DOD was responsible for 114 actions-31 actions as a lead agency and
83 actions as a supporting agency. Second, each federal department was to
include the department's approach to employee safety, continuity of
operations, and communications with stakeholders in its implementation
plan.

1Homeland Security Council, National Strategy for Pandemic Influenza
(Washington, D.C.: Nov. 2005).

2Homeland Security Council, Implementation Plan for the National Strategy
for Pandemic Influenza (Washington, D.C.: May 2006).

Figure 1: Issues to Be Addressed in DOD's Pandemic Influenza
Implementation Plan

WHO defines the emergence of an influenza pandemic in six phases (see fig.
2). Based on this definition, the world currently is in phase 3, in which
there are human infections from a new influenza subtype, but no or very
limited human-to-human transmission of the disease. In addition, the
Homeland Security Council developed "stages," also shown in figure 2, to
provide a framework for a federal government response to an influenza
pandemic, which characterize the outbreak in terms of the threat that the
pandemic virus poses to the U.S. population. Currently there are new
domestic animal outbreaks in an at-risk country, which is stage 0.

Figure 2: Comparison of WHO Pandemic Phases and U.S. Government Stages

You asked that we examine DOD's planning and preparedness efforts for an
influenza pandemic. Because DOD's implementation plan was still being
drafted at the time of our review, we focused our work on DOD's pandemic
influenza planning and preparedness efforts to date for its own workforce.
DOD is a large, complex organization of departments, agencies, and other
components with a workforce spread around the world, which, as of April
30, 2006, included nearly 1.4 million active duty military personnel and
nearly 675,000 civilian personnel. This total does not include the
numerous reserve and mobilized National Guard personnel,3 contractors,
dependents, and beneficiaries for which DOD also is responsible.

We are reporting to you at this time to highlight some of our observations
to date on DOD's approach to planning and preparing to protect its
workforce so DOD can consider and address them as the department continues
its ongoing planning efforts. This report is largely focused on DOD's
plans to protect its own workforce and addresses (1) actions DOD has taken
to date to prepare for an influenza pandemic and (2) management challenges
DOD faces going forward as the department continues its planning efforts.
We expect to issue another report at a later date on DOD's plans and
preparedness for an influenza pandemic, which will include our evaluation
of DOD's final implementation plan, the combatant command plans, and
selected installation plans.

To address these objectives, we reviewed a draft of the department's
implementation plan for pandemic influenza dated March 2006;4 guidance and
planning orders for pandemic influenza issued by the Assistant Secretary
of Defense (ASD) for Health Affairs, the Joint Chiefs of Staff, Army
Medical Command, and Army Installation Management Agency; and the
department's existing directives for force health protection. Also, we
reviewed the Implementation Plan for the National Strategy for Pandemic
Influenza, the Department of Health and Human Services' (HHS) contract
with a vaccine manufacturer, and DOD's contracts with two antiviral
manufacturers. Additionally, we met in the Washington, D.C., area with
cognizant DOD officials from the Office of the Secretary of Defense,
including officials from the Offices of the ASD for Homeland Defense, ASD
for Health Affairs, and ASD for Special Operations and Low Intensity
Conflict; the Joint Chiefs of Staff; and each of the military services.
Some officials from these offices were involved in the development of the
National Strategy for Pandemic Influenza and its implementation plan. We
conducted our review from December 2005 through August 2006 in accordance
with generally accepted government auditing standards. Further details on
our scope and methodology are in appendix I.

3According to DOD officials, DOD would be responsible for National Guard
personnel who have been mobilized under Title 10, United States Code.
Otherwise, the individual states would be responsible for National Guard
personnel serving under Title 32, United States Code, or under State
Active Duty.

4DOD released its implementation plan to the Homeland Security Council on
August 16, 2006, as we were completing our review. However, according to
an official in the Office of the ASD for Homeland Defense, DOD cannot
release its implementation plan externally until it is coordinated and
approved by the Homeland Security Council. We reviewed the final plan and
determined that it was not significantly different from the March 2006
draft that we previously reviewed.

                                Results in Brief

DOD has taken a number of important actions to prepare for an influenza
pandemic since September 2004, well before the federal government released
the National Strategy for Pandemic Influenza in November 2005 and its
implementation plan in May 2006, and these efforts continue to evolve.
Going forward, DOD faces several management challenges as it continues its
ongoing planning efforts. Certain offices within DOD established working
groups, such as the Pandemic Influenza Task Force, which coordinated and
implemented DOD's pandemic influenza policies and plans. Also, in
September 2004 and January 2006, the ASD for Health Affairs issued
guidance to the military departments, which, among other things, provided
tasks for several DOD organizations to complete for each of WHO's phases
of an influenza pandemic. The guidance also established generic priorities
for the distribution of vaccines and antivirals. For example, deployed
forces engaged in or supporting armed conflict and those personnel
necessary to provide essential health care for the force are in the top
tier of DOD's prioritization system. Further, at the time of our review,
two of the three military departments-the Departments of the Navy and the
Air Force-planned to issue servicewide instructions related to pandemic
influenza preparedness. The Department of the Army did not plan to issue a
similar instruction, but two organizations within the Army issued guidance
to installations on developing pandemic influenza plans. DOD also was
undertaking influenza pandemic planning efforts at several different
levels. Specifically, DOD completed its implementation plan for an
influenza pandemic, as required by the Implementation Plan for the
National Strategy for Pandemic Influenza. The department started drafting
its implementation plan in November 2005. The Joint Chiefs of Staff tasked
the geographic combatant commands to develop plans, which were to address
force health protection and defense support to civil authorities, among
other things. According to officials from the Joint Staff, these plans
were near completion at the time of our review. Installations were tasked
by the ASD for Health Affairs to develop pandemic influenza plans or
revise existing plans to address pandemic influenza. Also, DOD established
Web sites, including the Pandemic Influenza Watchboard, that provided
information for servicemembers and their families about avian and pandemic
influenza. Moreover, DOD procured more than 2 million treatment courses of
one antiviral, which were prepositioned in the continental United States,
Europe, and the Far East.5 Additionally, DOD procured over 2 million doses
of an existing H5N1 vaccine, based on the strain that circulated in
Vietnam in 2004, and planned to purchase in fiscal year 2007 additional
doses of the Vietnam strain and a strain that circulated in Indonesia in
2005.6 Internationally, the department initiated projects to help build
host nation capacity to prepare for, mitigate, and respond to a potential
influenza pandemic.

At the time of our review, DOD's planning efforts to protect its personnel
focused primarily on the military departments, geographic combatant
commands, and installations. However, as DOD's focus shifts to the
workforce departmentwide, including the civilian workforce and personnel
in defense agencies, we identified four key management challenges that DOD
faces going forward as it continues its planning and preparedness efforts
for pandemic influenza. In our prior work, we identified six desirable
characteristics of national strategies, including defining organizational
roles, responsibilities, and coordination; identifying goals, subordinate
objectives, activities, and performance measures; and addressing
resources, investments, and risk management.7 However, to date, DOD's
pandemic influenza planning may not be as effective as it could be because
the department had not yet (1) clearly and fully defined and communicated
departmentwide roles and responsibilities with clear lines of authority,
oversight mechanisms, and goals and performance measures; (2) requested
funding that is tied to the departmentwide goals of pandemic influenza to
complete the tasks in the national implementation plan and to protect
DOD's own workforce; (3) clearly defined the types of personnel-military
personnel, civilian personnel, contractors, dependents, and
beneficiaries-to be included in DOD's vaccine and antiviral distribution;
and (4) implemented a departmentwide communications strategy.
Specifically, at the time of our review, the following conditions existed.

5DOD has purchased an additional 470,000 treatment courses of the
antiviral, which are scheduled for delivery by the end of 2006.
Additionally, DOD has ordered another 530,000 treatment courses of the
antiviral, which will increase its stockpile to 3.4 million courses. DOD
has not yet received these two orders.

6These vaccines, which have not been approved by the Food and Drug
Administration, may not be effective against a future pandemic strain,
because the pandemic strain has not yet emerged.

7GAO, Combating Terrorism: Evaluation of Selected Characteristics in
National Strategies Related to Terrorism, GAO-04-408T (Washington, D.C.:
Feb. 3, 2004).

           o  First, neither the Secretary of Defense nor the Deputy
           Secretary of Defense had yet issued guidance clearly and fully
           defining and communicating lead and supporting roles and
           responsibilities for DOD's pandemic influenza planning with clear
           lines of authority; oversight mechanisms, including reporting
           requirements; and departmentwide goals-such as a description of a
           desired end-state-and performance measures. Some officials told us
           that the lines of authority for DOD's pandemic influenza planning
           efforts were unclear. For example, officials told us that some
           installation personnel were confused about whether or not they
           were supposed to be developing plans, since it was unusual for the
           ASD for Health Affairs to task installations directly with
           developing plans, and we observed differences in the military
           departments' approaches to installation planning. Further, DOD
           instituted reporting requirements for the organizations
           responsible for implementing the 31 tasks from the national
           implementation plan; however, there were not similar oversight
           mechanisms in place for tasks that were not part of the national
           implementation plan. For example, the January 2006 Health Affairs
           guidance tasked installations with developing pandemic influenza
           plans or modifying existing plans to address pandemic influenza
           and DOD's implementation plan tasked all DOD organizations with
           developing or modifying continuity of operations plans to address
           pandemic influenza; however, there were no reporting requirements
           for these tasks. Finally, Navy officials said that they started
           developing plans for pandemic influenza, but it was difficult
           because the Office of the Secretary of Defense had not provided
           specific goals for what would be expected of the services in the
           event of an influenza pandemic. Over time, a lack of clear lines
           of authority, oversight mechanisms, and goals and performance
           measures could hamper the leadership's abilities to ensure that
           planning efforts across the department are progressing as intended
           as DOD continues its pandemic influenza planning and preparedness
           efforts. Additionally, without clear departmentwide goals, it may
           be difficult for all DOD components to develop effective plans and
           guidance.

           o  Second, at the time of our review, DOD had started identifying
           funding requirements, but had not yet identified an appropriate
           funding mechanism or requested funding, tied to its departmentwide
           goals, for its pandemic influenza planning efforts. An official
           from the Office of the ASD for Homeland Defense said the
           department had options for requesting the required funding,
           including incorporating the request in future budget submissions
           or submitting a supplemental request to the Congress. Because DOD
           had not yet requested funding, it is unclear whether DOD can
           address the tasks assigned to it in the national implementation
           plan and pursue its own preparedness efforts for its workforce
           departmentwide within current resources.

           o  Third, at the time of our review, DOD had not yet clearly
           defined or communicated departmentwide which types of
           personnel-military personnel, civilian personnel, contractors,
           beneficiaries, and dependents-the department planned to include in
           its distribution of vaccines and antivirals in the event of an
           influenza pandemic. The ASD for Health Affairs issued generic
           priorities for the department's vaccine and antiviral distribution
           and noted that these priorities would be clarified when more was
           known about a pandemic strain. An official in the Office of the
           ASD for Homeland Defense said distinctions in the types of
           personnel who would be included in the distribution of
           DOD-purchased vaccines and antivirals would be based on whether
           the individual was identified as critical to the execution of an
           essential function, as determined by components as they develop or
           modify their continuity of operations plans to address pandemic
           influenza. A factor affecting DOD's ability to clarify priorities
           for distributing vaccines among its personnel is that the
           department's priority for receiving additional vaccines, including
           the vaccine for the pandemic strain, from HHS was not yet defined
           at the time of our review. As a result the department cannot
           realistically determine how well it will be able to meet its
           priorities for vaccinating personnel, and without knowing a rough
           estimate of how many vaccines will be available, DOD cannot
           accurately determine the funding required to purchase vaccines or,
           if needed, additional antivirals.

           o  Fourth, DOD had communicated information to many of its
           personnel about what actions they should take in the event of an
           influenza pandemic; however, these communication efforts were
           inconsistent departmentwide. Also, although DOD had not yet
           decided when, whether, or under what conditions it would dispense
           the vaccines and antivirals it purchased to date, DOD did not yet
           have a plan to communicate with personnel information on the
           safety and efficacy of vaccines and antivirals it purchased to
           date.8 However, DOD had posted on one of its Web sites the package
           inserts for the two antivirals that it purchased. While DOD
           established Web sites with some information on pandemic influenza,
           we identified unevenness across the department in terms of offices
           that regularly received actively distributed messages and other
           information. Without a comprehensive and effective communications
           strategy departmentwide, DOD personnel's awareness of actions that
           should be taken in the event of an influenza pandemic could become
           uneven and lead to confusion and increased numbers of affected
           personnel.

