    Influenza Pandemic: Efforts to Forestall Onset Are Under Way;
    Identifying Countries at Greatest Risk Entails Challenges
    (20-JUN-07, GAO-07-604).

    Since 2003, a global epidemic of avian influenza has raised
    concern about the risk of an influenza pandemic among humans,
    which could cause millions of deaths. The United States and its
    international partners have begun implementing a strategy to
    forestall (prevent or delay) a pandemic and prepare to cope
    should one occur. Disease experts generally agree that the risk
    of a pandemic strain emerging from avian influenza in a given
    country varies with (1) environmental factors, such as disease
    presence and certain high-risk farming practices, and (2)
    preparedness factors, such as a country's capacity to control
    outbreaks. This report describes (1) U.S. and international
    efforts to assess pandemic risk by country and prioritize
    countries for assistance and (2) steps that the United States and
    international partners have taken to improve the ability to
    forestall a pandemic. To address these objectives, we interviewed
    officials and analyzed data from U.S. agencies, international
    organizations, and nongovernmental experts. The U.S. and
    international agencies whose efforts we describe reviewed a draft
    of this report. In general, they concurred with our findings.
    Several provided technical comments, which we incorporated as
    appropriate.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-07-604
        ACCNO:   A71195
      TITLE:     Influenza Pandemic: Efforts to Forestall Onset Are Under
    Way; Identifying Countries at Greatest Risk Entails Challenges
         DATE:   06/20/2007
      SUBJECT:   Avian influenza
    	     Birds
    	     Emergency preparedness
    	     Epidemics
    	     Federal aid to foreign countries
    	     Infectious diseases
    	     International organizations
    	     International relations
    	     Pandemic
    	     Poultry
    	     Risk assessment
    	     Strategic planning

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    GAO-07-604

         * [1]Results in Brief
         * [2]Background

              * [3]Pandemic Risk Varies with Environmental Conditions and Prepa
              * [4]Different Systems and Approaches Are Used to Control Influen
              * [5]The United States and International Partners Have Adopted an

         * [6]Information Gaps Hinder Assessments of Comparative Risk and

              * [7]USAID Environmental Risk Assessment Illustrated Information
              * [8]USAID, State Department, and UN Data Collection Efforts Have

                   * [9]USAID and State Department Data Collection on Country
                     Prepar
                   * [10]UN Data Collection and Analysis on Country Preparedness

              * [11]World Bank-Led Missions Have Provided Additional Information
              * [12]Efforts to Assemble More Comprehensive Information on Countr
              * [13]The United States Has Prioritized Countries Based on Availab

         * [14]The United States Has Played a Prominent Role in Global Effo

              * [15]The United States Has Been a Leader in Financing Efforts to
              * [16]The United States and Other Donors Are Funding Efforts at Co
              * [17]Most Country-Specific Commitments Have Gone to U.S. Priority
              * [18]USAID and HHS Implement Most U.S.-Funded Activities
              * [19]U.S. Implementation Plan Establishes a Framework for U.S. Ac

                   * [20]Preparedness and Communications Actions Include Creating
                     Eme
                   * [21]Surveillance and Detection Actions Include Training
                     Foreign
                   * [22]Response and Containment Actions Include Development of
                     Outb
                   * [23]Homeland Security Council Reported Success on Action
                     Items t

         * [24]Concluding Observations
         * [25]Agency Comments and Our Evaluation
         * [26]Appendix I: Scope and Methodology
         * [27]Appendix II: Comments from the U.S. Agency for International
         * [28]Appendix III: Comments from the Department of Health and Hum

              * [29]GAO Comment

         * [30]Appendix IV: Comments from the Department of Agriculture
         * [31]Appendix V: Analysis of Selected USAID and State Department

              * [32]Scope and Methodology

         * [33]Appendix VI: Assistance to Regional and Global Organizations
         * [34]Appendix VII: U.S. Agency Obligations Funding by Pillar
         * [35]Appendix VIII: Distribution of USAID Personal Protective Equ
         * [36]Appendix IX: GAO Contacts and Staff Acknowledgments

              * [37]GAO Contacts
              * [38]Staff Acknowledgements

         * [39]Related GAO Products

              * [40]Order by Mail or Phone

    Report to Congressional Requesters

    United States Government Accountability Office

    GAO

    June 2007

    INFLUENZA PANDEMIC

    Efforts to Forestall Onset Are Under Way; Identifying Countries at
    Greatest Risk Entails Challenges

    GAO-07-604

    Contents

    Letter 1

    Results in Brief 3
    Background 5
    Information Gaps Hinder Assessments of Comparative Risk and Identification
    of Priority Countries 14
    The United States Has Played a Prominent Role in Global Efforts to Improve
    Preparedness 27
    Concluding Observations 42
    Agency Comments and Our Evaluation 43
    Appendix I Scope and Methodology 46
    Appendix II Comments from the U.S. Agency for International Development 51
    Appendix III Comments from the Department of Health and Human Services 55
    Appendix IV Comments from the Department of Agriculture 59
    Appendix V Analysis of Selected USAID and State Department Rapid
    Assessments of Avian Influenza Preparedness 60
    Appendix VI Assistance to Regional and Global Organizations 65
    Appendix VII U.S. Agency Obligations Funding by Pillar 68
    Appendix VIII Distribution of USAID Personal Protective Equipment Kits 69
    Appendix IX GAO Contacts and Staff Acknowledgments 71
    Related GAO Products 72

    Tables

    Table 1: Confirmed Human H5N1 Cases by Country, 2003 through 2006 8
    Table 2: U.S. Planned Funding for International Avian and Pandemic
    Influenza Assistance by Agency and by Pillar/Activity 34
    Table 3: Regional Recipients of Donor Assistance for International Avian
    and Pandemic Influenza Preparedness as of December 2006 65
    Table 4: U.S. Obligations for International Avian and Pandemic Influenza
    Assistance by Agency and by Pillar/Activity 68

    Figures

    Figure 1: Locations of Reported H5N1 Infection in Poultry, Wild Birds, or
    Both and in Humans through December 2006 7
    Figure 2: Global Response to the Spread of H5N1 through December 2006 13
    Figure 3: USAID Assessment of Country-by-Country Risk of H5N1 Outbreaks 16
    Figure 4: UN Summary of Country Preparedness, December 2006 - Bangladesh
    20
    Figure 5: Pledges and Commitments for International Avian and Pandemic
    Influenza Assistance by Donor, as of December 2006 29
    Figure 6: Allocation of U.S. and Global Commitments for International
    Avian and Pandemic Influenza Assistance, as of December 2006 30
    Figure 7: Top 15 Recipients of Committed, Country-Specific International
    Avian and Pandemic Influenza Funding as of December 2006 31
    Figure 8: U.S. Planned Funding for International Avian and Pandemic
    Influenza Assistance by Agency 33
    Figure 9: Selected Action Item for Preparedness and
    Communications--Creating Emergency Stockpiles 36
    Figure 10: Selected Action Item for Surveillance and Detection--Training
    Foreign Health Professionals 38
    Figure 11: Selected Action Item for Response and Containment--Developing
    Rapid Response Teams 40
    Figure 12: Avian Influenza Preparedness--Analysis of Selected Indicators
    and Countries from USAID and State Department Rapid Assessments
    (October/November 2005) 61
    Figure 13: Global Organization Recipients of Donor Commitments for
    International Avian and Pandemic Influenza Preparedness as of December
    2006 67
    Figure 14: Distribution of USAID PPE Kits as of October 2006 70

    Abbreviations

    CDC Centers for Disease Control and Prevention of the Department of Health
    and Human Services
    DOD Department of Defense
    FAO United Nations Food and Agriculture Organization
    HHS Department of Health and Human Services
    OIE World Organization for Animal Health (Office International des Epizooties)
    PPE personal protective equipment
    UN United Nations
    USAID U.S. Agency for International Development
    USDA Department of Agriculture
    WHO United Nations World Health Organization

    This is a work of the U.S. government and is not subject to copyright
    protection in the United States. It may be reproduced and distributed in
    its entirety without further permission from GAO. However, because this
    work may contain copyrighted images or other material, permission from the
    copyright holder may be necessary if you wish to reproduce this material
    separately.

    United States Government Accountability Office
    Washington, DC 20548

    June 20, 2007

    The Honorable Edward M. Kennedy
    Chairman
    Committee on Health, Education, Labor, and Pensions
    United States Senate

    The Honorable Daniel Akaka
    Chairman
    Subcommittee on Oversight of Government Management, the Federal
    Workforce, and the District of Columbia
    Committee on Homeland Security and Governmental Affairs
    United States Senate

    Since the end of 2003, a global epidemic of avian influenza^1 among
    poultry has raised concern about the risk of a global influenza
    epidemic--a pandemic--occurring among humans. Though initially confined to
    Southeast Asia, since mid-2005, this epidemic has spread to the Middle
    East, Europe, and Africa and has caused the deaths of more than 250
    million poultry, either directly or as a result of culling programs
    designed to stop its spread. While thus posing a serious threat to farmer
    livelihoods, the H5N1 strain of influenza that is causing this epidemic
    has also demonstrated the ability to infect and kill humans. From 2003
    through 2006, more than 260 humans contracted the H5N1 strain and more
    than half of them died.^2 Nearly all of these cases resulted from contact
    with infected poultry. However, if H5N1 develops the ability to pass
    easily among humans, an influenza pandemic could ensue. In contrast to the
    more moderate health threat presented by annual outbreaks of seasonal
    influenza,^3 pandemic influenza poses a grave threat to global public
    health. Scientists estimate that the pandemic of 1918 to 1919 killed more
    than 50 million humans, including an estimated 675,000 Americans, although
    the last two pandemics (in 1957 and 1968) were milder.

    ^1In this report, we use the term avian influenza to refer to the highly
    pathogenic form of this disease, which can cause nearly 100 percent
    mortality in infected poultry. The disease can also occur in low
    pathogenic forms that cause only mild symptoms in infected birds.

    ^2From December 2003 through the end of 2006, the World Health
    Organization confirmed 263 cases of H5N1 in humans and 158 deaths.

    ^3The World Health Organization estimates that annual epidemics of
    seasonal influenza affect about 10 to 20 percent of the world's population
    each year, causing 3 million to 5 million cases of severe illness and
    250,000 to 500,000 deaths.

    Disease experts caution that it is not possible to predict when or where
    the next influenza pandemic will begin--or whether it will involve H5N1.
    Nonetheless, concern that H5N1 may spark a pandemic has increased as the
    virus has spread among countries with comparatively high levels of
    environmental and preparedness-related risk--that is, countries where

               o the virus is already present, or is present in a neighboring
               country, and a range of conditions, such as high-risk poultry
               farming practices, are conducive to H5N1 spreading in poultry and
               infecting humans (environmental risk)^4 and
               o animal and human health systems are relatively unprepared to
               detect or respond appropriately to this virus (preparedness risk).

               The United Nations World Health Organization (WHO) has concluded
               that the H5N1 epidemic in poultry has brought the world closer to
               an influenza pandemic than at any time in the last 40 years.
               Concern about this threat has prompted the United States and its
               international partners to launch efforts aimed at improving global
               preparedness to both forestall (prevent or at least delay) the
               onset of an influenza pandemic and cope with a pandemic should one
               occur. As agreed with your offices, we focused on U.S. and
               international efforts to forestall a pandemic. This report
               addresses (1) the extent to which U.S. agencies and their
               international partners have assessed the country-by-country risk
               of H5N1 sparking a pandemic and prioritized countries for
               international assistance and (2) the steps that U.S. agencies and
               their international partners have taken to improve global
               preparedness to forestall a pandemic.

               In related work, we are examining constraints on the use of
               vaccines and antiviral drugs to help in forestalling a pandemic
               and efforts that are under way to overcome these constraints. Our
               analysis of these issues will be published in a separate report.

    ^4More specifically, we use the term environmental risk to include risk
    from a range of factors, including known disease presence or proximity
    (such as the H5N1 virus being well-established among domestic poultry and
    the risk that the virus will be introduced from neighboring countries by
    unregulated trade in poultry and other birds, or by wild birds); large
    numbers of poultry being raised in heavily populated areas; and high-risk
    agricultural practices, such as allowing poultry unrestricted access to
    family homes and selling poultry in markets with inadequate cleaning and
    disinfection.

               To address our objectives, we reviewed relevant Department of
               Agriculture (USDA), Department of Health and Human Services (HHS),
               Department of Defense (DOD), Department of State, and U.S. Agency
               for International Development (USAID) planning, funding, and
               reporting documents for avian and pandemic influenza programs and
               discussed them with agency officials. We examined and analyzed
               documents such as country risk and preparedness assessments,
               operational plans, and budget spreadsheets. We also analyzed the
               U.S government's strategy and plan for addressing pandemic
               influenza and associated reports on progress through December
               2006.^5 In addition, we studied relevant documents from the United
               Nations (UN) and other international organizations, including WHO,
               the United Nations Food and Agriculture Organization (FAO), the
               World Bank, and the World Organization for Animal Health (OIE).^6
               Finally, we consulted with nongovernmental and academic experts on
               avian and pandemic influenza. We determined that the data provided
               to us were sufficiently reliable for the purposes of this report.
               We conducted our work from January 2006 through March 2007 in
               accordance with generally accepted government auditing standards.
               Appendix I provides a detailed description of our scope and
               methodology. A list of other GAO reports on pandemic preparedness,
               influenza vaccine development, and related topics is included at
               the end of this report.

