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
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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 [email protected] or Marcia Crosse at (202) 512-7114
or [email protected] . 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 [email protected] Marcia Crosse (202)
512-7114 or [email protected]

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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(320396)

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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
*** End of document. ***