           As DOD continues its planning efforts going forward, and to
           enhance DOD's ongoing planning efforts, we are making
           recommendations to the Secretary of Defense. Specifically, we are
           recommending that the Secretary of Defense (1) instruct the ASD
           for Homeland Defense, as the individual accountable for DOD's
           pandemic influenza planning and preparedness efforts, to clearly
           and fully define and communicate departmentwide the roles and
           responsibilities of the organizations that will be involved in
           DOD's efforts with clear lines of authority; the oversight
           mechanisms, including reporting requirements, for all aspects of
           DOD's pandemic influenza planning efforts, to include those tasks
           that are not part of the national implementation plan; and the
           goals and performance measures of DOD's preparedness efforts; (2)
           instruct the ASD for Homeland Defense to work with the Under
           Secretary of Defense (Comptroller) to establish a framework for
           requesting funding for the department's preparedness efforts that
           includes the appropriate funding mechanism and controls to ensure
           needed funding for DOD's pandemic influenza preparedness efforts
           is tied to the department's goals; (3) instruct the ASD for Health
           Affairs to clarify DOD's guidance to explicitly define and
           communicate departmentwide whether and how all types of
           personnel-military and civilian personnel, contractors,
           dependents, and beneficiaries-would be included in DOD's
           distribution of vaccines and antivirals, and (4) instruct the ASD
           for Public Affairs to implement a comprehensive and effective
           communications strategy for personnel departmentwide.

           In written comments on a draft of this report, DOD generally
           concurred with four of our recommendations, and did not address
           one recommendation. DOD's comments and our evaluation of them are
           in the agency comments section of this report. Based on DOD's
           comments and additional documentation that DOD provided, we
           combined two of our recommendations and clarified another.
           Specifically, DOD provided additional documentation showing that
           the Deputy Secretary of Defense designated the ASD for Homeland
           Defense to lead the department's pandemic influenza efforts.
           Therefore, we deleted part of the original recommendation that the
           Secretary of Defense or Deputy Secretary of Defense designate an
           individual to be accountable for DOD's efforts. Additionally, DOD
           commented that it had started to determine funding requirements
           for its pandemic influenza efforts. We recognized this in our
           draft report and, subsequently, we clarified the recommendation to
           focus on requesting funding that is tied to the department's
           goals.

           Background
			  
			  Occasionally, worldwide influenza epidemics-called pandemics-occur
           that can have successive "waves" of disease that can last for up
           to 3 years. Three influenza pandemics occurred in the twentieth
           century. Notable among these was the influenza pandemic of 1918,
           called the "Spanish flu," which killed at least 20 million people
           worldwide, including 500,000 in the United States.9 The past
           pandemics have spread worldwide within months and a future
           pandemic is expected to spread even more quickly given modern
           travel patterns. The major implication of such a rapid spread is
           that many, if not most, countries will have minimal time to
           implement preparations and responses once a pandemic virus begins
           to spread.

           The current pandemic influenza threat stems from an unprecedented
           outbreak of H5N1 avian influenza that began in Hong Kong in 1997
           and has spread in bird populations across parts of Asia, the
           Middle East, Europe, and Africa, with limited infections in
           humans. The Food and Agriculture Organization of the United
           Nations reported in August 2006 that more than 220 million poultry
           were culled as a preventive measure or died from the H5N1 strain.
           From January 2003 through August 2006, WHO reported more than 240
           confirmed human cases and more than 140 confirmed human deaths
           from the H5N1 virus. Scientists and public health officials agree
           that the rapid spread of the H5N1 virus in birds and the
           occurrence of limited infections in humans have increased the risk
           that this disease may mutate into a form that is easily
           transmissible among humans, resulting in an influenza pandemic.
           Some experts at WHO and elsewhere believe that the world is now
           closer to another influenza pandemic than at any time since the
           last influenza pandemic in 1968. According to Central Intelligence
           Agency officials, the likelihood of an influenza pandemic
           occurring within the next 5 years is greater than any other time
           in the past 40 years. Furthermore, the agency officials reported
           that H5N1 is the most likely of all influenza viruses to cause a
           pandemic. Three conditions must be met before an influenza
           pandemic begins: (1) a new influenza virus subtype that has not
           previously circulated in humans must emerge, (2) the virus must be
           capable of causing disease in humans, and (3) the virus must be
           capable of being passed easily among humans. The H5N1 virus meets
           the first two of these three conditions.

           We previously reported vaccination is considered the first line of
           defense for preventing or reducing influenza-related illness and
           death; however, vaccines may be unavailable, in short supply, or
           ineffective for certain portions of the population during the
           first wave of a pandemic.10 Because a pandemic strain has not
           emerged and an effective vaccine needs to be a close match to the
           actual pandemic virus, vaccine production for the pandemic strain
           cannot begin until a pandemic virus emerges.11 Vaccine production
           generally takes at least 6 to 8 months after a virus strain has
           been identified. The length of time required to produce the
           vaccine, combined with limited U.S. manufacturing capability,
           could lead to a shortage of vaccines for the first wave of an
           influenza pandemic. We previously reported that limited studies
           have shown that when a vaccine produces a good antibody response
           to a virus, approximately 70 to 90 percent of healthy young adults
           may be protected from influenza. This protection drops to about 30
           to 40 percent for the elderly and those suffering from chronic
           illness or disease.12

           While vaccination has been the primary strategy for preventing
           influenza, antiviral drugs can also contribute to the prevention
           and treatment of influenza. The Food and Drug Administration has
           approved four antiviral medications for the prevention and
           treatment of influenza. If taken within 2 days of symptoms, these
           drugs can reduce symptoms and make someone with influenza less
           contagious to others. According to the Centers for Disease Control
           and Prevention, these antivirals are about 70 to 90 percent
           effective for preventing illness in healthy adults. However,
           influenza virus strains can become resistant, so these drugs may
           not always be effective. While antiviral drugs may help prevent or
           mitigate influenza-related illness or death until an effective
           vaccine becomes available, these drugs are expected to be in short
           supply during an influenza pandemic.

           We previously reported that DOD provides health care to over 9
           million active duty personnel, retirees, and their dependents
           through the department's TRICARE program.13 DOD's military health
           system has a dual role of medically supporting wartime deployments
           while caring for active duty members, retirees, and their families
           in peacetime. TRICARE beneficiaries can obtain health care through
           DOD's direct care system of military hospitals and clinics,
           commonly referred to as military treatment facilities, and through
           DOD's purchased care system of civilian providers. The Army, the
           Navy, and the Air Force provide most of the system's care through
           their own medical centers, hospitals, and clinics, while regional
           networks of civilian providers supply the remaining care.
			  
			  DOD Had Taken Actions to Prepare for an Influenza Pandemic

           DOD began its pandemic influenza planning and preparedness efforts
           as early as September 2004, well before the White House issued the
           National Strategy for Pandemic Influenza in November 2005 and its
           implementation plan in May 2006, and has taken a number of
           important actions since then to ensure that the department is
           ready in the event of an influenza pandemic. To date, DOD's
           actions to prepare for an influenza pandemic include establishing
           working groups, issuing guidance, developing plans, establishing
           Web sites, stockpiling vaccines and antivirals, and initiating
           projects to assist other nations' preparedness efforts. Figure 3
           summarizes DOD's efforts to date related to pandemic influenza
           planning and preparedness.

8Although information about the safety and efficacy of treatments that DOD
has purchased to date is available for dissemination, it is not known
whether these treatments would be effective against a future strain of the
virus because an influenza pandemic involving the H5N1 virus has not
occurred.

9The pandemics of 1957 ("Asian flu") and 1968 ("Hong Kong flu") caused
dramatically fewer fatalities-70,000 and 34,000, respectively, in the
United States-partly because of antibiotic treatment of secondary
infections and more aggressive supportive care.

10GAO, Influenza Pandemic: Plan Needed for Federal and State Response,
GAO-01-4 (Washington, D.C.: Oct. 27, 2000).

11Although a vaccine for a pandemic strain cannot be developed until the
pandemic strain emerges, some vaccine manufacturers have developed
vaccines based on the H5N1 strain isolated in Vietnam in 2004.

12 GAO-01-4 .

13GAO, Defense Health Care: Implementation Issues for New TRICARE
Contracts and Regional Structure, GAO-05-773 (Washington, D.C.: July 27,
2005).

Figure 3: Timeline of Actions DOD Has Taken to Prepare for an Influenza
Pandemic Compared to Key Homeland Security Council Plans

Certain DOD Offices Established Pandemic Influenza Working Groups

The ASD for Homeland Defense and ASD for Health Affairs, as well as the
Chief of Naval Operations and Commandant of the Marine Corps, established
pandemic influenza working groups. The ASD for Homeland Defense and ASD
for Health Affairs established the Pandemic Influenza Task Force in
November 2005, which was led by the ASD for Homeland Defense and met
bimonthly. As the lead entity for pandemic influenza policy within the
department, the Pandemic Influenza Task Force coordinated and implemented
policies and plans that would (1) prepare for, prevent, and contain the
effects of an influenza pandemic in military forces, (2) ensure DOD
protects U.S. interests at home and abroad, and (3) render appropriate
assistance to civilian authorities in the United States. The members of
the Pandemic Influenza Task Force included the following:

           o  Office of the ASD for Homeland Defense
           o  Office of the ASD for Health Affairs
           o  Office of the ASD for Special Operations and Low Intensity
           Conflict
           o  Joint Chiefs of Staff
           o  Office of the Under Secretary of Defense for Intelligence
           o  Office of the Under Secretary of Defense for Acquisition,
           Technology and Logistics
           o  Office of the Under Secretary of Defense (Comptroller)
           o  Office of the Deputy Under Secretary of Defense for Military
           Personnel Policy
           o  Office of the Deputy Under Secretary of Defense for Civilian
           Personnel Policy
           o  Office of the Assistant Secretary of Defense for Public Affairs

           The Deputy Secretary of Defense verbally designated the ASD for
           Homeland Defense as the lead for DOD's pandemic influenza planning
           efforts and DOD identified four functional leads to oversee the 31
           tasks assigned to DOD as a lead agency in the national
           implementation plan. In addition to its overall lead role, the
           Office of the ASD for Homeland Defense was the functional lead for
           those tasks in the national implementation plan related to
           providing defense support to civil authorities. The Office of the
           ASD for Health Affairs was the functional lead for force health
           protection tasks in the national implementation plan. The Office
           of the ASD for Special Operations and Low Intensity Conflict was
           the functional lead for tasks in the national implementation plan
           related to stability operations and international support.
           Finally, the Joint Chiefs of Staff were overseeing the combatant
           commands' planning and implementation efforts. According to
           officials in the Offices of the ASD for Homeland Defense and ASD
           for Health Affairs, DOD intentionally organized its functional
           lead offices to mirror the federal government's organization for
           pandemic influenza to improve coordination between DOD and other
           federal government agencies. For example, in general, the Office
           of the ASD for Health Affairs coordinated with HHS on medical
           issues and the Office of the ASD for Special Operations and Low
           Intensity Conflict coordinated with the Department of State on
           international issues.