    			  Results in Brief

               Assessments by U.S. agencies and international organizations have
               identified widespread environmental and preparedness-related risks
               in many countries and the United States has designated priority
               countries for assistance, but gaps in available information limit
               the capacity for comprehensive, well-informed comparisons of risk
               levels by country. Assessment efforts we examined, carried out by
               U.S. and international agencies, illustrate these gaps. For
               example, a USAID assessment categorized countries according to
               level of environmental risk, considering disease presence and the
               likelihood of transmission from nearby countries, but factors such
               as poor understanding of the role poultry trade and wild birds
               play in transmitting the disease constrained the reliability of
               USAID's conclusions. USAID, the State Department, and the UN have
               administered questionnaires aimed at assessing country
               preparedness in areas ranging from national planning to the
               availability of antiviral drugs. The information collected has
               proven useful in planning for projects but has not been
               sufficiently detailed or complete to permit well-informed country
               comparisons. Similarly, World Bank-led missions have gathered more
               detailed information in a limited number of countries, but these
               efforts do not provide a basis for making complete or
               comprehensive global comparisons. Efforts to assemble better
               information are under way, but will take time to produce results.
               Despite these limitations, the U.S. Homeland Security Council has
               used available information to designate about 20 priority
               countries for U.S. assistance.^7 In addition, U.S. agency
               officials stated that certain of these priority countries have
               emerged as being of especially high concern, and federal agencies
               are preparing interagency operating plans for these countries.

    ^5According to U.S. agency officials, the Homeland Security Council is
    currently preparing a new report that provides updated information on U.S.
    efforts to improve both domestic and international pandemic influenza
    preparedness and response.

    ^6OIE stands for Office International des Epizooties--the organization's
    original name, adopted at its founding in 1924. In 2003, the organization
    decided to begin using the name World Organization for Animal Health while
    retaining the OIE acronym. OIE is a multilateral organization but is not
    part of the UN system.

               The United States has played a prominent role in global efforts to
               improve avian and pandemic influenza preparedness, committing the
               greatest share of funds and creating a framework for managing its
               efforts. Through 2006, the United States had committed about $377
               million to improve global preparedness for pandemic influenza,
               about 27 percent of the $1.4 billion committed by all donors.^8
               U.S. agencies and other donors have reported committing funds to
               recipients at the global, regional, and country-specific levels,
               with more than 70 percent of country-specific funds going to U.S.
               priority countries. USAID and HHS have provided more than 90
               percent of U.S. funding, while the State Department coordinates
               agency efforts. Specific efforts funded to date include, for
               example, stockpiling personal protective equipment kits and other
               commodities for outbreak investigations and response and training
               foreign health professionals to detect and respond to disease
               outbreaks. The U.S. National Strategy for Pandemic Influenza
               Implementation Plan provides a framework for implementing U.S.
               international efforts, assigning agencies responsibility for
               completing specific actions, and in most cases specifying
               performance measures and time frames for determining whether the
               action items have been completed. The Homeland Security Council
               monitors agency efforts to implement the plan. It reported in
               December 2006 that all international action items due to be
               completed by November had been completed, and provided evidence of
               timely completion for the majority of these items.

    ^7The Homeland Security Council, with input from an interagency process,
    identified 19 priority countries in May of 2006, considering various risk
    and political factors; the list currently includes 21 countries, according
    to State Department officials.

    ^8Data on commitments by donor, including the United States, were obtained
    from the World Bank. U.S. data reflect amounts reported to the World Bank
    by the United States. Some U.S. activities that also benefit international
    influenza preparedness, such as DOD laboratories abroad with significant
    diagnostic capacities, are not included in these amounts. The World Bank
    monitors international financial flows for influenza preparedness in terms
    of funds pledged, committed, and disbursed. As defined by the bank,
    commitments are roughly equivalent to U.S. agency planned funding
    levels--the budget projections that agencies use for planning purposes.

               USAID, HHS, and USDA provided written comments on a draft of this
               report, and the Department of the Treasury (Treasury) provided
               oral comments. These agencies generally concurred with our
               findings. USAID briefly reviewed progress to date in improving
               global preparedness, and emphasized that in the coming months the
               agency will be focusing in particular on developing more effective
               approaches to controlling the spread of H5N1 in small-scale
               "backyard farms" where high-risk agricultural practices are
               common.^9 While acknowledging the information gaps that limit
               country-by-country risk assessment, HHS emphasized its support for
               targeting resources to priority countries as identified by the
               Homeland Security Council. In this context, HHS stressed the
               importance of improving information sharing among countries. USDA
               stated that it found the report accurate in its description of
               USDA's role and involvement in global efforts to improve
               preparedness. In its oral comments, Treasury described its efforts
               to encourage and support efforts by the World Bank and other
               international financial institutions to address the threats
               discussed in this report, and emphasized that in addition to
               providing funds, these international institutions have contributed
               to the global response in other ways, such as tracking and
               reporting on donor commitments and helping countries develop
               national strategies. In addition, we received technical comments
               from HHS and Treasury, as well as the Department of State, DOD,
               WHO, the United Nations System Influenza Coordinator, FAO, OIE,
               and the World Bank. We incorporated these comments in the report
               as appropriate.

    			  Background

               H5N1 has spread to infect poultry and wild birds over a wide
               geographic area. After appearing in southeastern China and Hong
               Kong in 1996 and 1997, the virus reappeared in late 2003 and early
               2004 in a number of other Southeast Asian countries. In 2005 and
               2006, it spread rapidly to countries in other parts of Asia and to
               Europe and Africa. Through December 2006, H5N1 had been detected
               in poultry and wild birds in nearly 60 countries. Figure 1 shows
               the progression of the disease across countries and also notes
               which of those countries have experienced human cases.

    ^9USAID also stated that it will be placing much greater emphasis on
    developing plans and capabilities for responding to an influenza
    pandemic--a matter that lies beyond the scope of this report.

    Figure 1: Locations of Reported H5N1 Infection in Poultry, Wild Birds, or
    Both and in Humans through December 2006

    Note: No new countries reported outbreaks among birds from July through
    December 2006. However, during the first 3 months of 2007 two additional
    countries--Bangladesh and Saudi Arabia--reported such outbreaks for the
    first time.

    H5N1 has infected increasing numbers of humans. WHO confirmed only 4 cases
    of H5N1 infection among humans in 2003, and 3 of these occurred in one
    country, Vietnam. In contrast, WHO confirmed 115 human cases in 2006, in
    nine different countries. Table 1 shows how the number and distribution of
    human cases grew from 2003 through 2006. The largest numbers of human
    cases occurred in Southeast Asian countries where the virus is well
    established in wild and domestic birds.

    Table 1: Confirmed Human H5N1 Cases by Country, 2003 through 2006

    Countries by group                   2003 2004 2005 2006 Total
    Southeast Asian countries Vietnam       3   29   61   --    93
                                 Indonesia    --   --   20   55    75
                                 Thailand     --   17    5    3    25
                                 China         1   --    8   13    22
                                 Cambodia     --   --    4    2     6
    Other countries           Egypt        --   --   --   18    18
                                 Turkey       --   --   --   12    12
                                 Azerbaijan   --   --   --    8     8
                                 Iraq         --   --   --    3     3
                                 Djibouti     --   --   --    1     1
    All countries                           4   46   98  115   263

    Source: WHO.

    Note: Through June 12, 2007 WHO confirmed an additional 49 cases in six
    different countries. Of these cases, 24 occurred in Indonesia and 18
    occurred in Egypt. The remainder occurred in Cambodia and in China, and in
    two countries that had not previously reported human case--Nigeria and
    Laos.

    Pandemics can occur when influenza strains emerge that have never
    circulated among humans but can cause serious illness in them and can pass
    easily from one person to the next. H5N1 has shown that it can cause
    serious illness in humans, and could spark a pandemic if it evolves into a
    strain that has the ability to pass easily from one human to the next.^10

    H5N1 may evolve into such a strain gradually, through accumulation of a
    number of small mutations, or suddenly, through the introduction of
    genetic material from another influenza virus. Influenza A viruses, which
    cause both avian influenza outbreaks and human influenza pandemics, occur
    naturally in wild birds and can also infect pigs, humans, and other
    mammals. The various subtypes, including H5N1, mutate as they reproduce in
    their avian or mammal hosts. These small mutations continually produce new
    strains with slightly different characteristics. More rarely, when an
    animal or human is infected with two different subtypes, an entirely new
    subtype can emerge. Scientists believe that the 1957 and 1968 pandemics
    began when subtypes circulating in birds and humans simultaneously
    infected and combined into new subtypes in other host animals, most likely
    pigs.^11

    10According to HHS and WHO, there have been a limited number of human
    cases in which human-to-human transmission cannot be ruled out. However,
    H5N1 has not yet demonstrated an ability to spread efficiently and
    sustainably among humans.

    Pandemic Risk Varies with Environmental Conditions and Preparedness

    Disease experts caution that there are significant gaps in our
    understanding of the H5N1 virus in wild and domestic birds and in humans,
    and it is not possible to quantify the pandemic risk presented by this
    strain. However, they generally agree that the level of risk that H5N1
    will spark a pandemic varies with (1) environmental factors, defined as
    the extent to which a country or region has already become infected with
    the virus--or may become infected from a neighboring country--and provides
    conditions in which the virus can spread in poultry and infect humans, and
    (2) preparedness factors, defined as the extent to which the country or
    region is prepared to detect the virus in poultry and humans and respond
    appropriately.

    Taking both environmental and preparedness factors into consideration, the
    risk of a pandemic emerging from the current H5N1 epidemic in poultry is
    considered higher in countries or regions where

               o the virus is well-established among domestic poultry;
               o there is substantial risk that wild birds or unregulated trade
               in poultry and other birds will introduce the virus from
               neighboring infected countries;
               o large numbers of poultry are raised in heavily populated areas;

    ^11H5N1 has been reported among pigs. Disease experts have also expressed
    concern about a pandemic virus emerging as a result of a human becoming
    simultaneously infected with H5N1 and one of the subtypes that commonly
    causes seasonal influenza.

               o high-risk agricultural practices (such as allowing poultry
               unrestricted access to family homes and selling them in "wet
               markets"^12) are common;
               o local authorities have little ability to detect, diagnose, and
               report H5N1 cases or outbreaks in either poultry or humans; or
               o local authorities have little ability to respond (apply control
               measures) and contain outbreaks when they occur.

               In such conditions, outbreaks among humans or poultry are more
               likely to occur and to persist for prolonged periods before they
               are detected or investigated. This increases the potential for
               mutations, and thus the emergence of a pandemic strain.

    			  Different Systems and Approaches Are Used to Control Influenza
    			  in Animals and Humans

               The global community maintains separate systems for addressing
               influenza and other infectious diseases in animals and humans. At
               the country level, agricultural agencies are responsible for
               addressing disease threats to animals, while public health
               agencies are responsible for addressing disease threats to humans.
               International organizations support and coordinate these national
               efforts. In particular, OIE and FAO share lead responsibility for
               addressing infectious disease threats to animal health, while WHO
               leads efforts to safeguard humans. National agencies with
               technical expertise, such as USDA and HHS, assist in these
               efforts.

               The animal and human health systems have traditionally approached
               influenza in different ways. The animal health system has
               emphasized measures to protect flocks from exposure to
               influenza--for example, by reducing contact with wild birds--and,
               when outbreaks nonetheless occur, taking action to contain them
               and eradicate threatening strains. Outbreak control measures
               include (1) identifying and isolating infected zones, (2)
               "stamping out" the virus by culling (killing) all poultry within
               these zones, and (3) cleaning and disinfecting facilities before
               reintroducing poultry. Vaccines that prevent clinical illness in
               poultry--and decrease the risk of transmission to both other
               poultry and humans--are available. However, these vaccines do not
               completely prevent influenza viruses from infecting and
               replicating in apparently healthy poultry and veterinary
               authorities recommend their use only in conjunction with other
               disease control measures.^13 No effective antiviral drugs are
               available for poultry and thus animal health agencies do not
               recommend their use.

    ^12FAO and OIE define a wet market as a "a place, either fixed or
    temporary, where members of the public go to buy small mammals and birds
    that are (a) live and slaughtered there, (b) live and taken home to be
    slaughtered, or (c) already slaughtered and sold as meat." Some of these
    markets provide greater risks of disease transmission than others.
    High-risk practices in some of these markets include stacking cages on top
    of one another, inadequate cleaning and disinfection, and returning unsold
    birds (which may have been exposed to the virus) to the farms from which
    they came.

    ^13In March 2007 an international scientific conference organized by FAO
    and OIE, among other organizations, recommended that poultry be vaccinated
    against avian influenza, particularly in countries where the disease is
    well-established and where other control measures cannot stop the disease
    from spreading. However, the conferees added that any vaccination policy
    should include a strategy for eventually ending the vaccinations so that
    countries do not rely on costly, long-term vaccination campaigns, and
    recommended the use of tools to differentiate infected from vaccinated
    animals. An OIE official emphasized that the organization does not
    recommend across-the-board preventive vaccination in countries not yet
    affected by H5N1.

               The human health system's approach to both seasonal and pandemic
               influenza has traditionally emphasized development and application
               of vaccines to limit spread and protect individuals.^14 However,
               while vaccines are likely to play a key role in mitigating the
               impact of the next pandemic, they are likely to play little role
               in forestalling its onset, barring major changes in technology.
               Prior to a strain being identified, the pharmaceutical industry
               cannot currently produce vaccines that are certain to be effective
               against it. Rather, when a new strain is identified, 6 months or
               more are required to develop and reach full production capacity
               for new vaccines. Therefore, a pandemic will likely be well under
               way before a vaccine that is specifically formulated to counteract
               the pandemic strain becomes available.^15 Antiviral drugs are also
               used to treat and prevent seasonal influenza in humans and could
               be used in the event of a pandemic to contain or slow the spread
               of the virus.^16 In contrast to the approach used with poultry,
               the human public health community has not generally attempted to
               contain an initial outbreak of a pandemic-potential strain or to
                eradicate it while it is still confined to a limited area.^17

    ^14Vaccines can provide full or partial immunity to influenza and thus
    help control the spread of the disease. Vaccines confer immunity by
    causing the body to produce antibodies to fight off particular strains.
    Vaccines that produce an adequate antibody response to a particular strain
    may prevent illness from that strain in 70 to 90 percent of healthy adults
    under the age of 65, with lower effectiveness among older adults.

