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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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 Nations� 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, DOD�s
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 DOD�s 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. ***