           In addition to the Pandemic Influenza Task Force, in June 2006 the
           ASD for Homeland Defense convened a senior officer steering group
           comprised of senior military and civilian officials. The steering
           group was to meet quarterly and submit a report to the Homeland
           Security Council detailing DOD's progress on the actions assigned
           to the department in the national implementation plan. The Chief
           of Naval Operations also developed a working group, called the
           Navy Pandemic Influenza Council, in January 2006, which met
           quarterly to examine issues related to an influenza pandemic. The
           Commandant of the Marine Corps originally established his own
           working group that merged with the Navy Pandemic Influenza Council
           to create one working group for the Department of the Navy.
			  
			  Some Offices and Components Issued Guidance on and Developed
			  Plans for Pandemic Influenza

           In September 2004, the ASD for Health Affairs issued guidance to
           the military departments related to preparing for an influenza
           pandemic,14 with the most recent guidance issued in January
           2006.15 This guidance is in addition to the department's existing
           policies on force health protection. The January 2006 guidance,
           which supersedes the September 2004 guidance, was developed by
           preventive medicine experts in the Office of the ASD for Health
           Affairs to provide comprehensive policy guidance for writing the
           combatant command and installation pandemic influenza plans. The
           guidance also provided information on assumptions to use when
           developing plans, such as the percentage of people that could be
           affected by a pandemic and that antiviral supplies will likely be
           insufficient to meet demands. The guidance listed tasks, such as
           developing and exercising plans, for the Office of the Secretary
           of Defense, Joint Chiefs of Staff, military departments,
           installation commanders, military treatment facility commanders,
           and Public Health Emergency Officers to complete for each of WHO's
           phases of an influenza pandemic. Additionally, the guidance tasked
           installations with developing community containment plans to
           contain infections at their source or slow the spread of the
           disease. The guidance also provided information on home care
           infection control that recommended infection control measures,
           such as hand washing. Finally, the guidance included a generic
           prioritization system for DOD's limited supplies of vaccines and
           antivirals and noted that these priorities would be clarified in
           the event of an influenza pandemic. Table 1 lists DOD's current
           generic priorities for vaccines and antivirals.

           Table 1: DOD's Current Priorities for Vaccine and Antiviral
           Distribution
			  
			  Tier   Personnel included in tier                                          
Tier 1 Those personnel necessary to respond to global military             
          contingencies and provide essential health care for the force       
          structure, including (1) those required to maintain national        
          strategic and critical operational capabilities, as defined by the  
          Joint Chiefs of Staff, (2) deployed forces engaged in or supporting 
          armed conflict, and (3) those personnel necessary to maintain a     
          functioning health care system.                                     
Tier 2 Nondeployed forces that are on alert or designated to conduct       
          critical contingency operations as defined by the Joint Chiefs of   
          Staff.                                                              
Tier 3 Personnel necessary to maintain critical mission-essential          
          capabilities at each organizational level.                          
Tier 4 All other Active Component or mobilized reserve component           
          personnel.                                                          
Tier 5 All other beneficiaries not included previously according to the    
          Centers for Disease Control and Prevention priority tiers.   

           Source: DOD.

           Note: DOD's antiviral priorities are the same as its vaccine
           priorities except for individuals who are hospitalized due to a
           pandemic influenza are in the top tier for antivirals.

           The Department of the Navy and the Department of the Air Force
           planned to issue servicewide instructions related to pandemic
           influenza preparedness. Navy and Marine Corps officials said that
           the Department of the Navy was drafting an instruction that would
           cover all biological hazards and would include information on an
           influenza pandemic. According to a Navy official, the instruction
           was expected to be released in the fall of 2006. Similarly, Air
           Force officials said that the Department of the Air Force was
           developing a servicewide instruction on disease containment that
           would include guidance on actions that personnel should take in
           the event of an influenza pandemic. The instruction was expected
           to be released by the end of the summer of 2006. At the time of
           our review, the Department of the Army had not drafted or released
           a servicewide instruction related to pandemic influenza for the
           department; however, its Medical Command and Installation
           Management Agency had released guidance to Army military treatment
           facilities and installations. In November 2004, the Army Medical
           Command tasked its military treatment facilities, including
           hospitals and clinics, on Army installations with updating
           existing plans for Severe Acute Respiratory Syndrome (SARS).16 The
           tasking included guidance to address issues related to influenza
           pandemics in the installations' revised plans, such as identifying
           facilities other than normal hospital or clinic locations at which
           mass vaccinations could be administered. In May 2006, the Army
           Installation Management Agency tasked Army installations to
           develop or update Installation Emergency Response Plans by the end
           of June 2006 to address a response to an influenza pandemic.17 The
           tasking included specific guidance on what should be included in
           the installation plans, such as incorporating pandemic-specific
           information into continuity of operations plans to account for a
           potential reduction of staff.

           The Office of the ASD for Homeland Defense, with support from the
           Offices of the ASD for Health Affairs and ASD for Special
           Operations and Low Intensity Conflict and the Joint Chiefs of
           Staff, completed DOD's implementation plan for an influenza
           pandemic, as required by the national implementation plan. DOD
           started drafting its implementation plan in November 2005 and had
           a draft implementation plan in December 2005. DOD submitted its
           implementation plan to the Homeland Security Council in August
           2006; however, according to an official in the Office of the ASD
           for Homeland Defense, DOD cannot release its implementation plan
           externally until after it is coordinated and approved by the
           Homeland Security Council. The official said that DOD's
           implementation plan provided some guidance on protecting DOD's
           military and civilian personnel, contractors, dependents, and
           beneficiaries in the event of an influenza pandemic; however, the
           plan focused on the actions assigned to DOD in the national
           implementation plan because force health protection measures
           already exist. Appendix II summarizes the guidance and existing
           force health protection policies related to DOD's efforts to
           protect its workforce in the event of an influenza pandemic. The
           officials indicated that DOD expected to update its implementation
           plan as needed. DOD's implementation plan also tasked all offices,
           components, and agencies departmentwide to begin developing or
           modifying existing continuity of operations plans in preparation
           for an influenza pandemic.

           Additionally, DOD's geographic combatant commands-U.S. Central
           Command, U.S. European Command, U.S. Northern Command, U.S.
           Pacific Command, and U.S. Southern Command-and installations were
           tasked with developing pandemic influenza plans. In November 2005,
           the Joint Chiefs of Staff requested that the geographic combatant
           commands develop plans for DOD's response to an influenza pandemic
           that addressed force health protection, defense support to civil
           authorities, and support to humanitarian assistance and disaster
           relief operations. According to an official in the Office of the
           ASD for Homeland Defense, the combatant command plans would
           further define how DOD would implement its assigned actions from
           the national implementation plan. According to officials with the
           Joint Staff, the combatant command plans were almost complete at
           the time of our review. Furthermore, the January 2006 Health
           Affairs guidance tasked installation commanders with developing
           pandemic influenza plans for their installations. According to
           officials in the offices of the ASD for Homeland Defense and ASD
           for Health Affairs, the military services were responsible for
           overseeing the installations' planning efforts.

           DOD Established Web Sites for Pandemic and Avian Influenza Information
			  
			  The Office of the Deputy ASD for Force Health Protection and
           Readiness developed a Web site, the Pandemic Influenza Watchboard,
           which provided information to servicemembers and their families on
           pandemic and avian influenza.18 The Web site provided answers to
           frequently asked questions about avian influenza; links to two of
           DOD's policies for pandemic influenza; data on confirmed human and
           animal H5N1 influenza cases; links to some WHO information on
           response to and containment of an influenza pandemic; links to
           federal government documents, such as the national implementation
           plan; and other federal government Web sites, such as the federal
           government's pandemic influenza Web site ( www.pandemicflu.gov ).
           Additionally, there was a link from the Watchboard to DOD's
           Deployment Health Web site, which is described below. According to
           an official from the Office of the ASD for Homeland Defense, by
           September 2006, all servicemembers, their families, and military
           health system providers will be directed to use the Watchboard as
           the primary DOD platform for messages and information on pandemic
           influenza, with appropriate hyperlinks to other non-DOD Web sites.

           Additionally, the Deployment Health Support Directorate, within
           the Office of the ASD for Health Affairs, established in November
           2005 an informational Web site on avian and pandemic influenza for
           servicemembers and their families.19 It included strategies for
           personnel to protect themselves, such as avoiding poultry farms in
           countries that have had avian influenza outbreaks and washing
           hands with soap and water or using alcohol-based hand sanitizer.
           In addition, it provided links to additional resources, such as
           the federal government's pandemic influenza Web site. At the time
           of our review, there was a link from the Deployment Health Web
           site to the DOD Military Vaccine Agency's pandemic influenza Web
           site, but not to DOD's other pandemic influenza Web sites.

           As part of its Disaster Preparedness and Response Information Web
           site, DOD's Civilian Personnel Management Service developed a Web
           site with some information on pandemic influenza.20 The Web site
           provided information for employees, supervisors, and managers,
           such as a list of phone numbers that civilian employees could call
           for assistance and information; statutory authorities for
           evacuations; and general information on pay, leave, telework, and
           benefits in a natural disaster or declared emergency. The Web site
           also provided links to other resources, such as DOD's Pandemic
           Influenza Watchboard, additional information on avian and pandemic
           influenza on WHO's and the Centers for Disease Control and
           Prevention's Web sites, and the Office of Personnel Management's
           guidance on human capital planning for an influenza pandemic.21
           The Civilian Personnel Management Service Web site stated that
           additional information will be posted as it becomes available.

           Additionally, DOD's Military Vaccination Agency Web site provided
           information on pandemic influenza.22 The Web site provided links
           to news articles on avian influenza; some of DOD's pandemic
           influenza policies and planning documents; two service messages
           related to pandemic influenza; questions and answers on avian and
           pandemic influenza; and some links to related information,
           including links to the Centers for Disease Control and Prevention,
           WHO, and some DOD components' Web sites.