    ^15While specifically targeted vaccines cannot be produced until a
    pandemic strain is identified, efforts are under way in the United States
    and other countries to produce pre-pandemic vaccines--that is, vaccines
    that are designed to provide protection against influenza strains (such as
    H5N1 strains) that have caused isolated infections in humans and have
    pandemic potential. Since such vaccines are prepared prior to the
    emergence of a pandemic strain, they may be a good or poor match (and thus
    provide greater or lesser protection) for the pandemic strain that
    ultimately emerges. In April 2007 the U.S. Food and Drug Administration
    approved the first such pre-pandemic vaccine for human use in the United
    States against H5N1.
    ^16Antiviral drugs can be used both to prevent illness and as a treatment.
    Studies suggest that such drugs may be as effective as vaccines in
    preventing influenza illness in healthy young adults and, when used for
    treatment, to shorten its duration and severity.

    ^17An exception was the U.S. government decision to mass vaccinate the
    public against an outbreak of swine flu in New Jersey in 1976. That effort
    was halted when a small apparent risk emerged of contracting
    Guillain-Barre syndrome--an inflammatory disorder that can cause
    paralysis--from the swine flu vaccine.

               The United States and International Partners Have Adopted an
    			  Overall Response Strategy

               The U.S. government has developed a national strategy for
               addressing the threats presented by H5N1, and has also worked with
               its international partners to develop an overall global strategy
               that is compatible with the U.S. approach. In November 2005 the
               Homeland Security Council published an interagency National
               Strategy for Pandemic Influenza, followed in May 2006 by an
               Implementation Plan that assigns responsibilities to specific U.S.
               agencies. The U.S. strategy, in addition to outlining U.S. plans
               for coping with a pandemic within its own territory, states that
               the United States will work to "stop, slow, or otherwise limit" a
               pandemic beginning outside its own territory. The strategy has
               three pillars that provide a framework for its implementation: (1)
               preparedness and communications, (2) surveillance and detection,
               and (3) response and containment. The United States has also
               worked with UN agencies, OIE, and other governments to develop an
               overall international strategy. Figure 2 shows key steps in the
               development of this international strategy in relation to the
               spread of the H5N1 virus. These steps included the appointment of
               a UN System Influenza Coordinator and periodic global conferences
               to review progress and refine the strategy. The most recent global
               conference was held in Bamako, Mali, in early December 2006.

    Figure 2: Global Response to the Spread of H5N1 through December 2006

    aFAO and OIE, in collaboration with WHO, A Global Strategy for the
    Progressive Control of Highly Pathogenic Avian Influenza (November 2005).

    bSee UN System Influenza Coordinator and World Bank, Responses to Avian
    and Human Influenza Threats: Progress, Analysis and Recommendations
    January-June 2006.

    cSee UN System Influenza Coordinator and World Bank, Responses to Avian
    and Human Influenza Threats: Progress, Analysis and Recommendations
    July-December 2006 (January 2007).

    At the global level, according to the UN coordinator, the overall
    strategic goal of avian and pandemic influenza-related efforts is to
    create conditions that enable all countries to (1) control avian influenza
    in poultry, and thus reduce the risk that it poses for humans; (2) watch
    for sustained human-to-human transmission of the disease (through improved
    surveillance) and be ready to contain it;^18 and (3) if containment is not
    successful, mitigate the impact of a pandemic. To guide efforts to improve
    capacity for performing these tasks, the UN System Influenza Coordinator
    has identified seven broad objectives. Four of these focus in large
    measure on improving capacity to forestall a pandemic:^19

    18WHO has developed a strategy for containing an initial outbreak of
    pandemic influenza. For the most recent version of this strategy, see WHO
    Interim Protocol: Rapid operations to contain the initial emergence of
    pandemic influenza (May 2007).

               o Improve animal health practices and the performance of
               veterinary services.
               o Sustain livelihoods of poorer farmers whose animals may be
               affected by illness or by control measures, including culling
               programs.
               o Strengthen public health services in their ability to protect
               against newly emerging infections.
               o Provide public information to encourage behavioral changes that
               will reduce pandemic risks.

    			  Information Gaps Hinder Assessments of Comparative Risk and
    			  Identification of Priority Countries

               Although U.S. and international assessments have identified
               serious and widespread environmental and preparedness-related
               risks in many countries, gaps in the available information on both
               types of risk have hindered comprehensive, well-informed
               comparisons of risk levels by country. Assessment efforts that we
               examined, carried out by U.S. and international agencies from late
               2005 through late 2006, illustrate these gaps.^20 Efforts to
               assemble more comprehensive information are under way, but will
               take time to produce results. Despite these limitations, the
               Homeland Security Council has used available information to
               designate about 20 priority countries for U.S. assistance, and
               U.S. officials have determined that the United States should
               focus, in particular, on certain of these countries where pandemic
               risk levels appear comparatively high, including Indonesia,
               Nigeria, and Egypt.

    ^19Two of the remaining three objectives focus on increasing preparedness
    for managing under pandemic conditions. The final objective focuses on
    coordinating national, regional, and international stakeholders in both
    areas. According to the World Bank, effective action against avian and
    pandemic influenza is multisectoral in nature and must involve players
    from many areas, including human health, agriculture, economics, and
    finance.

    ^20WHO, FAO, and other international, U.S., and foreign country agencies
    also have conducted a variety of assessment and assistance missions in
    individual countries. For example, WHO reported carrying out assessment
    missions in 29 countries during the first 6 months of 2006, often in
    collaboration with other agencies. Such missions provide useful
    information for planning preparedness improvement efforts. However, they
    have not been conducted in a comprehensive or uniform manner.

               USAID Environmental Risk Assessment Illustrated Information
    			  Shortfalls

               A global analysis based on environmental factors that USAID
               originally conducted during 2005^21 identified areas at greater
               risk for outbreaks but revealed gaps in available information.
               USAID considered two factors in its analysis: (1) the extent to
               which H5N1 was already present in animals and (2) the likelihood
               that the virus will be introduced from another country through
               factors such as trade in poultry and other birds and bird
               migration. USAID undertook this assessment to inform its decisions
               about spending priorities in the initial phase of heightened
               concern about human pandemic risk from H5N1, when very little risk
               information was available, according to USAID officials. USAID
               used OIE data on reported animal cases. For countries that had not
               yet reported cases, USAID estimated the risk of introduction based
               on proximity to affected countries and available information on
               poultry trade and bird migration patterns. USAID concluded that
               the countries at highest risk for new or recurring H5N1 outbreaks,
               or both, were those in Southeast Asia where the disease was
               well-established, with widespread and recurring infections in
               animals since 2003 (see fig. 3). Countries that were comparatively
               distant from those that had already reported cases were deemed at
               lowest risk.^22

    ^21USAID last updated this assessment in May 2006.

    ^22The World Bank conducted a similar risk assessment in December 2005,
    when H5N1 had been reported in fewer than 20 countries, mainly in Eastern
    and Central Asia. The subsequent detection of the virus in more than 30
    additional countries, including several in Africa, rendered this earlier
    assessment invalid, and the World Bank has not redone its analysis.

    Figure 3: USAID Assessment of Country-by-Country Risk of H5N1 Outbreaks

    We identified three constraints on the reliability of these USAID
    categorizations. First, global surveillance of the disease among domestic
    animals has serious shortfalls. While OIE and FAO collaborate to obtain
    and confirm information on suspected H5N1 cases, surveillance capacity
    remains weak in many countries.^23 Second, estimates of risk for disease
    transmission from one country to another, as well as among regions within
    countries, are difficult to make because of uncertainties about how
    factors such as trade in poultry and other birds and wild bird migration
    affect the movement of the disease. Specifically, illegal trade in birds
    is largely undocumented and movement of the virus through the wild bird
    population is poorly understood. Finally, these categorizations did not
    take other elements of environmental risk, such as high-risk agricultural
    practices, into account.^24

    23Similar weaknesses hamper surveillance among humans. For example, one
    senior WHO official said that numerous "disease blind spots" around the
    world hamper the organization's ability to identify H5N1 outbreaks.

    USAID, State Department, and UN Data Collection Efforts Have Found Widespread
    Preparedness Weaknesses but Have Not Resulted in Clear Country Comparisons

    USAID, the State Department, and the UN System Influenza Coordinator^25
    have each administered questionnaires to assess country-by-country avian
    and pandemic influenza preparedness. These efforts identified widespread
    preparedness weaknesses and provided information for planning improvement
    efforts in individual countries. However, the results did not provide
    information that was sufficiently detailed or complete to permit clear
    categorization of countries by level of preparedness.

      USAID and State Department Data Collection on Country Preparedness

    During 2005, USAID and the State Department collected country-level data
    that indicated widespread weaknesses in countries' ability to detect and
    respond to avian and pandemic influenza, but did not provide enough
    information to place the examined countries in preparedness categories.
    USAID and the State Department sent separate questionnaires to their
    respective missions around the world to obtain a quick overview of avian
    and pandemic influenza preparedness by country.^26 The two agencies
    requested information on key areas of concern, including surveillance,
    response, and communications capacity, and stockpiles of drugs and other
    supplies. These efforts identified widespread preparedness shortfalls. Our
    analysis of a selection of the USAID and State Department results found,
    for example, that many of the countries had not prepared stockpiles of
    antiviral drugs or did not have plans for compensating farmers in the
    event that culling becomes necessary. Missions in African countries
    reported the greatest overall shortfalls. (See app. V for our analysis of
    the USAID and State Department preparedness responses.)

    ^24Analysts from the U.S. intelligence community have attempted to provide
    a more thorough analysis of risk arising from environmental factors. This
    work was initially conducted in late 2006 under the auspices of the
    Department of State, focusing on Southeast Asia. The intelligence
    community analysts subsequently extended this analysis to cover other
    countries. They developed a statistical model for identifying areas at
    greater risk, introducing corrections for disease underreporting in areas
    known to have poor surveillance, and employing data on four general
    factors significant to the spread of H5N1 in animals: commerce, farming
    practices, terrain, and seasonality. (For example, the model uses detailed
    data on proximity to roads, poultry populations, terrain ruggedness, and
    monthly minimum and maximum temperatures.) The analysis used statistical
    techniques to identify areas at greater or lesser risk for future H5N1
    outbreaks. According to a State Department official, the model provides
    useful insights, but is of limited value for predicting new outbreaks and
    is not sufficiently robust to be relied upon as a basis for
    differentiating among countries or allocating resources to those
    presenting the greatest risk.

    ^25The UN effort was undertaken in collaboration with the World Bank.

    ^26USAID maintains country-specific missions in 80 developing countries
    and territories and regional offices in 6 such countries. The State
    Department maintains 258 embassies, consulates, and diplomatic missions in
    about 180 countries and territories.

    USAID disease experts used this information to rate each country according
    to a numerical "preparedness index," but decided against using the results
    of the exercise to help establish U.S. assistance priorities. According to
    USAID headquarters officials, the information submitted by its missions
    provided insights on preparedness strengths and weaknesses in the examined
    countries but was not sufficiently complete or detailed to allow them to
    rate countries on a numerical scale. The officials noted that they had
    difficulty interpreting the largely qualitative information provided by
    their field missions and, in some instances, found that the responses did
    not match their experience in the relevant countries. In addition, the
    USAID exercise did not include developed countries or developing countries
    where the agency does not maintain a presence. The State Department did
    not use the information it had collected to categorize countries by
    preparedness level.

      UN Data Collection and Analysis on Country Preparedness

    The UN System Influenza Coordinator, in collaboration with the World Bank,
    has completed two data collection and analysis efforts that provided
    useful information on country preparedness. However, this information was
    not sufficiently complete or comprehensive to allow clear country
    comparisons. These efforts, which surveyed UN mission staff in countries,
    were conducted before the June and December 2006 global conferences on
    avian and pandemic influenza preparedness, to inform discussion at the
    conferences. In collaboration with the World Bank, UN staff have used the
    information, in addition to information from government officials and the
    public domain, to summarize each country's status with regard to seven
    "success factors." The staff also analyzed the aggregate results for all
    countries and for specific regions.^27

    Similar to the USAID effort, this exercise identified widespread
    shortcomings in country-level preparedness. For example, the UN found that
    about one-third of the countries lacked the capacity to diagnose avian
    influenza in humans. Figure 4 presents the UN's summary for a
    representative country, Bangladesh. The information indicates, for
    example, that programs were in place to strengthen Bangladesh's
    surveillance and reporting for avian influenza in both animals and humans,
    but capacity to detect outbreaks was still constrained.

    ^27The country summaries and analyses of the combined results are
    available at http://www.undg.org/index.cfm?P=298 .

    Figure 4: UN Summary of Country Preparedness, December 2006 - Bangladesh

    Legend: AI = avian influenza; ADB = Asian Development Bank; AHI = avian
    and human influenza; DFID = Department for International Development (of
    the United Kingdom): GDP = gross domestic product; GNI/c at PPP = gross
    national income per capita at purchasing power parity; HDI = human
    development index; HPAI = highly pathogenic avian influenza; IDA =
    International Development Association (of the World Bank); JICA = Japan
    International Cooperation Agency; NGO = nongovernmental organization.