           DOD Procured Antiviral Medications and Vaccines
			  
			  The Office of the ASD for Health Affairs procured antivirals and
           an existing H5N1 vaccine. DOD purchased more than 2 million
           treatment courses of one antiviral and has prepositioned it at
           three storage sites around the world-40 percent of the stockpile
           is in the continental United States, 30 percent is in Europe, and
           30 percent is in the Far East.23 According to officials in the
           Office of the ASD for Health Affairs, DOD purchased an additional
           470,000 treatment courses of the antiviral, which were expected to
           be delivered by December 2006, and 241,000 treatment courses of
           another antiviral, which were expected to be delivered by March
           2007. The additional treatment courses of the first antiviral
           would be located at DOD's military treatment facilities on
           installations, and the second antiviral would be distributed among
           the three antiviral storage sites. Additionally, DOD purchased an
           additional 530,000 treatment courses of the first antiviral, which
           will increase DOD's stockpile of antivirals to 3.4 million
           treatment courses once all of the antivirals are delivered. The
           Office of the ASD for Health Affairs purchased more than 2 million
           doses of an existing H5N1 vaccine based on the strain that
           circulated in Vietnam in 2004 and, in fiscal year 2007, planned to
           purchase an additional 3.6 million doses of the Vietnam strain and
           2.5 million doses of a strain that circulated in Indonesia in
           2005. Officials said that even though a vaccine based on existing
           strains of the H5N1 virus will not necessarily protect its
           recipients from a further mutated pandemic strain, one option is
           to vaccinate personnel with an existing H5N1 vaccine before an
           influenza pandemic starts, which may provide personnel some
           immunity from the disease.24 Officials said that no decision had
           been made on whether to vaccinate personnel before a pandemic, but
           an official in the Office of the ASD for Health Affairs said that
           the current plan was not to administer the vaccine until it had
           been approved or licensed by the Food and Drug Administration.
           According to officials in the Office of the ASD for Health
           Affairs, DOD had a verbal agreement with HHS to purchase
           additional vaccines for future strains of the virus, including a
           pandemic strain.

           DOD Initiated Projects to Assist Other Nationsï¿½ Preparedness
			  
			  The ASD for Special Operations and Low Intensity Conflict and the
           Defense Security Cooperation Agency issued guidance and accepted
           proposals from the combatant commands for projects to build host
           nation military capacity for preparing for, mitigating, and
           responding to a potential influenza pandemic. The combatant
           commands could request funding for projects in four categories:
           (1) influenza planning and preparedness assessments, (2) influenza
           preparedness training programs, (3) response training and exercise
           programs, and (4) increasing military infrastructure capacity.
           Through the end of July 2006, the Office of the ASD for Special
           Operations and Low Intensity Conflict and the Defense Security
           Cooperation Agency had approved nearly 50 proposals from the U.S.
           European Command, U.S. Pacific Command, and U.S. Southern Command
           for projects covering 30 countries. Individual project costs
           ranged from about $17,000 to $150,000 and totaled over $3 million
           for fiscal years 2006 and 2007. For example, the U.S. Pacific
           Command requested a total of about $72,000 to provide the Chinese
           and Indonesian militaries with subject matter experts to share
           experiences in operational planning, health surveillance,
           laboratory testing, and other preparedness and control activities,
           including tools and mechanisms for detecting and tracking cases.
           Additionally, the U.S. European Command requested $100,000 to
           assess the Zambian Defense Force's current capabilities related to
           avian influenza and to develop and implement the capabilities
           necessary to respond to an avian influenza outbreak within Zambia.
			  
			  Going Forward, DOD Faces Four Key Management Challenges in Its
			  Pandemic Influenza Planning and Preparedness Efforts for Its
			  Workforce Departmentwide

           DOD began its planning efforts in September 2004 and, to date,
           efforts related to protecting DOD's personnel have focused
           primarily on the personnel in the military departments, geographic
           combatant commands, and installations. However, as the focus
           shifts to the workforce departmentwide, including its civilian
           workforce and personnel at defense agencies, DOD faces four key
           management challenges going forward as the department continues
           its planning and preparedness efforts related to an influenza
           pandemic. First, neither the Secretary of Defense nor the Deputy
           Secretary of Defense had yet issued departmentwide guidance that
           fully defined an accountability framework for DOD's pandemic
           influenza planning efforts, including defining lead and supporting
           roles and responsibilities with clear lines of authority, formal
           oversight mechanisms, and goals and performance measures.
           Establishing an accountability framework could help the Secretary
           of Defense or Deputy Secretary of Defense monitor the department's
           preparedness for an influenza pandemic. Second, at the time of our
           review, DOD had not yet requested funding for its preparedness
           efforts that was tied to its departmentwide goals. Additional
           funding was necessary to ensure that DOD could complete the
           actions assigned to the department in the national implementation
           plan. Third, DOD had not yet fully defined and communicated
           departmentwide which types of its personnel the department
           expected to include in its distribution of vaccines and antivirals
           in the event of an influenza pandemic. Clarifying this information
           before a pandemic may lessen the confusion over who is to receive
           DOD-purchased vaccines and antivirals during an influenza
           pandemic. Fourth, while certain parts of DOD received actively
           distributed guidance and other information, DOD had not yet fully
           communicated key information to personnel departmentwide on
           actions they should take in the event of an influenza pandemic, as
           well as information on the safety and efficacy of vaccines and
           antivirals. Ensuring that personnel departmentwide receive
           information in advance of an influenza pandemic may lessen
           confusion about what actions personnel should take to protect
           themselves in the event of an influenza pandemic.
			  
			  DOD Had Not Yet Fully Defined Departmentwide Lead and Supporting
			  Roles and Responsibilities, Formal Oversight Mechanisms, and
			  Goals and Performance Measures for Pandemic Influenza

           At the time of our review, neither the Secretary of Defense nor
           the Deputy Secretary of Defense had yet issued guidance that fully
           and clearly defined the lead and supporting roles and
           responsibilities and clear lines of authority for the
           organizations involved in departmentwide pandemic influenza
           planning efforts, formal oversight mechanisms, and goals and
           performance measures for what the leadership expects from DOD's
           preparedness efforts. In our prior work, we have identified six
           desirable characteristics of strategies.25 One of these
           characteristics is that the strategy should address who is
           implementing the strategy, what the roles of organizations will be
           compared to others, and mechanisms to coordinate efforts.
           Similarly, in our work on the federal government's response to
           Hurricane Katrina, we found that, in the event of a catastrophic
           disaster, the leadership roles, responsibilities, and lines of
           authority for response at all levels must be clearly defined and
           effectively communicated to facilitate rapid and effective
           decision making, especially in preparing for and in the early
           hours and days after the disaster.26

           Neither the Secretary of Defense nor the Deputy Secretary of
           Defense had issued guidance on the specific roles and
           responsibilities of the lead and supporting organizations with
           clear lines of authority for DOD's pandemic influenza planning
           efforts. Officials from the Offices of the ASD for Homeland
           Defense and ASD for Health Affairs said that the Deputy Secretary
           of Defense verbally designated the ASD for Homeland Defense to
           lead the department's pandemic influenza planning and preparedness
           efforts with the ASD for Health Affairs providing support on
           medical force health protection issues. However, at the time of
           our review, we were not able to corroborate this information
           because a memorandum documenting this verbal agreement had not
           been distributed throughout the department. In commenting on a
           draft of this report, DOD provided a memorandum dated July 25,
           2006, from the Principal Deputy to the ASD for Homeland Defense
           that documented this information.

           An official from the Office of the ASD for Homeland Defense stated
           that, in preparing for an influenza pandemic, organizations would
           handle issues for which they are responsible in their existing
           directives. However, we observed that the ASD for Homeland Defense
           had not issued a directive outlining its office's general roles
           and responsibilities. While existing policies and directives
           outline the general roles and responsibilities of most DOD
           organizations, we found that some organizations within the
           department were unclear about other organizations' specific roles
           and responsibilities related to preparing for an influenza
           pandemic. For example, an official from one combatant command said
           that clarification was needed on the roles and responsibilities of
           the service headquarters compared to the combatant commands.
           Moreover, an official in one of the services said that more
           guidance was needed on the services' responsibilities in planning
           for and responding to an influenza pandemic. Also, a defense
           agency official was unsure about the agency's role in preparing
           for an influenza pandemic.

           In addition to not yet clearly defining the roles and
           responsibilities for organizations involved in DOD's pandemic
           influenza planning efforts, lines of authority were not yet
           clearly defined. An official from the Office of the ASD for
           Homeland Defense stated that organizations would maintain their
           current lines of authority for DOD's pandemic influenza planning
           efforts; however, as noted earlier, the ASD for Homeland Defense
           currently did not have a directive, which should outline the
           office's relationship with others. Additionally, officials from
           different DOD organizations told us that the current lines of
           authority for DOD's pandemic influenza planning efforts were
           unclear. For example, officials from two of the military services
           said that it was unusual for the ASD for Health Affairs to task
           installations directly with developing plans; rather, the tasking
           usually comes through the military services. One official said
           that installation personnel in that service were confused about
           whether or not they were supposed to be developing plans. We
           further observed differences in the military departments' approach
           to installation planning. Specifically, the Army Medical Command
           and Installation Management Agency issued guidance directing Army
           installations to plan. On the other hand, an Air Force official
           said that the Air Force had not yet tasked its installations
           servicewide to develop plans for an influenza pandemic, but
           planned to task installations to develop disease containment
           plans, which would include information about pandemic influenza,
           after the Air Force's related instruction is published. Defining
           the roles and responsibilities of the lead and supporting offices
           and organizations participating in DOD's pandemic influenza
           planning efforts departmentwide with clear lines of authority
           could better ensure that there are not gaps in DOD's policies and
           plans for pandemic influenza or uncertainty about each
           organization's authorities and responsibilities.

           While the ASD for Homeland Defense established reporting
           requirements for the 31 tasks assigned to DOD in the national
           implementation plan, there was no oversight mechanism for those
           tasks that were not part of the national implementation plan.
           DOD's July 25, 2006, memorandum stated that organizations
           identified as the lead implementers for the 31 tasks assigned to
           DOD as a lead agency in the national implementation plan should
           report their progress on these tasks each month. However, this
           reporting requirement does not apply to other efforts that DOD has
           undertaken, including the tasking in DOD's implementation plan
           that all DOD organizations develop or revise their continuity of
           operations plans in preparation for an influenza pandemic.

           Because of the lack of reporting mechanisms for tasks that are not
           part of the national implementation plan, it is unclear whether
           anyone in the department had an accurate picture of the status of
           DOD's preparedness. At the time of our review, we identified some
           gaps in DOD's planning efforts. For example, at that time, only
           the geographic combatant commands and installations were required
           to develop plans for pandemic influenza. However, numerous DOD
           personnel would not have been covered by these plans, such as
           personnel located in the Pentagon or in DOD-leased space,
           functional combatant commands, and defense agencies. An official
           in the Office of the ASD for Homeland Defense acknowledged the gap
           in planning for personnel in the Pentagon and DOD-leased space.
           DOD has since addressed this gap by tasking all DOD organizations
           to develop or revise their respective continuity of operations
           plans in preparation for an influenza pandemic in DOD's
           implementation plan. Additionally, we identified some overlaps in
           DOD's planning efforts. For example, the January 2006 Health
           Affairs guidance tasked the military departments to develop plans
           for providing support to civil authorities and humanitarian
           assistance, but the combatant commands were already tasked to
           address these issues by the Joint Chiefs of Staff. Without
           oversight mechanisms that address the full range of DOD's
           preparedness efforts, to include those tasks that are not part of
           the 31 tasks for which DOD is named as a lead in the national
           implementation plan, it is unclear whether anyone in the
           department has an accurate picture of the status of DOD's
           preparedness. As DOD continues its planning and preparedness
           efforts for an influenza pandemic, this lack of a formal oversight
           mechanism for those tasks that are not part of the national
           implementation plan may hamper the leadership's abilities to
           ensure that departmentwide planning efforts are progressing as
           intended.