    Like USAID, the UN data-gathering effort encountered obstacles that
    preclude placing countries in preparedness categories. As shown in figure
    4, for example, the UN mission in Bangladesh could not provide a clear
    response concerning the country's planning for farmer compensation in the
    event that poultry culling becomes necessary.^28 In addition, the UN
    sought information from its mission staff in about 200 countries, but
    obtained information on 141 of these in its first round of data gathering
    and 80 in its second. The UN cautioned that there had been no independent
    validation of the information obtained on individual countries, and that
    the information could not be used to compare countries to one another or
    to make a comprehensive evaluation of preparedness levels.

    World Bank-Led Missions Have Provided Additional Information for Some Countries
    but Have Not Provided Basis for Comprehensive Comparisons

    The World Bank has conducted more in-depth assessments of both
    environmental and preparedness-related risk factors in some countries
    (those that have expressed interest in World Bank assistance), but they do
    not provide a basis for making complete or comprehensive global
    comparisons.

    The World Bank has developed guidance for its staff to apply in generating
    the information needed to design avian and pandemic influenza preparedness
    improvement projects in individual countries.^29 The guidance instructs
    bank staff charged with preparing assistance projects to examine and take
    into account both environmental and preparedness-related risk factors. In
    preparing their projects, bank staff often work with officials from other
    organizations with technical expertise, including U.S. agencies, WHO, and
    FAO, and conduct fieldwork in the countries requesting bank assistance. As
    of December 2006, the World Bank reported that it had completed or was
    conducting assessments of national needs in more than 30 countries.^30

    ^28In commenting on a draft of this report, the State Department stated
    that Bangladesh has had great difficulty in controlling the H5N1 outbreak
    that began in that country in February 2007. In addition, OIE commented
    that the UN assessments about preparedness in Bangladesh in table 4 are
    very optimistic. According to the State Department, like many nations
    facing severe budget constraints and with inadequate laboratory capacity
    and limited medical and animal health infrastructure, Bangladesh has not
    succeeded in developing precise plans for responding to avian influenza.
    According to the department, the UN mission's inability to get a clear
    response regarding compensation for culled birds reflected the fact that,
    despite government assurances that such a plan was forthcoming, no plan
    had been agreed upon and no compensation paid as of early May.

    ^29See World Bank, "Annex 2d: Country Preparedness Assessment Tool and
    Financing under the Adaptable Program Loan," Program Framework Document
    for Proposed Loans/Credits/Grants in the Amount of US $500 Million
    Equivalent for a Global Program for Avian Influenza Control and Human
    Pandemic Preparedness and Response (Washington, D.C: December 2005).

    The following are examples of preparedness shortfalls in the human and
    animal sectors identified by World Bank teams:

    Laos:

               o District-level staff responsible for human disease surveillance
               typically are not qualified in epidemiology and lack the equipment
               needed to report health events in a timely manner.^31
               o Public health laboratories are not capable of diagnosing
               influenza in humans.^32
               o The human health care system has insufficient professional staff
               and lacks essential drugs and needed equipment.

               Nigeria:

               o Veterinary services are inadequately equipped and trained to
               deal with large-scale outbreaks.
               o Most available laboratory facilities are outdated, with
               laboratory staff needing substantial training.

               Although the World Bank's assessment efforts generate information
               that is useful in designing country-specific programs, they do not
               provide a basis for making complete or comprehensive global
               comparisons of pandemic risk levels. The World Bank performs such
               studies only in countries that request bank assistance, and
               incorporates its findings into project documents as needed. That
               is, bank staff members cite assessment findings to support
               particular points in individual project plans.^33 The World Bank
               does not assess risk in countries that have not requested bank
               assistance, nor does it publish its assessment results in
               independent documents that employ a common format, and thus could
               be readily employed to make country-by-country comparisons.^34

    ^30As of the end of December, the World Bank reported having 17 avian and
    pandemic influenza preparedness projects under way--in Zambia, the West
    Bank and Gaza, Romania, Djibouti, Laos, Tajikistan, Albania, Moldova,
    Armenia, Georgia, Turkey, Nigeria, the Kyrgyz Republic, Vietnam,
    Azerbaijan, and the Middle East-North Africa region. According to
    Treasury, the World Bank reported that it had another 15 projects in
    preparation.

    ^31According to the World Bank, Laos has 141 administrative districts.

    ^32According to HHS, this information is no longer accurate. With HHS
    assistance, Laos has established a national influenza laboratory that is
    capable of diagnosing H5N1 cases without outside assistance.

               Efforts to Assemble More Comprehensive Information on Country
    			  Preparedness Are Under Way but Will Take Time to Produce Results

               U.S. government and international agencies have initiated several
               data-gathering and analysis efforts to provide more complete
               information on country preparedness levels. However, these efforts
               will take time to produce substantial results.

    ^33See, for example, the technical annexes that describe the bank's
    influenza preparedness projects in Laos and Nigeria, available through the
    World Bank's Internet project information portal at
    http://web.worldbank.org/WBSITE/EXTERNAL/PROJECTS/0,,menuPK:115635~pagePK:64020917~piPK:64021009~theSitePK:40941,00.html
    .

               First, HHS's Centers for Disease Control and Prevention (CDC) is
               developing an assessment protocol or "scorecard" that the United
               States could employ to obtain systematic, and therefore
               comparable, information on pandemic preparedness levels by
               country. CDC officials explained that no such assessment tool
               currently exists. CDC officials are developing indicators that
               could be applied to rate core capabilities in key areas, such as
               differentiating among influenza strains and identifying clusters
               of human illness that may signal emergence of a pandemic strain.
               According to CDC officials, creating such a system would provide
               the United States with a basis for comparing preparedness in
               different countries, identifying response capabilities within
               countries that are particularly weak, and--over time--gauging the
               impact of U.S. efforts to address these shortcomings. CDC
               officials said that they hoped to begin testing these indicators
               before the end of 2007. They stated that their efforts have so far
               been limited to human public health functions, but they have
               discussed with USDA and USAID opportunities to incorporate animal
               health functions into this format once the prototype has been
               worked out for human health capabilities.

               Second, the UN System Influenza Coordinator's staff has indicated
               that it is working with the World Bank to improve the quality of
               the UN's country preparedness questionnaire and increase the
               response rate. The goal is for their periodic efforts to assess
               global and country-level preparedness to generate more useful
               information. The impact of these efforts will not be clear until
               the staff publishes the results of its third survey prior to the
               next major global conference on avian and pandemic influenza,
               which is scheduled to take place in New Delhi in December 2007.

               Third, in 2006 OIE published an evaluation tool that can be used
               to assess the capacity of national veterinary services.^35 While
               it has established standards for national veterinary services, the
               organization had not previously developed a tool that could be
               used to determine the extent to which national systems meet these
               standards. With assistance from the United States and other
               donors, OIE reports that it has trained over 70 people in how to
               apply its evaluation tool and has initiated assessments of
               veterinary services in 15 countries. A senior OIE official
               indicated that the organization intends to complete assessments of
               over 100 countries over the next 3 years.^36

               Finally, under the terms of a 2005 revision of the International
               Health Regulations, WHO member countries have agreed to establish
               international standards for "core capacity" in disease
               surveillance and response systems and to assess the extent to
               which their national systems meet these standards. However,
               guidance on how to conduct such assessments is still being
               developed.^37 Such assessments would provide consistent
               information on preparedness in all participating countries. WHO is
               required to support implementation of these regulations in several
               ways, including supporting assessments of national capacity. The
               UN System Influenza Coordinator has identified development of
               national systems that comply with the new international standards
               as a key objective of global efforts to improve pandemic
               preparedness, and WHO has begun developing assessment tools.
               However, while the regulations enter into force in June 2007,
               member states are not required to assess their national capacities
               until 2009 and are not required to come into compliance with the
               revised regulations until 2012.^38

    ^34The World Bank stated that the bank is prepared to work with national
    or international agencies undertaking global risk assessments by making
    relevant information from its project appraisal reports available to them.
    The World Bank also noted that, over time, implementation progress reports
    will become available from the World Bank's regular supervision of
    influenza-related programs and information from those reports will also be
    made available.

    ^35This tool, Performance, Vision and Strategy for Veterinary Services,
    can be viewed at
    http://www.oie.int/eng/oie/organisation/en_vet_eval_tool.htm?e1d2 .

    ^36The World Bank has indicated that it intends to rely upon this tool to
    evaluate veterinary systems in countries that have requested
    influenza-related assistance.

    ^37Annex 1 of the revised regulations defines core capacity requirements
    for national surveillance and response systems. For the revised
    regulations and the regulations as they stood prior to this revision, see
    http://www.who.int/csr/ihr/en/ .

    ^38The revised regulations specify that each state party shall assess its
    systems within 2 years of the regulations entering into force on June 15,
    2007. They also specify that each state party shall develop systems that
    meet the new requirements as soon as possible, but no later than 5 years
    from the date the regulations enter into force. In certain circumstances,
    the revised regulations allow countries to request an extension of up to 4
    years to develop systems that meet the requirements.

               The United States Has Prioritized Countries Based on Available
    			  Information

               The United States has prioritized countries for U.S. assistance,
               with the Homeland Security Council identifying about 20 "priority
               countries," and agency officials have determined that the United
               States should focus in particular on certain of these countries
               where pandemic risk levels appear comparatively high.

               In May 2006, the Homeland Security Council categorized countries,
               using the limited information available on environmental and
               preparedness-related risks from U.S. and international agencies,
               and also taking U.S. foreign policy concerns into account. The
               council differentiated among countries primarily according to
               available information on H5N1's presence in these countries or
               their proximity to countries that have reported the disease.
               According to agency officials and planning documents, more
               detailed information on environmental risk factors and country
               preparedness would have provided a more satisfactory basis for
               differentiating among countries, but such information was not
               available.

               In May 2006 the council grouped 131 countries into four risk
               categories:

               o At-risk countries: Unaffected countries with insufficient
               medical, public health, or veterinary capacity to prevent, detect,
               or contain influenza with pandemic potential.
               o High-risk countries: At-risk countries located in proximity to
               affected countries, or in which a wildlife case of influenza with
               pandemic potential has been detected.
               o Affected countries: At-risk countries experiencing widespread
               and recurring or isolated cases in humans or domestic animals of
               influenza with human pandemic potential.
               o Priority countries: High-risk or affected countries meriting
               special attention because of the severity of their outbreaks,
               their strategic importance, their regional role, or foreign policy
               priorities.

               Through this process, the Homeland Security Council initially
               identified 19 U.S. priority countries.^39 They include countries
               in Southeast Asia where H5N1 has become well-established (such as
               Indonesia) as well as countries that

               o have experienced severe outbreaks (such as Egypt);
               o have not yet experienced major outbreaks, but U.S. foreign
               policy considerations mandate their identification as a priority
               (such as Afghanistan); or
               o are playing an important regional role in responding to the H5N1
               threat (such as Thailand).

               The council has updated the country categorizations, according to
               State Department officials, and there have been slight changes
               since the original list was completed. According to these
               officials, the council had designated 21 countries as priority
               countries as of March 2007.

               In addition, U.S. agency officials stated that certain of these
               priority countries have emerged as being of especially high
               concern, and the State Department is coordinating preparation of
               interagency operating plans for U.S. assistance to these
               countries. Based on ongoing evaluation of both environmental and
               preparedness-related factors, agency officials stated that
               Indonesia, Egypt, Nigeria, and a small number of Southeast Asian
               countries present comparatively high levels of pandemic risk and
               thus merit greatest attention. According to the State Department,
               a plan for Indonesia has been completed and plans are being
               prepared for Egypt, Nigeria, and three additional Southeast Asian
               countries, as well as for U.S. assistance to international
               organizations such as WHO. According to State Department
               officials, each plan will provide information on a country's avian
               and pandemic influenza preparedness strengths and weaknesses and
               lay out a U.S. interagency strategy for addressing them, taking
               into account the actions of the host governments and other donors.
               The country plans are to be laid out according to the three
               pillars of the U.S. National Strategy for Pandemic Influenza:
               preparedness and communications, surveillance and detection, and
               response and containment.

    ^39According to U.S. officials, the list of priority countries has not
    been made public because of the sensitivity of the categorizations for
    some countries. With respect to the other three categories, the Homeland
    Security Council initially identified 63 at-risk countries, 39 high-risk
    countries, and 10 affected countries. The council did not categorize 62
    countries that were viewed as not needing U.S. assistance. This group was
    composed primarily of high- or upper-middle-income countries and small
    island nations.

               The United States Has Played a Prominent Role in Global Efforts
    			  to Improve Preparedness

               The United States has played a prominent role in global efforts to
               improve avian and pandemic influenza preparedness, committing more
               funds than any other donor country and creating a framework for
               monitoring its efforts. According to data assembled by the World
               Bank, U.S. commitments amounted to about 27 percent of overall
               donor assistance as of December 2006. U.S. agencies and other
               donors are supporting efforts to improve preparedness at the
               country-specific, regional, and global levels, and the bulk of the
               country-specific assistance has gone to U.S. priority countries.
               USAID and HHS have provided most of the U.S. funds, while the
               State Department coordinates the United States' international
               efforts. The U.S. National Strategy for Pandemic Influenza
               Implementation Plan establishes a framework for U.S. efforts to
               improve international (and domestic) preparedness, listing
               specific action items, assigning agencies responsibility for
               completing them, and specifying performance measures and time
               frames for determining whether they have been completed. The
               Homeland Security Council is responsible for monitoring the plan's
               implementation. The council reported in December 2006 that all
               action items due to be completed by November had been completed,
               and provided evidence of timely completion for the majority of the
               items.