           Moreover, DOD had not yet established goals or performance
           measures for its pandemic influenza preparedness efforts. Another
           desirable characteristic of strategies is that they should
           establish goals for what the strategy strives to achieve-such as a
           description of a desired end-state-and performance measures to
           gauge progress toward results. Identifying goals and performance
           measures aids implementing parties in achieving results and
           enables more effective oversight and accountability. Additionally,
           the goals would provide a baseline, or minimum expectation, of
           what the Secretary of Defense or the Deputy Secretary of Defense
           expects from DOD organizations as they move forward in their
           planning efforts.

           One example of a potential goal, with some modification, for DOD's
           pandemic influenza preparedness efforts comes from the
           department's January 2006 Health Affairs guidance. The purpose of
           the January 2006 guidance was to maintain operational
           effectiveness by minimizing death, disease, and lost duty time due
           to an influenza pandemic. While the purpose of the January 2006
           Health Affairs guidance may serve as the underpinning of a goal
           for DOD's overall preparedness efforts, we previously reported
           that goals should have quantifiable, numerical targets or other
           measurable values, which facilitate assessments of whether overall
           goals were achieved. Other examples of goals for DOD's efforts
           could be ensuring 100 percent of DOD's organizations develop plans
           or update existing plans to address pandemic influenza and
           communicate this information to personnel, or identifying
           personnel supporting critical operations and have a backup plan
           for their absence. After DOD has established overall goals for its
           preparedness efforts, performance measures can assist DOD in
           assessing its progress toward its goals.

           Navy officials said that they had started developing plans for
           pandemic influenza, but it was difficult because the Office of the
           Secretary of Defense had not provided specific information to the
           military services on what is expected of the military services in
           the event of an influenza pandemic. The Navy officials explained
           that if the Office of the Secretary of Defense set goals, such as
           required readiness levels, then Navy officials could develop
           detailed plans for an influenza pandemic. Without overall goals
           for DOD's preparedness efforts and performance measures, it could
           be difficult for combatant commands, the military services, and
           installations to develop plans for an influenza pandemic and for
           the Secretary of Defense to gauge the department's progress toward
           preparedness as DOD continues its ongoing planning efforts.

           Issuing departmentwide guidance detailing roles and
           responsibilities, reporting mechanisms, and goals is not without
           precedent. For example, in November 2002, the Secretary of Defense
           issued a memorandum initiating DOD's Base Realignment and Closure
           process. The memorandum specifically:

           o  Identified the Deputy Secretary of Defense as the individual
           responsible for overseeing the departmentwide process and the
           Under Secretary of Defense for Acquisition, Technology and
           Logistics as the individual responsible for issuing operating
           policies and detailed direction necessary to conduct the process.
           o  Established two senior groups to oversee the departmentwide
           efforts and identified the members of these groups.
           o  Described the roles of the organizations involved in the
           effort.
           o  Established the reporting mechanisms for the process and future
           memoranda more clearly defined the specific reporting time frames.
           o  Established goals for the process.
			  
			  DOD Had Not Yet Identified an Appropriate Funding Mechanism or
			  Requested Funding Tied to Departmentwide Goals

           At the time of our review, DOD had started identifying funding
           requirements, but had not yet identified an appropriate funding
           mechanism or requested funding, tied to its departmentwide goals,
           for its pandemic influenza planning efforts. Another desirable
           characteristic of a strategy is that the strategy should address
           resources, investments, and risk management-what the strategy will
           cost; where resources will be targeted to achieve the end-state;
           and how the strategy balances benefits, risks, and costs. Using a
           risk management approach helps implementing parties allocate
           resources according to priorities; track costs and performance;
           and shift resources, as appropriate. This information also would
           assist DOD in developing a more effective strategy to achieve its
           desired end-state.

           DOD started collecting information on funding requirements for its
           pandemic influenza preparedness efforts. In June 2006, the Joint
           Chiefs of Staff requested that the combatant commands and military
           services identify funding necessary to meet the requirements in
           the national implementation plan and the combatant command plans,
           which could include funding for force health protection, training
           and exercises, laboratory surveillance, and other activities.
           According to most officials we met with in the Office of the
           Secretary of Defense and the military services, funding was a
           challenge regarding the department's influenza pandemic
           preparedness efforts. For example, according to an official in the
           Office of the ASD for Homeland Defense, the national
           implementation plan tasked DOD with increased surveillance
           activities, which will require substantial additional funding to
           complete, but DOD had not yet included this requirement in a
           budget request to the Congress.

           While DOD had started identifying its funding requirements, at the
           time of our review, DOD had not yet identified a mechanism to
           request funding to complete the tasks assigned to DOD in the
           national implementation plan and protect its own personnel. An
           official from the Office of the ASD for Homeland Defense said the
           department had options for requesting the required funding,
           including incorporating the request in future budget submissions
           or submitting a supplemental request to the Congress. An official
           from the Office of the ASD for Health Affairs noted that it was
           difficult for the department to accurately identify the
           department's funding requirements before DOD completed its
           implementation plan. Additionally, according to the official, the
           department was not aware of the funding requirements in support of
           the national implementation plan before the department's previous
           budget submissions to the Congress. However, there were more than
           50 tasks in the national implementation plan for which DOD was
           either a lead or support agency that were to be completed before
           the end of 2006. Because DOD had not yet requested funding, it is
           unclear whether DOD can address the tasks assigned to it in the
           national implementation plan and pursue its own preparedness
           efforts for its workforce departmentwide within current resources.
			  
			  DOD Had Not Yet Defined the Types of Personnel Included in Its
			  Vaccine and Antiviral Distribution Plans or Communicated That
			  Information Departmentwide

           At the time of our review, DOD had not yet clearly defined or
           communicated departmentwide which types of DOD personnel-military
           and civilian personnel, contractors, dependents, and
           beneficiaries-the department planned to include in its
           distribution of vaccines and antivirals in the event of an
           influenza pandemic. We have reported on the importance of DOD
           managing its workforce from a total force perspective, which
           includes active duty and reserve military personnel, civilian
           personnel, and contractor personnel.27 In addition to providing
           medical care to active duty and reserve personnel, DOD is required
           by law to provide medical care to dependents of military personnel
           and certain beneficiaries.28 At the same time, planning to protect
           all of DOD's active duty and reserve personnel, civilian
           personnel, and contractor personnel-as well as beneficiaries and
           dependents-with vaccines and antivirals in the event of an
           influenza pandemic would require extensive resources and likely is
           unrealistic. It will take 6 to 8 months after the pandemic strain
           is identified to produce a vaccine and there are only two
           manufacturers producing vaccines domestically and a limited number
           of antiviral manufacturers. Moreover, there will be widespread
           demand for vaccines and antiviral medications.

           DOD's guidance was vague as to the types of personnel to be
           included in the department's distribution of vaccines and
           antivirals. The ASD for Health Affairs developed generic
           priorities for distributing vaccines to its personnel, as detailed
           in table 1, which would be clarified in the event of an influenza
           pandemic. While DOD's vaccine and antiviral priorities
           specifically mentioned DOD beneficiaries, the guidance did not
           clearly state which types of DOD's employees-military personnel,
           civilian personnel, and contractors-would receive vaccines and
           antivirals from the DOD stockpile. An official in the Office of
           the ASD for Homeland Defense said that the primary purpose of
           DOD's vaccine and antiviral stockpiles was to preserve the
           department's ability to meet the mission requirements of national
           defense and domestic support. The official stated that
           distinctions regarding types of employees-military personnel,
           civilian personnel, and contractors-were not made because whether
           an individual would be included in the distribution of vaccines
           and antivirals was based on whether the individual was identified
           as critical to the execution of an essential mission, which would
           be determined by components as they developed their continuity of
           operations plans. However, this information was not stated in the
           January 2006 Health Affairs guidance or DOD's implementation plan.
           Additionally, DOD's January 2006 Health Policy guidance stated
           that military treatment facilities would obtain vaccines for
           civilian beneficiaries through their usual logistics channels or
           local or state health departments. Similarly, the military
           treatment facilities would obtain antivirals for civilian
           beneficiaries through their usual logistics channels or through
           the local health department to access the Strategic National
           Stockpile. An official in the Office of the ASD for Homeland
           Defense stated that specific use of the antiviral supply through
           the Strategic National Stockpile would be described in an updated
           antiviral release policy that was expected to be issued soon. The
           lack of clarity of which types of personnel DOD plans to include
           in its distribution of vaccines and antivirals could lead to
           confusion among personnel as to whether they will receive vaccines
           and antivirals from the department or should try to obtain them
           from other sources.

           A major factor affecting DOD's ability to clarify priorities for
           the department's current and future vaccine supplies is that DOD's
           priority for receiving future influenza vaccines from HHS had not
           yet been defined. The Office of the ASD for Health Affairs had a
           verbal agreement with HHS to purchase vaccines for future strains
           of influenza, including the pandemic strain. In the event of an
           influenza pandemic, there will likely be high, widespread demand
           for a vaccine across the United States and vaccine production
           capabilities will be limited, particularly compared to the demand.
           At the time of our review, DOD's priority compared to others for
           receiving vaccines for future strains-including the pandemic
           strain-and how many vaccines it will receive was not defined and
           DOD did not have a written agreement with HHS addressing these
           issues. An official from the Office of the ASD for Health Affairs
           said that the prioritization of vaccines for future influenza
           strains, including the pandemic strain, from the HHS contract with
           the vaccine manufacturer was being reevaluated by the Homeland
           Security Council; however, the official said that previous
           discussions had placed DOD in the first tier of agencies to
           receive the vaccine for a pandemic strain when it becomes
           available. The exact number of vaccine doses for future influenza
           strains that will be available is unknown, in part because of the
           unknown production output for a pandemic-specific vaccine. Under
           these circumstances, the department cannot realistically determine
           how well it will be able to meet its priorities for vaccinating
           personnel. Additionally, without knowing a rough estimate of how
           much vaccine will be available, DOD cannot accurately determine
           the funding required to purchase vaccines or, if needed,
           additional antivirals.
			  
			  Although a Communications Strategy Was under Development, DODï¿½s
			  Communication Efforts to Date Were Inconsistent Departmentwide

           At the time of our review, DOD was developing a communications
           strategy for an influenza pandemic, and while not fully developed,
           it continues to evolve. We reported that communication on threats
           should be timely and include specific information on the nature,
           location, and timing of the threat as well as guidance on actions
           to take in response to the threat to ensure early and
           comprehensive information sharing and allow for informed decision
           making.29 These risk communication concepts have been used in a
           variety of warning contexts, including warnings of infectious
           disease outbreaks. Additionally, the national implementation plan
           states that government officials must communicate clearly and
           continuously with the public now and throughout a pandemic, and
           public officials at all levels of government must provide
           unambiguous and consistent guidance on what individuals can do to
           protect themselves, how to care for family members at home, when
           and where to seek medical care, and how to protect others and
           minimize the risks of disease transmission. However, so much is
           unknown about a potential influenza pandemic that it is difficult
           to provide extensive information on preparing for an influenza
           pandemic.

           Some, but not all, organizations received frequent communications
           about avian or pandemic influenza. Several officials across the
           department said their organizations distributed information about
           the current avian influenza threat and pandemic influenza to their
           personnel. For example, an official from U.S. Northern Command's
           Washington office mentioned receiving frequent e-mails from the
           command on the status of avian influenza. In contrast, it was
           unclear whether other DOD organizations, such as the defense
           agencies, received and distributed such information to their
           personnel. For example, at least one defense agency had not
           received any information on planning or preparing for an influenza
           pandemic, including what actions its personnel should take in the
           event of an influenza pandemic. DOD officials said the
           department's communications with its personnel were currently
           limited, in part because DOD's communications strategy for an
           influenza pandemic still was under development and had been
           implemented only to a limited extent. As a result, there currently
           may be gaps and unevenness in awareness among DOD's personnel
           across the department, including military and civilian personnel,
           contractors, dependents, and beneficiaries, about actions they
           should take in the event of an influenza pandemic, which could
           lead to confusion and increased numbers of personnel affected by a
           pandemic.

           Officials from the Offices of the ASD for Homeland Defense and ASD
           for Health Affairs said that DOD planned to use communications
           strategies already in place in addition to those created
           specifically for an influenza pandemic to share information on the
           disease to ensure that personnel know how to protect themselves.
           DOD's January 2006 Health Affairs guidance, which was issued to
           the military departments but not departmentwide, provided some
           information on actions, such as hand washing, that personnel
           should take in the event of an influenza pandemic. According to a
           public affairs official with the Joint Staff, the department
           planned to use its existing influenza Web sites, as well as key
           messages that will be distributed at the installation level, to
           let personnel know what actions to take in the event of an
           influenza pandemic. Existing Web sites had some information on
           what personnel should do to protect themselves, but as DOD
           continues its planning and preparedness efforts, more information
           could be added. For example, one Web site mentioned, among other
           things, that personnel should wash hands and cover coughs and
           sneezes; however, there was no information on what personnel
           should do specifically in the event of an influenza pandemic, such
           as the department's policies on who should seek medical care at
           DOD's military treatment facilities or whether personnel should
           telework from home during an influenza pandemic. Using multiple
           methods-both active and passive-of sharing information on what
           actions to take in the event of an influenza pandemic will be
           useful. For example, some of DOD's personnel are deployed in
           austere or rural environments and may not have access to the
           Internet and, therefore, may not have access to the information
           currently posted on various Web sites.

           In addition to providing information passively on Web sites and
           actively through distributed messages, there is a need to
           communicate with employees deemed "critical" and in the top tiers
           for vaccine and antiviral distribution. These personnel will need
           to know who they are and when and where they should obtain
           vaccines and antivirals. Conversely, employees in the lower tiers
           for vaccine and antiviral distribution will need to be told that
           they will need to rely on other resources to obtain these
           treatments, such as HHS's Strategic National Stockpile or other
           state and local public health sources.

           DOD also had not yet developed a plan to communicate information
           to its personnel on the efficacy of vaccines and antivirals, in
           the event DOD decides to dispense those it has purchased to date,
           but it had posted the package inserts for the two antivirals that
           it purchased on one of its Web sites. In 2002, we reported that
           survey respondents from the Air National Guard and Air Force
           Reserve were generally dissatisfied with the information DOD
           provided about its Anthrax Vaccine Immunization Program. They were
           particularly concerned about the (1) military threat from anthrax,
           (2) anthrax vaccine's battlefield effectiveness, (3) vaccine's
           history and past usage, (4) short-term and long-term safety risks
           of the vaccine, and (5) possible side effects from reactions to
           the vaccine.30 As indicated earlier, DOD is considering whether or
           not to vaccinate personnel before an influenza pandemic to
           possibly provide personnel some degree of immunity from the
           pandemic strain. Based on DOD's experience with the anthrax
           vaccine, if DOD decides to vaccinate its personnel early or after
           an influenza pandemic starts, then the department would benefit
           from a plan addressing how it will communicate information to its
           personnel on the threat of an influenza pandemic and the vaccine's
           efficacy, risks, and potential side effects.
			  
			  Conclusions

           To date, DOD's efforts to protect its personnel from an influenza
           pandemic have focused primarily on the military departments,
           geographic combatant commands, and installations. However, going
           forward, as the department's focus shifts to the workforce
           departmentwide, DOD faces some key management challenges as it
           continues its planning and preparedness efforts related to an
           influenza pandemic. While we recognize that DOD's planning for an
           influenza pandemic continues to evolve, we believe DOD's planning
           efforts would benefit from taking steps to address the challenges
           and gaps we have identified. Planning in an environment of
           tremendous uncertainty for a large workforce deployed worldwide is
           an extremely difficult and complex task. Although DOD has
           mechanisms, systems, and processes in place for force health
           protection, an influenza pandemic would create a different set of
           challenges for DOD. Unlike most diseases, an influenza pandemic
           would spread quickly around the world and, according to government
           estimates, the disease could result in a 40 percent absenteeism
           rate in general through illness, taking care of someone who is
           ill, or fear of becoming ill. Although DOD has taken many
           appropriate and important steps to prepare for an influenza
           pandemic, challenges remain. First, DOD's planning efforts would
           benefit from an accountability framework, with clearly defined
           roles and responsibilities, an oversight mechanism, and goals and
           performance measures. Such an accountability framework could help
           the Secretary of Defense or Deputy Secretary of Defense to monitor
           the department's readiness for an influenza pandemic and the
           Secretary of Defense-and the Congress-could better ascertain when
           and to what extent the Armed Forces and critical functions
           departmentwide are prepared to meet this potential emergency at
           home and abroad. Second, by identifying an appropriate funding
           mechanism and requesting funding for pandemic influenza
           preparedness efforts that is tied to the department's goals, the
           Secretary of Defense can better ensure that the department can
           accomplish its tasks in the national implementation plan and
           protect its personnel. Third, going forward, DOD would benefit
           from clarifying in advance and communicating with personnel which
           types of personnel it plans to include in its distribution of
           vaccines and antivirals, which may lessen the confusion over who
           is to receive DOD-purchased vaccines and antivirals during an
           influenza pandemic. Fourth, by developing a departmentwide
           strategy that communicates key information to all of its
           workforce, DOD's military and civilian personnel, contractors,
           dependents, and beneficiaries may better know what actions to take
           to protect themselves in the event of an influenza pandemic.
			  
			  Recommendations for Executive Action

           To improve accountability and oversight of planning efforts across
           DOD as the department continues its pandemic influenza planning
           for its workforce, we recommend that the Secretary of Defense do
           the following.

           o  Instruct the Assistant Secretary of Defense for Homeland
           Defense, as the individual accountable for DOD's pandemic
           influenza planning and preparedness efforts, to clearly and fully
           define and communicate departmentwide the roles and
           responsibilities of the organizations that will be involved in
           DOD's efforts, with clear lines of authority; the oversight
           mechanisms, including reporting requirements, for all aspects of
           DOD's pandemic influenza planning efforts, to include those tasks
           that are outside of the national implementation plan; and the
           goals and performance measures for DOD's planning and preparedness
           efforts.

           o  Instruct the Assistant Secretary of Defense for Homeland
           Defense to work with the Under Secretary of Defense (Comptroller)
           to establish a framework for requesting funding for the
           department's preparedness efforts. The framework should include
           the appropriate funding mechanism and controls to ensure that
           needed funding for DOD's pandemic influenza preparedness efforts
           is tied to the department's goals.

           o  Instruct the Assistant Secretary of Defense for Health Affairs
           to clarify DOD's guidance to explicitly define whether or how all
           types of personnel-including DOD's military and civilian
           personnel, contractors, dependents, and beneficiaries-would be
           included in DOD's distribution of vaccines and antivirals and
           communicate this information departmentwide.

           o  Instruct the Assistant Secretary of Defense for Public Affairs
           to implement a comprehensive and effective communications strategy
           departmentwide that is transparent as to what actions each group
           of personnel should take and the limitations of the efficacy,
           risks, and potential side effects of vaccines and antivirals.

           Agency Comments and Our Evaluation
			  
			  In written comments on a draft of this report, DOD concurred, with
           comment, with four of our five original recommendations, and did
           not address one recommendation. DOD also provided technical
           comments, which we have incorporated in the report, as
           appropriate. Based on DOD's written and technical comments and
           supporting documentation DOD provided in response to our draft
           report, we combined two of our recommendations and modified
           another recommendation, as discussed below.

           In written comments, DOD stated that the recommendations in the
           draft report reflected information that was over a year old. As
           stated in our scope and methodology in appendix I, we based our
           report on information gathered from December 2005 through August
           2006. Notwithstanding, after reviewing a draft of this report, DOD
           provided some additional documentation, which we incorporated, as
           discussed below.

           We originally recommended that the Secretary of Defense designate
           a lead individual within DOD who is accountable to the Secretary
           for influenza pandemic planning and preparedness efforts, and
           provide the individual with the authority to establish oversight
           mechanisms, including reporting requirements, for the department's
           pandemic influenza efforts. We also recommended that this lead
           individual identify and communicate roles and responsibilities of
           the offices and components involved in DOD's preparedness efforts,
           and the goals and performance measures for DOD's efforts. In its
           written and technical comments, DOD stated that the Deputy
           Secretary of Defense verbally designated the ASD for Homeland
           Defense to lead the department's preparation for a potential
           influenza pandemic. Our draft report reflected this statement and
           noted we could not corroborate or find documentation of this
           verbal designation. DOD's comments referred to a July 25, 2006,
           memorandum from the Principal Deputy to the ASD for Homeland
           Defense, which we subsequently obtained. This memorandum states
           that the Deputy Secretary of Defense designated the ASD for
           Homeland Defense to lead the department's preparation for a
           potential pandemic influenza. The memorandum also directs
           individual offices to carry out each of the 31 tasks for which DOD
           is the lead agency in the national implementation plan and report
           each month on their progress on the 31 tasks. However, the 31
           tasks do not address the entirety of DOD's planning efforts and
           specifically exclude DOD organizations' planning efforts to
           protect its workforce departmentwide. With regard to our
           recommendation to establish goals and performance measures, DOD
           concurred and commented that the January 2006 Health Affairs
           guidance and the national and DOD implementation plans describe
           the roles and responsibilities of several DOD organizations. While
           we agree that these documents list specific tasks for some
           organizations to complete, they do not address overall roles and
           responsibilities for departmentwide pandemic influenza planning
           efforts. DOD also commented that the national implementation plan
           and DOD's implementation plan already provide specific tasks with
           specific time frames for completion. We agree that these
           implementation plans, as well as the July 25, 2006, memorandum
           from the Principal Deputy to the ASD for Homeland Defense, provide
           time frames to complete individual tasks. Nevertheless, the intent
           of our recommendation is that DOD develop departmentwide goals and
           performance measures for DOD's overall pandemic influenza planning
           and preparedness efforts, including that for its total workforce,
           rather than time frames for individual tasks. In light of the
           additional information DOD provided on the role of the ASD for
           Homeland Defense as the lead for DOD's pandemic influenza planning
           efforts, we revised our recommendation to read that the Secretary
           of Defense instruct the ASD for Homeland Defense to clearly and
           fully define and communicate departmentwide the roles and
           responsibilities of organizations involved in DOD's efforts with
           clear lines of authority, oversight mechanisms, and goals and
           performance measures for DOD's efforts.