    			  The United States Has Been a Leader in Financing Efforts to
    			  Improve Global Preparedness

               As shown in figure 5, the United States has been a leader in
               financing efforts to improve preparedness for pandemic influenza
               around the world.^40 Through December 2006, the United States had
               committed about $377 million to improve global preparedness for
               avian and pandemic influenza.^41 This amounted to about 27 percent
               of the $1.4 billion committed by all donors combined; exceeded the
               amounts other individual donors, including the World Bank, the
               Asian Development Bank, and Japan, had committed;^42 and was also
               greater than combined commitments by the European Commission and
               European Union member countries.^43 In terms of pledged amounts,
               the United States has pledged $434 million, behind the World Bank
               and the Asian Development Bank, which offer loans and grant
               assistance.^44

    ^40Data on commitments by donor, including the United States, were
    obtained from the World Bank. U.S. data reflect amounts reported to the
    World Bank by the United States. Some U.S. activities that also benefit
    international influenza preparedness, including certain efforts that
    improve global response capacity for a range of infectious diseases, are
    not included in the amounts the United States reports.

    ^41Overall, Congress has appropriated about $6.1 billion for avian and
    pandemic influenza-related preparedness, through the Emergency
    Supplemental Appropriations Act for Defense, the Global War on Terror, and
    Tsunami Relief, 2005 (Pub. L. No. 109-13); the Department of Defense,
    Emergency Supplemental Appropriations to Address Hurricanes in the Gulf of
    Mexico, and Pandemic Influenza Act, 2006 (Pub. L. No. 109-148); and the
    Emergency Supplemental Appropriations Act for Defense, the Global War on
    Terror, and Hurricane Recovery, 2006 (Pub. L. No. 109-234). These
    appropriations provided funds for a variety of domestic and international
    purposes, including (in addition to the types of activities described in
    this report) support for developing vaccines and antiviral drugs.

    ^42As noted above, the World Bank is preparing a number of additional
    projects that will substantially increase the total that the bank has
    committed to avian and pandemic influenza preparedness.

    ^43According to the World Bank, the total amount committed by the European
    Commission and European Union member countries was about $360 million.

    ^44The World Bank has provided nearly all of its funding in the form of
    loans, sometimes at highly concessional rates, to individual countries.
    Asian Development Bank financing has been more evenly divided between
    loans and grants. These institutions have also provided funds to concerned
    international organizations. For example, through October 2006 the World
    Bank has committed $1 million to OIE, and the Asian Development Bank has
    committed a total of nearly $19 million to WHO and FAO.

    Figure 5: Pledges and Commitments for International Avian and Pandemic
    Influenza Assistance by Donor, as of December 2006

    Notes:

    The World Bank defines a pledge as an indication of intent to mobilize
    funds for which an approximate sum of contribution is indicated. The World
    Bank defines a commitment as the result of an agreement between the donor
    and recipient for designated purposes or a firm decision, such as a
    legislative appropriation, that prevents the use of an allocated amount
    for other purposes.

    These data reflect amounts reported to the World Bank by member countries,
    with some validation by the World Bank. Some U.S. activities that also
    benefit international influenza preparedness, including certain efforts
    that improve global response capacity for a range of infectious diseases,
    are not included in the amounts the United States reports.

    The World Bank has provided nearly all of its funding in the form of
    loans, sometimes at highly concessional rates, to individual countries.
    Asian Development Bank financing has been more evenly divided between
    loans and grants.

    The pledge and commitment totals allocated to the World Bank in this
    presentation do not include the Avian and Human Influenza Facility--a
    World Bank-administered grant-making mechanism. Funds contributed to this
    facility are reflected in the totals for the European Commission, the
    United Kingdom, Australia, and other donors. The United States has not
    contributed to the facility.

    See app. I for additional information on these data.

    The United States and Other Donors Are Funding Efforts at Country, Regional, and
    Global Levels

    The United States and other donors are supporting efforts to improve
    preparedness at the country-specific, regional, and global levels (see
    fig. 6). According to the World Bank, more than one-third of U.S. and
    total global commitments have gone to assist individual countries.
    Substantial shares of U.S. and global commitments also have been directed
    to regionally focused programs, with primary emphasis on the Asia-Pacific
    region, and to relevant global organizations, with primary emphasis on WHO
    and FAO (see app. VI for additional detail). More than half of U.S.
    funding in the "other" category has been used to stockpile
    nonpharmaceutical equipment, such as protective suits for workers involved
    in addressing outbreaks in birds or humans. The other category also
    includes support for research, wild bird surveillance, and a variety of
    other purposes.

    Figure 6: Allocation of U.S. and Global Commitments for International
    Avian and Pandemic Influenza Assistance, as of December 2006

    Notes: The World Bank defines a commitment as the result of an agreement
    between the donor and recipient for designated purposes or a firm
    decision, such as a legislative appropriation, that prevents the use of an
    allocated amount for other purposes. See app. I for additional information
    on these data.

    aThe World Bank-administered Avian and Human Influenza Facility can
    support country-specific, regional, and global projects.

    Most Country-Specific Commitments Have Gone to U.S. Priority Countries

    The bulk of U.S. and other donors' country-specific commitments have been
    to countries that the United States has designated as priorities, with
    funding concentrated among certain of these countries (see fig. 7). Of the
    top 15 recipients of committed international funds, 11 are U.S. priority
    countries. According to data compiled by the World Bank, about 72 percent
    of U.S. country-specific commitments and about 76 percent of overall donor
    country-specific commitments through December 2006 were to U.S. priority
    countries.

    Figure 7: Top 15 Recipients of Committed, Country-Specific International
    Avian and Pandemic Influenza Funding as of December 2006

    Notes:

    The World Bank defines a commitment as the result of an agreement between
    the donor and recipient for designated purposes or a firm decision, such
    as a legislative appropriation, that prevents the use of an allocated
    amount for other purposes.

    Totals include funds from donor countries, international organizations,
    and the World Bank-administered Avian and Human Influenza Facility.

    See app. I for additional information on these data.

    As figure 7 shows, Vietnam and Indonesia have been the leading recipients
    of country-specific commitments from the United States and from other
    donors. Indonesia, which U.S. officials have indicated is their
    highest-priority country, has received the largest share of U.S.
    country-specific commitments (about 18 percent), followed by Vietnam and
    Cambodia.

    USAID and HHS Implement Most U.S.-Funded Activities

    USAID, HHS, USDA, DOD, and the State Department carry out U.S.
    international avian and pandemic influenza assistance programs, with USAID
    and HHS playing the largest roles. According to funding data provided by
    these agencies, USAID accounts for 51 percent of U.S. planned spending,
    with funds going to provide technical assistance, equipment, and financing
    for both animal and human health-related activities.^45 HHS accounts for
    about 40 percent of the total, with the focus on technical assistance and
    financing to improve human disease detection and response capacity. ^46
    USDA provides technical assistance and conducts training and research
    programs, and DOD stockpiles protective equipment. The State Department
    leads the federal government's international engagement on avian and
    pandemic influenza and coordinates U.S. international assistance
    activities through an interagency working group.^47 Figure 8 shows planned
    funding levels by agency.

    ^45Planned funding levels indicate agency budget projections for planning
    purposes. According to U.S. agency officials, such figures are roughly
    equivalent to commitments as defined by the World Bank.

    ^46According to HHS, the focus of technical assistance and financing to
    improve surveillance in both humans and birds is to increase and enhance
    early recognition and reporting of outbreaks and facilitate sharing of
    virus samples.

    ^47In addition to DOD, HHS, the State Department, USAID, and USDA,
    representatives from the Department of Homeland Security, the National
    Security Council, the Homeland Security Council, and U.S. intelligence
    agencies attend working group meetings. Treasury has not been a regular
    participant. However, Treasury officials stated that their department has
    worked with U.S. executive directors at the World Bank, the Asian
    Development Bank, and other international financial institutions to
    encourage and support these institutions in their efforts to address avian
    and pandemic influenza threats.

    Figure 8: U.S. Planned Funding for International Avian and Pandemic
    Influenza Assistance by Agency

    Notes:

    Planned funding levels indicate agency budget projections for planning
    purposes. According to U.S. agency officials, such figures are roughly
    equivalent to commitments as defined by the World Bank.

    USAID and USDA provided planned funding levels through December 2006. The
    remaining agencies provided information on planned funding through
    September 2006. See app. I for additional information on these data.

    aThe DOD total does not include (1) $5 million in Overseas Humanitarian,
    Disaster and Civic Aid programs to strengthen foreign military capacity
    for responding to a potential pandemic or (2) $17 million in
    influenza-related support for DOD's Global Emerging Infections
    Surveillance and Response System. The United States did not include these
    funds in the information that it provided to the World Bank.

    U.S. Implementation Plan Establishes a Framework for U.S. Action

    The U.S. National Strategy for Pandemic Influenza Implementation Plan,
    adopted in May 2006, provides a framework for monitoring U.S. efforts to
    improve both domestic and international preparedness. The plan assigns
    agencies responsibility for completing specific action items under the
    three pillars of the overall U.S. strategy (preparedness and
    communications, surveillance and detection, and response and containment)
    and, in most cases, specifies performance measures and time frames for
    determining whether they have been completed. The Homeland Security
    Council is responsible for monitoring the plan's implementation.

    In its international component, the Implementation Plan identifies 84
    action items. It designates HHS as the lead or co-lead agency for 34 of
    these, the State Department for 25, USAID for 19, USDA for 19, and DOD for
    11.^48 Table 2 shows the distribution of planned funding by agency within
    each of the three pillars in the strategy. Appendix VII provides
    information on obligations by agency and pillar.

    Table 2: U.S. Planned Funding for International Avian and Pandemic
    Influenza Assistance by Agency and by Pillar/Activity

    Dollars in millions
                                                        Agency
                                                                         Total by
    Pillar/activity               HHS^a USAID DOD^b USDA State pillar/activity
    Preparedness and                 53   104    10    9     5             181
    communications
    Surveillance and detection       48    51     0    5     0             104
    Response and containment         34    36     0    6     0              76
    Other                            15    --    --   --    --              15
    Total by agency                 150   191    10   20     5             376

    Sources: DOD, HHS, State Department, USDA, and USAID.

    Notes:

    Planned funding levels indicate agency budget projections for planning
    purposes. According to U.S. agency officials, such figures are roughly
    equivalent to commitments as defined by the World Bank.

    USAID and USDA provided planned funding levels through December 2006. The
    remaining agencies provided information on planned funding through
    September 2006.

    See app. I for additional information on these data.

    aAs the table shows, HHS did not designate a pillar for a portion of its
    planned funds, including about $5 million to expand influenza-related
    staffing levels in key global, regional, and country-level facilities
    (such as WHO's regional offices for Africa and the Western Pacific and
    regional surveillance and response facilities in Thailand and Egypt), and
    about $10 million for HHS headquarters management of its influenza-related
    initiatives.

    bThe DOD total does not include (1) $5 million in Overseas Humanitarian,
    Disaster and Civic Aid programs to strengthen foreign military capacity
    for responding to a potential pandemic or (2) $17 million in
    influenza-related support for DOD's Global Emerging Infections
    Surveillance and Response System. The United States did not include these
    funds in the information that it provided to the World Bank.

    ^48The allocation of action items among agencies sums to more than 84
    because in some cases the implementation plan assigns multiple agencies
    lead responsibility for individual items.

      Preparedness and Communications Actions Include Creating Emergency Stockpiles

    Within the preparedness and communications pillar, the Implementation Plan
    assigns U.S. agencies responsibility for action items that focus on (1)
    planning for a pandemic; (2) communicating expectations and
    responsibilities; (3) producing and stockpiling vaccines, antiviral drugs,
    and other medical material; (4) establishing distribution plans for such
    supplies; and (5) advancing scientific knowledge about influenza viruses.
    For example, action item 4.1.5.2 assigns HHS and USAID lead responsibility
    for setting up stockpiles of protective equipment and essential
    commodities (other than vaccines and antiviral drugs) with action to be
    completed within 9 months--that is, by February 2007 (see fig. 9). Through
    fiscal year 2006, USAID reported spending about $56 million to create a
    stockpile of personal protective equipment (PPE) kits and other nonmedical
    commodities to facilitate outbreak investigation and response.^49 The
    USAID stockpile consisted of 1.5 million PPE kits to be used by personnel
    investigating or responding to outbreaks, 100 laboratory kits, and 15,000
    decontamination kits.^50 As of October 2006, USAID reported having
    deployed approximately 193,000 PPE kits for immediate or near-term use in
    more than 60 countries (see app. VIII).

    ^49Approximately $40 million represents commodity purchases for this
    stockpile, with the remainder for logistical needs, such as deployment and
    storage.

    ^50A PPE kit consists of items such as a mask, protective suit, goggles,
    and hand sanitizer wipes. Laboratory kits include materials and
    instructions to collect and ship specimens to national or international
    reference laboratories for confirmation. A decontamination kit includes a
    backpack sprayer, disinfectant powder, and other items to clean affected
    equipment, vehicles, and so forth.

    Figure 9: Selected Action Item for Preparedness and
    Communications--Creating Emergency Stockpiles

      Surveillance and Detection Actions Include Training Foreign Health
      Professionals

    To improve global surveillance and detection capacity, the Implementation
    Plan assigns U.S. agencies responsibility for action items that focus on
    (1) ensuring rapid reporting of outbreaks and (2) using surveillance to
    limit their spread. For example, action item 4.2.2.4 assigns HHS lead
    responsiblity for training foreign health professionals to detect and
    respond to infectious diseases such as avian influenza with action to be
    completed within 12 months--that is, by May 2007 (see fig. 10).^51 In
    2006, HHS established or augmented five regional global disease detection
    and response centers located in Egypt ($4.4 million), Guatemala ($2
    million), Kenya ($4.5 million), Thailand ($6.5 million), and China ($3.9
    million) to enhance global disease surveillance and response capacity.^52
    Among other things, these centers provide training in field epidemiology
    and laboratory applications. For example, in July 2006, the Thailand
    center conducted a workshop aimed at teaching public health officials what
    to do when investigating a respiratory disease outbreak that may signal
    the start of a pandemic. More than 100 participants from 14 countries
    participated in this workshop, which was cosponsored by WHO and Thai
    authorities.^53

    ^51In addition to training activities, HHS officials stressed that
    development of effective surveillance and detection systems also requires
    improvements in laboratory capacity and development of effective rapid
    response protocols. The U.S. Implementation Plan includes action items in
    both of these areas.

    ^52According to State Department officials, this HHS funding to strengthen
    or establish global disease detection centers does not include additional
    funds provided through these centers to assist individual countries.

    ^53The goal of this course was to prepare participants to teach additional
    courses in their own countries to further build international capacity. In
    addition to the United States, participating countries were Bangladesh,
    Burma, Cambodia, China, Egypt, Guatemala, India, Indonesia, Kenya, Laos,
    South Africa, Thailand, and Vietnam. (Source: U.S. Embassy, Bangkok, and
    WHO Press Release, July 13, 2006).

    Figure 10: Selected Action Item for Surveillance and Detection--Training
    Foreign Health Professionals

      Response and Containment Actions Include Development of Outbreak Response
      Teams

    To improve global response and containment capacity, the Implementation
    Plan assigns U.S. agencies responsibility for action items that focus on
    (1) containing outbreaks; (2) leveraging international medical and health
    surge capacity; (3) sustaining infrastructure, essential services, and the
    economy; and (4) ensuring effective risk communication. Action item
    4.3.1.5, for example, assigns USDA and USAID lead responsibility for
    supporting operational deployment of response teams when outbreaks occur
    in poultry^54 (see fig. 11).^55 In 2006, USDA and USAID supported the
    creation of a crisis management center at FAO to coordinate and respond to
    avian influenza outbreaks globally. According to FAO, the center is able
    to dispatch its experts to any location in the world in under 48 hours.
    USAID and USDA have provided approximately $5 million in support to the
    center.^56 USDA detailed three veterinary specialists to the center for
    headquarters operations as well as an official to serve as its deputy
    director. USDA is also providing experts to respond to outbreaks. USAID
    has directed its support toward enhancing coordination with WHO on rapid
    deployment of joint animal health/human health teams and facilitating
    operations in underresourced African countries.

    ^54Action item 4.3.1.3 assigns HHS lead responsibility for deploying
    surveillance and response teams to investigate potential human outbreaks,
    in coordination with other U.S. agencies and with WHO.

    ^55The Implementation Plan did not specify a time frame for completing
    this action.

    ^56According to FAO, other major donors include Germany and the Asian
    Development Bank.

    Figure 11: Selected Action Item for Response and Containment--Developing
    Rapid Response Teams

      Homeland Security Council Reported Success on Action Items to Be Completed by
      November 2006

    The Homeland Security Council's first progress report on U.S. pandemic
    influenza-related efforts reported that agencies had completed all of the
    22 international action items scheduled for completion by November 2006.
    In December 2006, the council issued a compendium of the action items in
    the Implementation Plan, with updates on the corresponding performance
    measures.^57 The council reported that all 22 of the international action
    items in the Implementation Plan that agencies were to complete by
    November 2006 had been completed.^58 (The 84 action items in the
    international section of the Implementation Plan have time frames for
    completion that range from 3 months to 2 years.)

    The Homeland Security Council's report did not clearly indicate the basis
    for determining completion in a number of cases, generally because the
    report did not fully reflect agency efforts or the wording of the
    performance measure made it difficult for agency staff to respond. Our
    review of the progress report found that for 14 of the 22 action items,
    the report directly addressed the specified performance measures and
    indicated that these measures had been addressed within the specified time
    frames. However, for 8 of the action items, the information in the
    progress report did not directly address the performance measure or did
    not indicate that the completion deadline had been met. Based on
    interviews and information we obtained from the responsible agencies, we
    determined that the lack of clarity in these cases was primarily because
    of omission of key facts on agency activities or agency difficulties in
    reporting on poorly worded performance measures.^59 For example, 1 action
    item directed DOD to prepare to limit the spread of a pandemic-potential
    strain by controlling official military travel between affected areas and
    the United States.^60 The performance measure was designation of military
    facilities that could serve as points of entry from affected areas. The
    council's report described the department's preparedness for controlling
    travelers' movements but did not state that DOD had identified facilities
    that could serve as points of entry. Our review of DOD documents indicated
    that the department had designated such facilities. A second action item
    assigned the State Department lead responsibility for developing plans to
    communicate U.S. avian and pandemic influenza objectives to key
    stakeholders.^61 The performance measure was the "number and range of
    target audiences reached" and the impact of relevant efforts on the
    public. The council's report provided a rough estimate of the number of
    people reached through U.S. government communication efforts to date.
    However, State Department officials told us that the performance measure
    was difficult to address because they did not have the means to accurately
    estimate the effective reach or impact of their efforts.

    ^57See the U.S. Pandemic Influenza Strategy Implementation Plan: Summary
    of Progress, December 2006, available on the Internet at
    http://www.pandemicflu.gov/plan/federal/stratergyimplementationplan.html
    .

    According to U.S. agency officials, a report providing updated information
    on U.S. efforts to improve domestic and international pandemic influenza
    preparedness and response is being prepared.

    ^58The council's report added that while determinations that action items
    had been completed meant that the indicated measure of performance had
    been met, this did not necessarily mean that work had ended. In many
    cases, the agencies were continuing their efforts.

    ^59State Department, DOD, and Treasury officials responded to our requests
    for information on the seven items for which they exercised lead
    responsibility. HHS officials declined to provide information on the
    remaining item, for which they held lead responsibility.

    ^60Action item 4.3.2.2.

    Concluding Observations

    Difficulties in obtaining and applying accurate and complete information
    present an overarching challenge to U.S. efforts to identify countries at
    greatest risk and effectively target resources against the threat
    presented by the H5N1 virus. In particular, although country preparedness
    is a primary consideration in determining relative risk levels, U.S.
    determinations on priority countries have relied primarily on information
    about environmental risks, which is itself incomplete. While the United
    States, the UN, and the World Bank, as well as WHO and OIE, are refining
    and expanding their efforts to gather useful information, substantial gaps
    remain in our understanding of both environmental and preparedness-related
    risks in countries around the world.

    With strong leadership from the United States, the international community
    has launched diverse efforts to increase global preparedness to forestall
    an influenza pandemic. These efforts constitute a substantial response to
    the threat presented by H5N1. They reflect significant international
    cooperation, and the U.S. National Strategy for Pandemic Influenza
    Implementation Plan provides a useful framework for managing U.S.
    agencies' participation in these efforts. The Homeland Security Council's
    first update on U.S. efforts and UN reports on donor efforts in general
    suggest that U.S. and global efforts to improve preparedness are producing
    results, but challenges remain in accurately measuring their impact. Many
    countries remain relatively unprepared to recognize or respond to highly
    pathogenic influenza in poultry or humans, and sustained efforts will be
    required to overcome these challenges.^62

    61Action Item 4.3.6.1.

    Agency Comments and Our Evaluation

    USAID, HHS, and USDA provided written comments on a draft of this report.
    These comments are reproduced in appendixes II, III and IV. In addition,
    Treasury provided oral comments. HHS and Treasury also provided technical
    comments, as did the Department of State, DOD, WHO, the World Bank, and
    the United Nations System Influenza Coordinator. The Coordinator's
    comments included comments from FAO and OIE, and the latter organization
    also provided us with technical comments independently. These agencies
    generally concurred with our findings, and we incorporated their technical
    comments in the report as appropriate.

    USAID briefly reviewed progress in improving global preparedness, citing,
    for example, reductions in outbreaks among poultry and humans in Vietnam
    and Thailand. The agency observed, however, that the practices employed in
    small-scale "backyard farms" continue to present a major challenge to
    efforts to control the spread of H5N1. USAID will therefore be paying
    particular attention to this challenge in the coming months.^63

    While acknowledging the information gaps that limit capacity for comparing
    country-level risks, HHS emphasized its support for targeting resources
    according to the Homeland Security Council's country prioritization
    decisions. In this context, HHS stressed the importance of improved
    information sharing among countries, as called for under the revised
    International Health Regulations, and noted the particular importance of
    sharing influenza virus samples and surveillance data. In addition, HHS
    commented that limited human-to-human transmission of H5N1 could not be
    ruled out in some clusters of cases in Indonesia, and explained certain
    differences in the roles played by HHS, USDA and USAID under the response
    and containment pillar of the U.S. National Strategy for Pandemic
    Influenza. In response, we clarified the information in the background
    section of this report on human-to-human transmission and our presentation
    on the roles played by the HHS, USDA, and USAID in responding to poultry
    and human outbreaks. In its technical comments, HHS elaborated upon our
    concluding observation regarding the need for sustained effort to overcome
    challenges in improving global preparedness. We added a footnote to our
    concluding observations to summarize the HHS comments in this area.

    ^62In its technical comments on a draft of this report, HHS stated, in
    particular, that sustained financial and technical support for priority
    countries is needed to maximize the return on U.S. investments to date and
    to build sustainable laboratory and epidemiologic surveillance systems.

    ^63USAID also stated that it will be placing much greater emphasis on
    developing plans and capabilities for responding to an influenza
    pandemic--a matter that lies beyond the scope of this report.

    USDA stated that the report provides a comprehensive evaluation of
    pandemic influenza and global efforts needed to improve avian and pandemic
    influenza preparedness. USDA also stated that it found the report accurate
    in its description of USDA's role and involvement in global efforts to
    improve preparedness.

    In oral comments, Treasury stated that it has been actively engaged in the
    U.S. government's efforts to respond to avian influenza and increase
    readiness to address a potential influenza pandemic, both internationally
    and within the United States. To coordinate the department's activities,
    Treasury created an informal avian influenza working group that includes
    staff from its domestic and internationally focused offices. Among other
    things, the working group ensures that Treasury is fully engaged in all
    Homeland Security Council-led initiatives against avian and pandemic
    influenza. Treasury also stated that, in coordination with U.S. executive
    directors at the various international financial institutions (including
    the World Bank), it has encouraged and supported these institutions in
    their efforts to develop adequate responses to the threat of an influenza
    pandemic. However, Treasury stated that its efforts in this area have been
    constrained by U.S. legislation that requires the United States to vote
    against multilateral development bank programs in cases where Burma might
    receive support. According to Treasury, this has occurred two times with
    respect to Asian Development Bank regionally-focused projects. While these
    matters were largely outside the scope of our report, we modified the text
    to acknowledge Treasury efforts to encourage and support international
    financial institution efforts against avian and pandemic influenza.

    Treasury also stated that, building on experiences drawn from the 2003
    severe acute respiratory syndrome outbreak, the international financial
    institutions (including the World Bank) have responded to the H5N1
    epidemic by providing financing, and also by helping countries develop
    national strategies, providing relevant technical assistance and training,
    serving as focal points for donor and regional coordination, tracking and
    reporting on donor commitments, preparing impact analyses, and hosting
    international conferences. Treasury further noted that in addition to
    providing financing for individual countries, the multilateral development
    banks have provided financial and technical support to international and
    regional technical organizations working in this area, including WHO and
    FAO.

    We are sending copies of this report to the Secretaries of Agriculture,
    Defense, Health and Human Services, State, and the Treasury; the
    Administrator of the U.S. Agency for International Development;
    appropriate congressional committees; and other interested parties. We
    will also 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, please contact David Gootnick at
    (202) 512-3149 or gootnickd@gao.gov or Marcia Crosse at (202) 512-7114
    or crossem@gao.gov . Contact points for our Offices of Congressional
    Relations and Public Affairs may be found on the last page of this report.
    Key contributors to this report are listed in appendix IX.

    David Gootnick
    Director, International Affairs and Trade

    Marcia Crosse
    Director, Health Care

    Appendix I: Scope and Methodology

    We provided relevant background information on the spread of the H5N1
    virus, factors that may affect the comparative risk that this virus
    presents in different countries, methods that health systems traditionally
    employ to respond to influenza in animals and humans, and the overall
    strategy that the United States and its international partners have
    developed to respond to the threats presented by H5N1. To describe how
    H5N1 has spread internationally, we used country-specific data on cases
    among humans assembled by the United Nations World Health Organization
    (WHO), and on cases and outbreaks in humans and in wild and domestic birds
    assembled by the United Nations (UN) World Food Program. World Food
    Program officials told us their data on human cases were provided by WHO,
    while their data on cases in birds were provided by the World Organization
    for Animal Health (OIE) and the UN Food and Agriculture Organization
    (FAO). WHO, OIE, and FAO have cautioned that global surveillance is
    imperfect, and some human and animal cases and outbreaks may go
    unrecorded. However, these organizations work with a wide variety of
    global partners, including national governments, to identify and verify
    outbreaks of this disease. We determined that these data on human and
    animal outbreaks were sufficiently reliable for the purposes of this
    report, which were to convey a general sense of the manner in which the
    disease has spread across international boundaries and the extent to which
    it has infected humans. However, these data should not be relied upon to
    precisely identify countries where the disease has occurred or to indicate
    with absolute certainty the number of human cases that have occurred.