           DOD concurred, with comment, with our recommendation that the
           Secretary's designated lead for DOD's influenza pandemic planning
           and preparedness efforts task the combatant commands and military
           departments to identify funding requirements that are linked to
           the department's preparedness goals and build them into DOD's
           future budget requests. DOD commented, and we acknowledged in our
           draft report, that DOD had begun to gather funding requirements
           for the department's pandemic influenza efforts. Nevertheless, we
           modified our recommendation to include a focus on requesting
           needed funding that is tied to departmentwide goals.

           DOD's written comments did not address our recommendation that the
           Secretary's designated lead for DOD's planning and preparedness
           efforts instruct the ASD for Health Affairs to clarify DOD's
           guidance to more clearly define the types of personnel included in
           DOD's distribution of vaccines and antivirals and communicate this
           information departmentwide. However, in its technical comments,
           DOD stated that the department's prioritization list for vaccines
           and antivirals is based on functional roles in the organization
           and distinctions in the type of personnel are not made because
           these divisions do not reflect function. DOD also stated that
           individual components are responsible for determining which
           individuals are critical when updating their continuity of
           operations plans. We incorporated this information into our
           report. We continue to believe our recommendation has merit and
           should be implemented because DOD's existing guidance remains
           unclear on what types of personnel are included in DOD's
           distribution of vaccines and antivirals and components' continuity
           of operations plans are not yet complete.

           Additionally, DOD concurred, with comment, with our recommendation
           that the ASD for Public Affairs clarify and implement a
           comprehensive and effective communications strategy. In its
           written and technical comments, DOD stated that the Office of the
           ASD for Public Affairs developed an annex for DOD's implementation
           plan and plans to issue an integrated internal communications plan
           in September 2006. We are encouraged that the ASD for Public
           Affairs is developing an integrated internal communications plan
           for reaching DOD's internal audiences. Because the plan is not yet
           complete, we continue to believe our recommendation has merit and
           should be implemented.

           As we agreed with your office, unless you publicly announce the
           contents of this report earlier, we plan no further distribution
           of it until 30 days from the date of this letter. We will then
           send copies to the Chairmen and Ranking Members of the Senate and
           House Committees on Appropriations; the Chairmen and Ranking
           Members, Senate and House Committees on Armed Services; and other
           interested congressional parties. We also are sending copies to
           the Secretary of Defense; Secretary of Health and Human Services;
           Secretary of Homeland Security; and Director, Office of Management
           and Budget. We will make copies available to others upon request.
           In addition, the report will be available at no charge on GAO's
           Web site at http://www.gao.gov.

           If you or your staff have any questions concerning this report,
           please contact me at (202) 512-5431 or by e-mail at
           [email protected]. 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 contributions to this
           report are listed in appendix IV.

           Davi M. D'Agostino
			  Director Defense Capabilities and Management

           Appendix I: Scope and Methodology
			  
			  As part of our review of the Department of Defense's (DOD)
           planning and preparedness for a pandemic influenza, we determined
           (1) actions that DOD has taken to date to prepare for an influenza
           pandemic and (2) management challenges that DOD faces going
           forward as the department continues its planning efforts. We are
           reporting on these issues now so that DOD can consider and address
           our findings as the department continues its planning and
           preparedness efforts. We have not yet assessed DOD's
           implementation plan for pandemic influenza, since it was not yet
           complete at the time of our review; however, we plan to assess
           DOD's implementation plan, the combatant commands' implementation
           plans, and selected installation plans in another report that will
           be issued at a later date.

           To determine the actions that DOD has taken to date to prepare for
           an influenza pandemic, we reviewed a draft of DOD's implementation
           plan for pandemic influenza dated March 2006.1 Additionally, we
           reviewed guidance issued by the Office of the Assistant Secretary
           of Defense (ASD) for Health Affairs in September 2004 and January
           2006; a planning order issued by the Joint Chiefs of Staff to the
           combatant commands in November 2005; planning guidance issued by
           the Army Medical Command to the Army regional medical commands in
           November 2004; and planning guidance issued by the Army
           Installation Management Agency to Army installations in May 2006.
           We also reviewed the department's existing force health protection
           directives, which were identified in DOD's January 2006 Health
           Affairs guidance and DOD's draft implementation plan and by
           officials in the Office of the ASD for Health Affairs. These
           directives are summarized in appendix II. We reviewed the
           Implementation Plan for the National Strategy for Pandemic
           Influenza to understand what was required of federal
           departments-including DOD-in their pandemic influenza preparedness
           efforts. Furthermore, we reviewed HHS's contract with a vaccine
           manufacturer and DOD's antiviral contracts with two manufacturers.
           Additionally, we met in the Washington, D.C., area with DOD
           officials from the Office of the Under Secretary of Defense for
           Policy, Office of the ASD for Homeland Defense, Office of the ASD
           for Health Affairs, Office of the ASD for Reserve Affairs, Office
           of the Deputy Under Secretary of Defense for Logistics and
           Materiel Readiness, Office of the Deputy ASD for Stability
           Operations, Office of Force Transformation (Defense), National
           Guard Bureau, Joint Chiefs of Staff, Department of the Army,
           Department of the Navy, Marine Corps Headquarters, and Department
           of the Air Force.

           To better understand the threat of an influenza pandemic, we met
           with officials from the Defense Intelligence Agency's Armed Forces
           Medical Intelligence Center, Fort Detrick, Maryland, and the
           Central Intelligence Agency, McLean, Virginia.

           To determine management challenges that DOD faces as it continues
           its planning efforts, we compared the department's actions to date
           to best practices that we have identified in our prior work.
           Specifically, we compared DOD's actions to date to the desirable
           characteristics of national strategies, which state that a
           national strategy should include

           o  purpose, scope, and methodology;
           o  problem definition and risk assessment;
           o  goals, subordinate objectives, activities, and performance
           measures;
           o  resources, investments, and risk management;
           o  organizational roles, responsibilities, and coordination; and
           o  integration and implementation.

           While we are not yet assessing DOD's draft implementation plan and
           it is not a national strategy, we determined that some of the
           characteristics are applicable to planning efforts in general,
           specifically those related to identifying goals and performance
           measures, resources and investments, and organizational roles and
           responsibilities. Because we are not yet assessing DOD's
           implementation plan, we used the characteristics as guidance for
           how DOD could approach its planning efforts, as opposed to a
           checklist of what DOD should be doing. Additionally, we relied on
           our previous work on total force management to determine which
           types of personnel DOD should include in its plans for vaccine and
           antiviral distribution. Furthermore, we relied on our previous
           work on risk communication principles to determine whether DOD's
           current communications strategy meets these principles. Finally,
           we reviewed our prior work on influenza pandemics.

           We conducted our review from December 2005 through August 2006 in
           accordance with generally accepted government auditing standards.

           Appendix II: Summary of DODï¿½s Guidance for Pandemic Influenza and Related Force Health Protection Policies
			  
			  Title of guidance,                                                         
responsible office or                              Applicability of the    
organization, and date   Purpose of guidance       guidance
Department of Defense    To provide policy and     Military departments,   
Influenza Pandemic       instructions to prepare   the Joint Staff, and    
Preparation and Response for and respond to an     the combatant commands; 
Health Policy Guidance   influenza pandemic;       the guidance was        
(January 2006)           facilitate integration    provided to the Coast   
                            into the National         Guard as a reference.   
                            Strategy for Pandemic     
                            Influenza, outline an     
                            appropriate response for  
                            military installations    
                            and contingency           
                            operations worldwide, and 
                            provide guidance for      
                            defense support to civil  
                            authorities.              
Policy for Release of    To provide guidance for   Applicability was not   
Tamiflu(R) (Oseltamivir) the release of the        listed, but guidance    
Antiviral Stockpile      Department of Defense's   was addressed to the    
During an Influenza      (DOD) Tamiflu stockpile;  secretaries of the      
Pandemic (January 2006)  establishes generic       military departments,   
                            prioritization tiers for  Chairman of the Joint   
                            Tamiflu.                  Chiefs of Staff, Under  
                                                      Secretaries of Defense, 
                                                      Commandant of the U.S.  
                                                      Coast Guard, Assistant  
                                                      Secretaries of Defense, 
                                                      DOD General Counsel,    
                                                      DOD Inspector General,  
                                                      and directors of        
                                                      defense agencies.       
Policy for the Use of    To set policy and         Applicability was not   
Influenza Vaccine for    priorities for use of     listed, but guidance    
the 2005-2006 Influenza  influenza vaccine for the was addressed to the    
Season (November 2005)   2005-2006 influenza       Assistant Secretaries   
                            season.                   of the Military         
                                                      Departments for         
                                                      Manpower and Reserve    
                                                      Affairs; Director,      
                                                      Joint Staff; ASD for    
                                                      Reserve Affairs;        
                                                      Military Department     
                                                      Surgeons General; and   
                                                      Defense Supply Center   
                                                      Philadelphia.           
DOD Directive 6490.2,    To establish policy and   Office of the Secretary 
Comprehensive Health     assign responsibility for of Defense, military    
Surveillance (October    routine, comprehensive    departments, Chairman   
2004)                    health surveillance of    of the Joint Chiefs of  
                            all military              Staff, combatant        
                            servicemembers during     commands, defense       
                            active federal service.   agencies, DOD field     
                                                      activities, and all     
                                                      other organizational    
                                                      entities in DOD.        
DOD Directive 6200.4,    To establish policy and   Office of the Secretary 
Force Health Protection  assign responsibility for of Defense, military    
(October 2004)           implementing force health departments, Chairman   
                            protection measures on    of the Joint Chiefs of  
                            behalf of all military    Staff, combatant        
                            servicemembers during     commands, Office of the 
                            active and reserve        Inspector General,      
                            military service.         defense agencies, DOD   
                                                      field activities, and   
                                                      all other               
                                                      organizational entities 
                                                      in DOD.                 
Department of Defense    To provide instruction on Military departments,   
Guidance for Preparation actions to take in        nonmilitary persons     
and Response to an       preparation for the       under military          
Influenza Pandemic       possibility of an         jurisdiction, selected  
Caused by the Bird Flu   influenza pandemic, to    federal employees, and  
(Avian Influenza)        implement recommendations family members and      
(September 2004)         from the Department of    other people eligible   
                            Health and Human          for care within the     
                            Services' National        military health system. 
                            Pandemic Influenza        
                            Response Plan.            
DOD Directive 6200.3,    To establish policy to    Office of the Secretary 
Emergency Health Powers  protect installations,    of Defense, military    
on Military              facilities, and personnel departments, Chairman   
Installations (May 2003) in the event of a public  of the Joint Chiefs of  
                            health emergency due to   Staff, Office of the    
                            biological warfare,       Inspector General,      
                            terrorism, other public   combatant commands,     
                            health emergency, or a    defense agencies, DOD   
                            communicable disease      field activities, and   
                            epidemic.                 all other               
                                                      organizational entities 
                                                      in DOD.                 
Policy for Use of Force  To establish policy to    Applicability was not   
Health Protection        comply with the statutory listed, but guidance    
Prescription Products    requirement regarding use was addressed to the    
(April 2003)             of prescription-only      Assistant Secretaries   
                            drugs, vaccines, and      of the Military         
                            other medical products.   Services for Manpower   
                                                      and Reserve Affairs;    
                                                      Director, Joint Staff;  
                                                      Surgeons General of the 
                                                      Military Departments;   
                                                      and Deputy Director for 
                                                      Medical Readiness,      
                                                      Joint Staff.            
DOD Directive 6200.2,    To establish policy and   Office of the Secretary 
Use of Investigational   assign responsibility     of Defense, military    
New Drugs for Force      regarding legal           departments, Chairman   
Health Protection        requirements for use of   of the Joint Chiefs of  
(August 2000)            investigational new drugs Staff, combatant        
                            and designates the        commands, Office of the 
                            Secretary of the Army as  DOD Inspector General,  
                            the Executive Agent for   defense agencies, DOD   
                            the use of                field activities, and   
                            investigational new drugs all other               
                            for force health          organizational entities 
                            protection.               within DOD.             
Policy for DOD Global,   To set DOD policy to      Applicability was not   
Laboratory-Based         conduct global,           listed, but guidance    
Influenza  Surveillance  operationally relevant    was addressed to the    
(February 1999)          laboratory-based          Surgeons General of the 
                            influenza surveillance.   Military Services; and  
                                                      Deputy Director for     
                                                      Medical Readiness, J-4, 
                                                      Joint Staff.            
Joint Tactics,           To guide combatant        Commanders of combatant 
Techniques, and          commanders and their      commands, subunified    
Procedures for           subordinate joint force   commands, joint task    
Noncombatant Evacuation  and component commanders  forces, and subordinate 
Operations Joint Report  in preparing for and      components of the       
3-07.51 (September 1997) conducting noncombatant   commands.               
                            evacuation operations.    
DOD Instruction 3020.37, Enclosure E3 sets policy  Office of the Secretary 
Continuation of          for civilian contractors  of Defense; military    
Essential DOD Contractor entering a theater of     departments including   
Services During Crises   operations, including     the Coast Guard when    
(November 1990),         ensuring them the same    operating as a service  
Administrative           medical care given to     in the Navy; Chairman   
Reissuance Incorporating military personnel.       of the Joint Chiefs of  
Change 1 (January 1996),                           Staff and the Joint     
Enclosure E3, Guidelines                           Staff; combatant        
for Theater Admission                              commands; Inspector     
Procedures                                         General; and defense    
                                                      agencies.               
DOD Directive 1404.10,   Updates policy,           Office of the Secretary 
Emergency Essential      responsibilities, and     of Defense; military    
(E-E) DOD U.S. Citizen   procedures regarding      departments, including  
Civilian Employees       employees in civilian     the Coast Guard when    
(April 1992)             positions designated      operating as a service  
                            emergency essential.      in the Navy; Chairman   
                                                      of the Joint Chiefs of  
                                                      Staff and the Joint     
                                                      Staff; combatant        
                                                      commands; Inspector     
                                                      General; defense        
                                                      agencies; and DOD field 
                                                      activities.             
DOD Directive 3025.14,   Updates policies,         Office of the Secretary 
Protection and           responsibilities, and     of Defense; military    
Evacuation of U.S.       procedures for protection departments, including  
Citizens and Designated  and evacuation of U.S.    the Coast Guard when    
Aliens in Danger Areas   citizens and designated   operating as a service  
Abroad (November 1990)   aliens in danger areas    in the Navy; Chairman   
                            abroad, and assigns       of the Joint Chiefs of  
                            responsibilities for      Staff and the Joint     
                            noncombatant evacuation   Staff; combatant        
                            operations planning and   commands; and defense   
                            implementation.           agencies.               
DOD Directive 6205.2,    Addresses immunization    Office of the Secretary 
Immunization             policies for all armed    of Defense; military    
Requirements (October    forces members, DOD       departments, including  
1986)                    civilian employees, and   their guard and reserve 
                            eligible beneficiaries of components;             
                            the military health care  Organization of the     
                            system.                   Joint Chiefs of Staff;  
                                                      and defense agencies. 
			  