    To identify and describe factors that affect the level of risk that H5N1
    presents in different countries and the methods that animal and health
    systems generally employ against influenza, we interviewed officials and
    consulted documents produced by avian and human disease experts in
    relevant U.S. government agencies, international organizations, academic
    institutions, and nongovernmental organizations. To describe the overall
    strategy that the United States and its international partners have
    developed to respond to the H5N1 epidemic, we interviewed and examined
    relevant documents from U.S. and UN agencies, including the U.S. National
    Strategy for Pandemic Influenza and strategy statements and progress
    reports produced by the UN System Influenza Coordinator and the World
    Bank.

    To examine the extent to which U.S. and international agencies have been
    able to assess the pandemic risk that H5N1 presents in individual
    countries and prioritize them for international assistance, we reviewed
    and analyzed assessments of environmental risk and preparedness.
    Specifically, we reviewed assessments prepared by the U.S. Agency for
    International Development (USAID), the Department of State, the UN, and
    the World Bank and spoke with cognizant officials at these agencies and
    organizations about how they were conducted. These assessments evaluated
    country-level pandemic risk deriving from environmental conditions,
    country preparedness for responding to avian and pandemic influenza, or
    both. We analyzed a sample of 17 country-specific avian influenza
    preparedness assessments compiled by USAID and the State Department to
    provide summary information on capacity in several regions. (See app. V
    for a detailed description of the scope and methodology for our analysis
    of sampled USAID and State Department assessments.) We also reviewed the
    U.S. Homeland Security Council Country Prioritization Matrix as of May 3,
    2006, which designates country priority levels for U.S. actions to address
    the avian and pandemic influenza threat. We discussed this priority
    ranking with officials from the State Department and USAID. We requested a
    meeting with officials from the council, but the council declined, stating
    that we could obtain needed information from other agencies and
    departments. In addition, we reviewed analyses of environmental risk
    factors prepared by U.S. intelligence community analysts during 2006 and
    early 2007 and discussed these analyses with U.S. agency officials. We
    also reviewed assessments of risks in particular countries prepared by a
    U.S. intelligence agency.^1

    To determine the actions U.S. agencies and their international partners
    took to address these risks, we examined funding, planning, and reporting
    documents and spoke with cognizant officials. To determine the overall
    level of financial support that the donor community is providing for
    efforts to improve global avian and pandemic influenza preparedness, we
    examined World Bank and UN documents detailing donor pledges and
    commitments resulting from the international pledging conferences on avian
    and pandemic influenza, including funding levels by donor, by recipient,
    and by purpose. We also reviewed World Bank and UN documents describing
    recipient countries, regions, and organizations.

    To describe the international activities of the U.S. government, we
    reviewed the National Strategy for Pandemic Influenza and the National
    Strategy for Pandemic Influenza Implementation Plan. We reviewed pertinent
    planning, reporting, and funding documents for U.S. international avian
    influenza control and pandemic preparedness assistance programs. We also
    consulted cognizant officials from USAID and from the Departments of
    Agriculture (USDA), Health and Human Services (HHS), Defense (DOD), and
    State about their efforts. We reviewed the international action items
    tasked to these U.S. agencies and assessed by the Homeland Security
    Council in its 6-month status report issued on December 18, 2006.^2 We
    independently compared the performance measures associated with each
    action item with the agency responses to it. Finally, we visited the WHO,
    OIE, and FAO headquarters in Geneva, Paris, and Rome, respectively.

    ^1Some of these assessments contained classified information. We do not
    discuss these assessments in this report so that our report remains
    unclassified and because the classified documents we reviewed did not lead
    to substantially different observations than the unclassified assessments
    we examined.

    To assess the reliability of the pledges and commitments data that
    national governments and other donors submitted to the World Bank, we
    spoke with World Bank officials responsible for maintaining these data and
    reviewed supporting documentation. The pledges and commitments data are
    self-reported by individual donor countries in response to a standard
    request template. The World Bank staff responsible for this data
    collection provided countries with standard definitions of key terms, such
    as pledges, commitments, and in-kind and cash payments. However, because
    countries' data reporting systems vary substantially, World Bank staff
    conduct ongoing discussions with donor countries to establish the
    correspondence between those systems and the World Bank terms. World Bank
    staff also stated that the pledges and commitments totals provided by
    countries may include funding not strictly related to pandemic influenza
    and may therefore be somewhat overstated. Therefore, based on our review,
    we use these data to identify general levels of pledges and commitments
    made by particular countries or organizations; they should not be relied
    upon to support precise comparisons of funding by donor or recipient.
    Overall, we concluded that the World Bank pledges and commitments data
    were sufficiently reliable for the purposes of this report.

    To obtain data on U.S. agency funding for international avian and pandemic
    influenza preparedness by agency and by the three pillars of the overall
    U.S. pandemic strategy, we requested separate submissions from each of the
    five U.S. agencies, showing planned, obligated, and expended funds by
    pillar. Two of the five agencies (USAID and USDA) maintained funding data
    by pillar prior to our requesting these data. Two others (DOD and the
    State Department) found it relatively easy to comply with our request,
    since all of their reported activities fell within the preparedness and
    communications pillar.^3 However, providing this information was
    comparatively complex for HHS. The various units within that agency (for
    example, the Centers for Disease Control and Prevention and the National
    Institutes of Health) support a wide variety of relevant programs, many of
    which involve more than one pillar. In addition, HHS can utilize other
    sources of funding in addition to influenza-specific appropriations for
    many of these programs. To respond to our request, the HHS Office of
    Global Health Affairs collected data from relevant HHS units. The Director
    of the Office of Global Health Affairs reviewed the final HHS submission
    for accuracy before reporting back to GAO. The pillar-specific totals HHS
    was able to provide were for planned funds and for obligated funds. Thus,
    the funding information by agency that we provide is for these two
    categories of funding data and not for expenditures.

    ^2According to U.S. agency officials, a report providing updated
    information on U.S. efforts to improve domestic and international pandemic
    influenza preparedness and response is being prepared.

    We identified a number of limitations in the data that the agencies
    provided. First, the data are not from consistent periods. USDA and USAID
    provided information on planned funding levels and obligations through
    December 2006. HHS, DOD, and the State Department provided data through
    September 2006. In addition, DOD and the State Department received funding
    for international avian and pandemic influenza activities through
    appropriations in 2006 only; whereas, USAID, HHS, and USDA received
    funding through 2005 and 2006 appropriations. Second, the distribution of
    funds among the pillars is somewhat imprecise. When programs addressed
    more than one pillar, agency officials employed their professional
    judgment to decide which pillar was most significant. This limitation was
    most pronounced in the HHS data. While HHS decided how to allocate most of
    its funds, the agency did not specify a pillar for about $15 million of
    its planned funds. This total included about $5 million to expand staffing
    levels in key global, regional, and country-level facilities, including
    the WHO regional offices for Africa and the Western Pacific and
    surveillance and response facilities in Thailand and Egypt, and about $10
    million for HHS headquarters management of its influenza-related
    initiatives.

    ^3The DOD total does not include (1) $5 million in Overseas Humanitarian,
    Disaster and Civic Aid programs to strengthen foreign military capacity
    for responding to a potential pandemic or (2) $17 million in
    influenza-related support for DOD's Global Emerging Infections
    Surveillance and Response System. The United States did not include these
    funds in the information that it provided to the World Bank. For more
    information on the Global Emerging Infections Surveillance and Response
    System, which includes units in Egypt, Indonesia, Kenya, Peru, and
    Thailand, see http://www.geis.fhp.osd.mil .

    Third, the total planned and obligated amounts are also somewhat
    imprecise. Some of the agency funds come from programs that are not
    dedicated specifically to avian or pandemic influenza. In such cases,
    agency officials used professional judgment to decide what portion of the
    funds should be designated as supporting avian or pandemic influenza
    preparedness.

    Despite these limitations, we determined that these data were sufficiently
    reliable for the purpose of this report, which was to provide information
    on general levels of agency planned and obligated funding by pillar.
    However, we rounded the funding information that the agencies provided to
    the nearest million dollars.

    We conducted our work from January 2006 through March 2007 in accordance
    with generally accepted government auditing standards.

    Appendix II: Comments from the U.S. Agency for International Development

    Appendix III: Comments from the Department of Health and Human Services

    Note: GAO comments supplementing those in the report text appear at the
    end of this appendix.

    See comment 1.

    The following are GAO's comments on the Department of Health and Human
    Services letter dated June 11, 2007.

    GAO Comment

               1. HHS said that it is inaccurate to state, without qualification,
               that H5N1 has never circulated among humans; limited
               human-to-human transmission cannot be ruled out in a few clusters
               of cases in Indonesia. We agreed with the need to qualify this
               statement. We revised the background section of this report to
               acknowledge that limited human-to-human transmission cannot be
               ruled out in these cases.

    Appendix IV: Comments from the Department of Agriculture

    Appendix V: Analysis of Selected USAID and State Department Rapid
    Assessments of Avian Influenza Preparedness

    This appendix presents the results of our analysis of avian influenza
    preparedness information submitted by USAID and State Department field
    staff from 17 of more than 100 countries surveyed by USAID and State
    Department headquarters during late 2005. These characterizations reflect
    our analysis of information gathered through assessment efforts at that
    time. For some countries, the assessments may not reflect current
    capabilities. As figure 12 shows, the field staff charged with providing
    information identified widespread shortcomings in national preparedness.
    However, the figure also shows that field staff often could not obtain
    sufficient information to provide clear or definitive information on every
    topic.

    Figure 12: Avian Influenza Preparedness--Analysis of Selected Indicators
    and Countries from USAID and State Department Rapid Assessments
    (October/November 2005)

    Note: The categorizations in this figure reflect GAO analysis of
    assessments done at a particular point in time. They do not necessarily
    reflect current capability.

    The preparedness and communications section of the figure suggests that
    most of the countries in our sample were aware of the need to position
    themselves for effective action, 16 of the 17 were reported to have made
    at least limited progress in preparing a national plan for responding to
    the threats presented by avian influenza, and 14 of 15 countries for which
    data were available were reported to have established national task forces
    to address these threats. However, the remainder of the figure suggests
    that there were at the time of the assessments widespread weaknesses in
    the elements of preparedness. For example, only 9 of the 17 countries were
    reported to have made at least limited efforts to educate the public about
    avian influenza. Only 4 of the 12 countries for which data were available
    were reported to have made at least limited progress toward preparing
    stockpiles of both antiviral drugs and PPE kits that could be used by
    those responding to poultry or human outbreaks. Most of the countries were
    found to be conducting at least limited surveillance for avian influenza.
    However, many countries were found to have gaps in their capacity to carry
    out key outbreak response activities. For example, only 4 of the 15
    countries for which data were available were reported to have plans for
    compensating farmers in the event that culling became necessary.

    The USAID and State Department officials who provided this information
    reported shortcomings in each of the 17 countries we reviewed. The
    officials identified multiple shortcomings in Cambodia, Indonesia, and
    Vietnam, where H5N1 is well-established. In addition, the figure
    illustrates why there is particular concern about weak capacity in Africa.
    USAID and State Department officials recorded negative responses in most
    categories for the 2 of the 3 African countries in the table (Djibouti and
    Uganda). Additionally, officials recoded limited or negative responses for
    11 of 15 categories for Nigeria--the remaining African country in our
    analysis.

    The figure also demonstrates the data-gathering and analysis difficulties
    that field and headquarters staff experienced in completing this exercise.
    The information provided by field staff was insufficient to allow us to
    arrive at definitive entries for about 15 percent (39 of 255) of the cells
    in the figure. Field staff had particular difficulty in providing clear
    information on response and containment measures, such as stockpile
    distribution and culling plans and quarantine capacity. Staff in some
    countries (for example, Vietnam) were able to provide comparatively clear
    information on all or nearly all issues, while others (for example, India)
    were unable to provide sufficient information on several matters.

    Scope and Methodology

    The study population for our analysis included rapid country avian
    influenza preparedness assessment reports prepared by USAID and State
    Department overseas missions from October to November 2005. USAID
    maintains country-specific missions in 80 developing countries and
    regional offices in 6 such countries, and these missions provided USAID
    headquarters with information on more than 100 countries. The State
    Department maintains diplomatic missions in about 180 countries and
    territories. From the population of USAID missions, we drew a
    nonprobability sample of 17 countries. Of these countries, 14 had reports
    from USAID and the State Department, 3 had USAID reports only, and 1 had a
    State Department report only. State Department assessments were missing
    from the following countries: India, Pakistan, and Indonesia. USAID did
    not perform a country assessment on Thailand.

    To select our sample, we took a variety of factors into account. To ensure
    geographic diversity, we included countries from four regions: Asia,
    Africa, Eurasia and the Near East, and the Americas. Based on influenza
    experts' opinions and congressional interest, we chose to oversample Asian
    countries and not represent North America or Europe. We sought to include
    countries in a variety of situations with regard to the presence of H5N1
    in animals or humans, concentrations of poultry and humans living in
    proximity to each other, exposure to migratory patterns that could allow
    wild birds to transmit H5N1 into the country, political stability, and
    strength of the public health infrastructure. We did not include China in
    our table of countries because the relevant reports were classified.

    USAID and the State Department conducted their assessments by sending out
    sets of questions to personnel at their respective missions. The questions
    asked in the two instruments differed in their wording, and as a
    consequence, our first step in developing our analysis was to identify a
    set of broader dimensions, or indicators, encompassing data from both sets
    of assessments. Through a review of these two sets of questions, as well
    as survey questions recently developed by WHO and the World Bank to assess
    country preparedness, we identified a set of 15 qualitative indicators
    covering a wide array of issues within the topic areas of preparedness and
    communications, surveillance and detection, and response and containment.
    These indicators then became the dimensions along which we analyzed the
    data contained in the USAID and State Department assessments.