			  Source: GAO analysis.
			  
			  Appendix III: Comments from the Department of Defense

           Appendix IV: GAO Contact and Staff Acknowledgments
			  
			  GAO Contact
			  
			  Davi M. D'Agostino, Director, 202-512-5431, [email protected]

           Staff Acknowledgments
			  
			  Mark A. Pross, Assistant Director; Susan Ditto; Nicole Gore; Simon
           Hirschfeld; Aaron Johnson; John E. Miller; and Hilary Murrish made
           key contributions to this report.

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14Department of Defense, Office of the Assistant Secretary of Defense for
Health Affairs, Department of Defense Guidance for Preparation and
Response to an Influenza Pandemic Caused By the Bird Flu (Avian Influenza)
(Washington, D.C.: Sept. 21, 2004).

15Department of Defense, Office of the Assistant Secretary of Defense for
Health Affairs, Department of Defense Influenza Pandemic Preparation and
Response Health Policy Guidance (Washington, D.C.: Jan. 25, 2006).

16United States Army Medical Command, Avian Influenza Planning Guidance
and Tasking (Fort Sam Houston, Tx.: 2004).

17United States Army Installation Management Agency, Influenza Pandemic
Preparation and Response (Arlington, Va.: 2006).

18See https://fhp.osd.mil/aiWatchboard/index.html .

19See
http://deploymentlink.osd.mil/medical/medical_issues/immun/avian_flu.shtml
.

20See http://www.cpms.osd.mil/disasters/pan.htm .

21Office of Personnel Management, Agency Guidance - Human Capital
Management Policy for a Pandemic Influenza (Washington, D.C.: Aug. 2006).

22See http://www.vaccines.mil/ .

23A treatment course consists of two capsules per day for 5 days if used
for treatment, and one capsule per day for at least 10 days for
prevention.

24There is currently some scientific debate regarding the appropriateness
of using a pre-pandemic vaccine. In addition to concerns about the
vaccine's effectiveness against a pandemic strain, some health experts
have expressed concern that vaccinating individuals with a pre-pandemic
vaccine could reduce the effectiveness of vaccines subsequently produced
from the pandemic strain for these individuals.

25 GAO-04-408T .

26GAO, Hurricane Katrina: GAO's Preliminary Observations Regarding
Preparedness, Response, and Recovery, GAO-06-442T (Washington, D.C.: Mar.
8, 2006).

27GAO, DOD Personnel: DOD Actions Needed to Strengthen Civilian Human
Capital Strategic Planning and Integration with Military Personnel and
Sourcing Decisions, GAO-03-475 (Washington, D.C: Mar. 28, 2003).

2810 U.S.C. 1071 et. seq.

29 GAO, Homeland Security: Communication Protocols and Risk Communication
Principles Can Assist in Refining the Advisory System, GAO-04-682
(Washington, D.C.: June 25, 2004).

30GAO, Anthrax Vaccine: GAO's Survey of Guard and Reserve Pilots and
Aircrew, GAO-02-445 (Washington, D.C.: Sept. 20, 2002).

Appendix I: Scope and Methodology Appendix I: Scope and Methodology

1DOD released its implementation plan to the Homeland Security Council on
August 16, 2006, as we were completing our review. However, according to
an official in the Office of the ASD for Homeland Defense, DOD cannot
release its implementation plan externally until it is coordinated and
approved by the Homeland Security Council. We reviewed the final plan and
determined that it was not significantly different from the March 2006
draft that we previously reviewed. 

(350890)

www.gao.gov/cgi-bin/getrpt? GAO-06-1042 .

To view the full product, including the scope
and methodology, click on the link above.

For more information, contact Davi M. D'Agostino at (202) 512-5431 or
[email protected].

Highlights of GAO-06-1042 , a report to the Chairman and Ranking Minority
Member, Committee on Government Reform, House of Representatives

September 2006

INFLUENZA PANDEMIC

DOD Has Taken Important Actions to Prepare, but Accountability, Funding,
and Communications Need to be Clearer and Focused Departmentwide

An influenza pandemic would be of global and national significance and
could affect large numbers of Department of Defense (DOD) personnel,
seriously challenging DOD's readiness.

GAO was asked to examine DOD's pandemic influenza preparedness efforts.
This report focuses on DOD's planning for its workforce, specifically (1)
actions DOD has taken to prepare and (2) challenges DOD faces going
forward. GAO analyzed guidance, contracts, and plans, and met with DOD
officials.

What GAO Recommends

GAO recommends that DOD

(1) define and communicate roles and responsibilities, oversight
mechanisms, and goals and performance measures for DOD's efforts, (2)
establish a framework to request funding, tied to its goals, (3) define
and communicate departmentwide which types of personnel DOD plans to
include in its vaccine and antiviral distribution, and (4) implement a
comprehensive and effective departmentwide communications strategy. DOD
generally concurred with four recommendations, and did not address one in
its written comments. Based on DOD's comments and additional information
provided showing DOD designated a lead authority for its efforts, GAO
combined two recommendations. GAO clarified another recommendation to
focus on requesting funding tied to the department's goals.

DOD had taken a number of actions since September 2004 to prepare for an
influenza pandemic, and its planning efforts continue to evolve. The
Implementation Plan for the National Strategy for Pandemic Influenza,
released in May 2006, tasked each federal department to develop its own
implementation plan that details how it will carry out its
responsibilities as outlined in the national plan and how it will prepare
its workforce. DOD established working groups for its pandemic influenza
planning efforts, including the Pandemic Influenza Task Force, which
included representatives from across the department, including the Offices
of the Assistant Secretary of Defense (ASD) for Homeland Defense, ASD for
Health Affairs, ASD for Special Operations and Low Intensity Conflict, and
the Joint Chiefs of Staff. In addition, the Office of the ASD for Health
Affairs developed guidance that provided tasks for the Office of the
Secretary of Defense, military departments, installation commanders, and
others to complete to prepare for a pandemic. Further, several entities
within DOD drafted plans and guidance, and DOD had taken other important
steps, such as establishing Web sites, stockpiling vaccines and
antivirals, and initiating projects to assist other nations with their
preparedness efforts.

Going forward, DOD faces four management challenges that it needs to
address as it shifts its focus to the department as a whole. First, at the
time of GAO's review, neither the Secretary of Defense nor the Deputy
Secretary of Defense had yet issued guidance defining lead and supporting
roles and responsibilities with clear lines of authority, oversight
mechanisms, and goals and performance measures for DOD's influenza
pandemic planning efforts. The lack of these accountability mechanisms
over time may hamper the leadership's ability to ensure that planning
efforts across the department are progressing as intended. Second, DOD had
not yet requested funding for its pandemic influenza preparedness efforts
linked to departmentwide goals. Therefore, it is unclear whether DOD can
address the tasks assigned to it in the national implementation plan and
pursue its own preparedness efforts for its workforce departmentwide
within current resources. Third, DOD had not yet fully defined or
communicated departmentwide which types of personnel-military and civilian
personnel, contractors, beneficiaries, and dependents-it plans to include
in its distribution of vaccines and antivirals. Fourth, DOD had not yet
fully developed its communications strategy or communicated information to
its personnel departmentwide on what actions to take in the event of an
influenza pandemic. Also, DOD had not yet developed a plan to communicate
information on the safety and efficacy of vaccines and antivirals, if DOD
decides to dispense them. While DOD established Web sites with some
information on pandemic influenza, GAO identified some unevenness across
the department in terms of the information personnel received. A
comprehensive and effective communications strategy could ensure that
DOD's personnel departmentwide are aware of actions they should take in
the event of an influenza pandemic.
*** End of document. ***