    We reviewed USAID rapid country assessments and State Department cables
    assessing the level of country preparedness for avian influenza. The
    analysis of the 17 USAID and State Department assessments was performed by
    two GAO analysts, reviewing the reports separately and recording answers,
    with justifications, in workpapers. To enhance inter-rater reliability in
    our analysis of the USAID and State Department assessments, we developed a
    code book to reflect the specific characteristics needed for a country to
    be classified in one of three categories for each indicator: yes, no, or
    limited. Subsequently, the two analysts compared their answers and
    justifications, reconciled their analyses when they diverged, and modified
    the code book as needed to ensure consistent coding across indicators and
    countries. A methodologist performed a final check on the consistency and
    accuracy of the analysis.

    The USAID and State Department instruments had a number of limitations.
    First, the information provided in these assessments is limited by the
    rapidly evolving dynamic of the H5N1 virus and ongoing efforts to improve
    capacity. As a consequence the information provided in them is already
    dated and should be understood as a snapshot of the countries assessed at
    a particular point in time (fall 2005), rather than directly reflecting
    the current status of country capacities. Second, the purpose of these
    assessments was to rapidly assess country capacities in this evolving
    environment, and as a result, the instruments developed were limited in
    the design of the questions asked, restricted primarily to open-ended
    questions that could be interpreted and answered in multiple ways. Third,
    the instruments were limited in the manner in which they were implemented.
    In particular, the data reported reflect the individualized data-gathering
    and assessment efforts of the point of contact at USAID or the State
    Department rather than a standardized approach to data gathering and
    assessment.

    Fourth, while many respondents addressed the indicators we identified for
    analysis, because the questions were open-ended, there is inconsistency in
    the depth and coverage of responses. Furthermore, in some cases, the
    response to a question was simply "yes" or "no" without any details. When
    this occurred, we recorded the answer the respondent gave. Fifth, some
    indicators had only one source of information (they were addressed in one
    report but left blank in another), and we could not compare them for
    consistency. Sixth, in some instances, respondents did not answer
    questions sufficiently for us to make determinations or left them blank.
    We could not determine the level of these indicators based on available
    data and rated them as missing and left them blank in those cases. Despite
    these limitations, we determined that the data contained in these
    statements were sufficient for the purpose of our report, which was to
    provide information broadly demonstrating the limited capacities of
    countries at a particular point in time with implications for the
    challenges posed in subsequent periods.

    Appendix VI: Assistance to Regional and Global Organizations

    According to data submitted to the World Bank by the United States and
    other donors, Asia-Pacific regional initiatives have received the largest
    share of regionally focused funding from international donors, including
    the United States (see table 3). Approximately 67 percent of committed
    funds have gone to programs in this region. For example, donors reported
    providing the Association of Southeast Asian Nations about $50 million in
    committed funds, including about $47 million from Japan to procure
    antiviral drugs, PPE kits, and influenza test kits. Examples of support in
    other regions include HHS's provision of $3.3 million in committed funds
    to support the Gorgas Institute, a laboratory network in Panama, and the
    European Commission's provision of about $28 million to the African Union.

    Table 3: Regional Recipients of Donor Assistance for International Avian
    and Pandemic Influenza Preparedness as of December 2006

    Dollars in millions
                                                     Commitments (All       Total
    Region                      Commitments(U.S.)    other donors) commitments
    Asia-Pacific
    Asia-Pacific Economic                      --             $7.6        $7.6
    Cooperation
    Asian Development Bank                     --             10.3       $10.3
    Association of Southeast                   --             51.2       $51.2
    Asian Nations
    U.S. Global Disease                     $14.9               --       $14.9
    Detection Centers
    Pacific Island Nations                     --              6.1        $6.1
    Research in Southeast Asia               18.0               --       $18.0
    Other regional assistance                 7.5             15.5       $23.0
    Subtotal                                $40.4            $90.7      $131.1
    Africa
    African Union                              --            $28.8       $28.8
    Partnership for Livestock                  --             10.2       $10.2
    Development, Poverty
    Alleviation and Sustainable
    Growth in Africa
    U.S. Global Disease                      $8.9               --        $8.9
    Detection Centers
    Other regional assistance                 2.5              0.1        $2.6
    Subtotal                                $11.4            $39.1       $50.5
    Americas
    U.S. Global Disease                      $2.0               --        $2.0
    Detection Center
    Gorgas Memorial Institute                 3.3               --        $3.3
    of Tropical and Preventive
    Medicine
    Other regional assistance                 3.5               --        $3.5
    Subtotal                                 $8.8               $0        $8.8
    Eastern Europe/Eurasia
    U.S. Government Regional                 $1.1               --        $1.1
    Platform
    Other regional assistance                 2.9               --        $2.9
    Subtotal                                 $4.0               $0        $4.0
    Total                                   $64.6           $129.8      $194.4

    Source: GAO analysis of data from UN System Influenza Coordinator and
    World Bank, Responses to Avian and Human Influenza Threats: Progress,
    Analysis and Recommendations July-December 2006 (January 2007).

    According to data submitted to the World Bank, WHO and FAO have received
    the greatest shares of overall funding committed to global organizations
    (see fig. 13). Of the $240 million in reported overall donor commitments
    for global organizations, the WHO and FAO shares constituted about 35
    percent and 27 percent, respectively. U.S. agencies are supporting WHO and
    FAO with funds, staff, equipment, and technical assistance to improve
    these organizations' capacity to support countries. For example, HHS has
    provided funding to all six WHO regional offices. Some of this assistance
    is directed at improving collaboration on human and animal components of
    the response.^1 OIE, the UN Children's Fund, and the UN System Influenza
    Coordinator (among others) share the remaining $91 million, with the
    Children's Fund accounting for more than half of this amount--about $49
    million from Japan, provided primarily to enhance communications on avian
    and pandemic influenza risks.

    ^1According to State Department officials, U.S. contributions to FAO and
    WHO do not include funds provided to those organizations to carry out
    programs in country or at the regional level. The United States counts
    those funds as bilateral or regional assistance.

    Figure 13: Global Organization Recipients of Donor Commitments for
    International Avian and Pandemic Influenza Preparedness as of December
    2006

    Appendix VII: U.S. Agency Obligations Funding by Pillar

    In response to our request, HHS, USAID, DOD, USDA, and the State
    Department reported having obligated about 64 percent of their planned
    funding for international avian and pandemic influenza-related assistance.
    However, the data are not from consistent time periods. HHS, DOD, and
    State Department data represent obligations through the end of fiscal year
    2006 (that is, through the end of September 2006). USAID and USDA provided
    data on their obligations through December 2006. (See table 4.)

    Table 4: U.S. Obligations for International Avian and Pandemic Influenza
    Assistance by Agency and by Pillar/Activity

    Dollars in millions
                                                      Agency
                                                            State        Total by
    Pillar/activity            HHS^a USAID DOD USDA Department pillar/activity
    Preparedness and              21    96  10    5          2             134
    communications
    Surveillance and detection    25    38   0    1          0              64
    Response and containment      15    22   0    3          0              40
    Other                          1    --  --   --         --               1
    Total by agency               62   156  10    9          2             239

    Sources: HHS, USAID, DOD, USDA, and the State Department.

    Notes:

    Obligations create a legal liability for payment. For example, an agency
    incurs an obligation when it places an order, signs a contract, or awards
    a grant. See app. I for additional information on these data.

    USAID and USDA provided obligated funds through December 2006. The
    remaining agencies provided information on obligated funds through
    September 2006.

    ^aAs the table shows, HHS did not designate a pillar for a portion of its
    obligations. These funds were devoted primarily to expanding
    influenza-related staffing levels in regional surveillance and response
    facilities in Thailand and Egypt.

    Appendix VIII: Distribution of USAID Personal Protective Equipment Kits

    Figure 14 shows USAID's distribution of PPE kits by country as of the end
    of fiscal year 2006. As the figure shows, Indonesia accounted for the
    majority of these kits. According to a USAID official, approximately
    193,000 PPE kits were distributed for immediate use in surveillance and
    response activities in more than 60 countries. Additionally, USAID had
    begun to create long-term stockpiles of PPE, laboratory, and
    decontamination kits in 20 countries.^1

    1USAID designated the following countries as having the greatest need for
    forward deployment of PPE kits: Nigeria, Cameroon, Cote d'Ivoire, Niger,
    Sudan, Democratic Republic of the Congo, Bulgaria, Romania, Moldova,
    Ukraine, Georgia, Armenia, Azerbaijan, Jordan, Egypt, Bangladesh, India,
    Nepal, Pakistan, and Indonesia. According to USAID, the agency selected
    these countries because they were in regions where outbreak risk remains
    high.

    Figure 14: Distribution of USAID PPE Kits as of October 2006

    Appendix IX: GAO Contacts and Staff Acknowledgments

    GAO Contacts

    David Gootnick (202) 512-3149 or gootnickd@gao.gov Marcia Crosse (202)
    512-7114 or crossem@gao.gov

    Staff Acknowledgements

    Key contributors to this report were Celia Thomas, Assistant Director;
    Thomas Conahan, Assistant Director; Michael McAtee; Robert Copeland; R.
    Gifford Howland; Syeda Uddin; David Fox; Jasleen Modi; David Dornisch;
    Etana Finkler, Debbie Chung, Monica Brym, and Jena Sinkfield.

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    Highlights of [71]GAO-07-604 , a report to congressional requesters

    June 2007

    INFLUENZA PANDEMIC

    Efforts to Forestall Onset Are Under Way; Identifying Countries at Highest
    Risk Entails Challenges

    Since 2003, a global epidemic of avian influenza has raised concern about
    the risk of an influenza pandemic among humans, which could cause millions
    of deaths. The United States and its international partners have begun
    implementing a strategy to forestall (prevent or delay) a pandemic and
    prepare to cope should one occur. Disease experts generally agree that the
    risk of a pandemic strain emerging from avian influenza in a given country
    varies with (1) environmental factors, such as disease presence and
    certain high-risk farming practices, and

    (2) preparedness factors, such as a country's capacity to control
    outbreaks.

    This report describes (1) U.S. and international efforts to assess
    pandemic risk by country and prioritize countries for assistance and (2)
    steps that the United States and international partners have taken to
    improve the ability to forestall a pandemic.

    To address these objectives, we interviewed officials and analyzed data
    from U.S. agencies, international organizations, and nongovernmental
    experts.

    The U.S. and international agencies whose efforts we describe reviewed a
    draft of this report. In general, they concurred with our findings.
    Several provided technical comments, which we incorporated as appropriate.

    Assessments by U.S. agencies and international organizations have
    identified widespread risks of the emergence of pandemic influenza and the
    United States has identified priority countries for assistance, but
    information gaps limit the capacity for comprehensive comparisons of risk
    levels by country. Several assessments we examined, which have considered
    environmental or preparedness-related risks or both, illustrate these
    gaps. For example, a U.S. Agency for International Development (USAID)
    assessment categorized countries according to the level of environmental
    risk--considering factors such as disease presence and the likelihood of
    transmission from nearby countries, but factors such as limited
    understanding of the role of poultry trade or wild birds constrain the
    reliability of the conclusions. Further, USAID, the State Department, and
    the United Nations have administered questionnaires to assess country
    preparedness and World Bank-led missions have gathered detailed
    information in some countries, but these efforts do not provide a basis
    for making comprehensive global comparisons. Efforts to get better
    information are under way but will take time. The U.S. Homeland Security
    Council has designated priority countries for assistance, and agencies
    have further identified several countries as meriting the most extensive
    efforts, but officials acknowledge that these designations are based on
    limited information.

    The United States has played a prominent role in global efforts to improve
    avian and pandemic influenza preparedness, committing the greatest share
    of funds and creating a framework for managing its efforts. Through 2006,
    the United States had committed about $377 million, 27 percent of the

    $1.4 billion committed by all donors. USAID and the Department of Health
    and Human Services have provided most of these funds for a range of
    efforts, including stockpiles of protective equipment and training foreign
    health professionals in outbreak response. The State Department
    coordinates international efforts and the Homeland Security Council
    monitors progress. More than a third of U.S. and overall donor commitments
    have gone to individual countries, with more than 70 percent of those
    going to U.S. priority countries. The U.S. National Strategy for Pandemic
    Influenza Implementation Plan provides a framework for U.S. international
    efforts, assigning agencies specific action items and specifying
    performance measures and time frames for completion. The Homeland Security
    Council reported in December 2006 that all international actions due to be
    completed by November had been completed, and provided evidence of timely
    completion for the majority of those items.

    References

    Visible links
      52. http://www.gao.gov/cgi-bin/getrpt?GAO-07-399
      53. http://www.gao.gov/cgi-bin/getrpt?GAO-06-1042
      54. http://www.gao.gov/cgi-bin/getrpt?GAO-05-984
      55. http://www.gao.gov/cgi-bin/getrpt?GAO-05-863T
      56. http://www.gao.gov/cgi-bin/getrpt?GAO-05-760T
      57. http://www.gao.gov/cgi-bin/getrpt?GAO-05-177T
      58. http://www.gao.gov/cgi-bin/getrpt?GAO-04-1100T
      59. http://www.gao.gov/cgi-bin/getrpt?GAO-04-458T
      60. http://www.gao.gov/cgi-bin/getrpt?GAO-01-722
      61. http://www.gao.gov/cgi-bin/getrpt?GAO-01-786T
      62. http://www.gao.gov/cgi-bin/getrpt?GAO-01-624
      63. http://www.gao.gov/cgi-bin/getrpt?GAO-01-4
      71. http://www.gao.gov/cgi-bin/getrpt?GAO-07-604
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