    Influenza Pandemic: DOD Combatant Commands' Preparedness Efforts
    Could Benefit from More Clearly Defined Roles, Resources, and
    Risk Mitigation (20-JUN-07, GAO-07-696).

    An influenza pandemic could impair the military's readiness,
    jeopardize ongoing military operations abroad, and threaten the
    day-to-day functioning of the Department of Defense (DOD) due to
    a large percentage of sick or absent personnel. GAO was asked to
    examine DOD's pandemic influenza planning and preparedness
    efforts. GAO previously reported that DOD had taken numerous
    actions to prepare departmentwide, but faced four management
    challenges as it continued its efforts. GAO made recommendations
    to address these challenges and DOD generally concurred with
    them. This report focuses on DOD's combatant commands (COCOM) and
    addresses (1) actions the COCOMs have taken to prepare and (2)
    management challenges COCOMs face going forward. GAO reviewed
    guidance, plans, and after-action reports and interviewed DOD
    officials and more than 200 officials at the 9 COCOMs.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-07-696
        ACCNO:   A71045
      TITLE:     Influenza Pandemic: DOD Combatant Commands' Preparedness
    Efforts Could Benefit from More Clearly Defined Roles, Resources,
    and Risk Mitigation
         DATE:   06/20/2007
      SUBJECT:   Defense capabilities
    	     Defense contingency planning
    	     Emergency preparedness
    	     Homeland security
    	     Infectious diseases
    	     Military forces
    	     Pandemic
    	     Public health
    	     Strategic planning

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    GAO-07-696

         * [1]Results in Brief
         * [2]Background
         * [3]COCOMs Have Taken Numerous Actions to Prepare for an Influen

              * [4]COCOMs Have Established Working Groups to Address Pandemic I
              * [5]COCOMs Have Developed Pandemic Influenza Plans for Their Are
              * [6]COCOMs Have Conducted Exercises for Pandemic Influenza Plans
              * [7]COCOMs Have Started to Provide Information to Personnel abou
              * [8]COCOMs Have Coordinated with Other Nations

         * [9]COCOMs Face Three Management Challenges as They Continue to

              * [10]Roles, Responsibilities, and Authorities of Key Organization
              * [11]DOD Has Not Identified Resources to Complete Planning and Pr
              * [12]COCOMs Have Not Yet Developed Options to Mitigate the Effect

                   * [13]COCOMs Have Not Yet Developed Options to Mitigate the
                     Effect
                   * [14]COCOMs Have Not Yet Developed Options to Mitigate the
                     Effect
                   * [15]COCOMs Have Not Yet Developed Options to Mitigate the
                     Effect
                   * [16]COCOMs Have Not Yet Develped Options to Mitigate the
                     Effects
                   * [17]COCOMs Have Not Yet Developed Options to Mitigate the
                     Effect

         * [18]Conclusions
         * [19]Recommendations for Executive Action
         * [20]Agency Comments and Our Evaluation
         * [21]Appendix I: Actions Assigned to DOD as a Lead Agency in the
         * [22]Appendix II: Scope and Methodology
         * [23]Appendix III: Comments from the Department of Defense
         * [24]Appendix IV: GAO Contact and Staff Acknowledgments

              * [25]GAO Contact
              * [26]Staff Acknowledgments

         * [27]Related GAO Products
         * [28]PDF6-Ordering Information.pdf

              * [29]Order by Mail or Phone

    Report to the Committee on Oversight and Government Reform, House of
    Representatives

    United States Government Accountability Office

    GAO

    June 2007

    INFLUENZA PANDEMIC

    DOD Combatant Commands' Preparedness Efforts Could Benefit from More
    Clearly Defined Roles, Resources, and Risk Mitigation

    GAO-07-696

    Contents

    Letter 1

    Results in Brief 6
    Background 9
    COCOMs Have Taken Numerous Actions to Prepare for an Influenza Pandemic 11
    COCOMs Face Three Management Challenges as They Continue to Prepare for an
    Influenza Pandemic 21
    Conclusions 36
    Recommendations for Executive Action 37
    Agency Comments and Our Evaluation 38
    Appendix I Actions Assigned to DOD as a Lead Agency in the National
    Implementation Plan 40
    Appendix II Scope and Methodology 47
    Appendix III Comments from the Department of Defense 50
    Appendix IV GAO Contact and Staff Acknowledgments 52
    Related GAO Products 53

    Tables

    Table 1: Summary of COCOMs' Actions to Prepare for an Influenza Pandemic
    12
    Table 2: COCOM Perceptions of Responsibility for Actions Assigned to DOD
    25

    Figures

    Figure 1: Geographic COCOMs' Areas of Responsibility 4
    Figure 2: Comparison of WHO Pandemic Phases and Federal Government Stages
    11
    Figure 3: Timeline of COCOMs' Pandemic Influenza Planning Efforts 14
    Figure 4: Official Provides Information about Pandemic Influenza at
    PACOM's Outreach Event 19

    Abbreviations

    ASD Assistant Secretary of Defense
    ASD(HD&ASA) Assistant Secretary of Defense for Homeland Defense and
      Americas' Security Affairs
    CENTCOM Central Command
    COCOM combatant command
    DOD Department of Defense
    EUCOM European Command
    JFCOM Joint Forces Command
    NORTHCOM Northern Command
    PACOM Pacific Command
    SOCOM Special Operations Command
    SOUTHCOM Southern Command
    STRATCOM Strategic Command
    TRANSCOM Transportation Command WHO World Health Organization

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

    United States Government Accountability Office
    Washington, DC 20548

    June 20, 2007

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

    An influenza pandemic--a novel influenza virus that has the ability to
    infect and be passed efficiently among humans--could significantly impair
    the military's readiness, jeopardize ongoing military operations abroad,
    and threaten the day-to-day functioning of the Department of Defense (DOD)
    due to a large percentage of sick or absent personnel. The vulnerability
    of U.S. armed forces to an influenza pandemic was demonstrated during
    World War I when at least 43,000 U.S. servicemembers died--about half of
    all of the deaths of U.S. servicemembers during World War I--due to
    influenza or influenza-related complications, and another 1 million
    servicemembers were hospitalized, which limited the military's ability to
    continue ongoing missions. According to the Centers for Disease Control
    and Prevention, the "Spanish flu" pandemic of 1918-1919 killed at least 50
    million people worldwide, including approximately 675,000 in the United
    States.^1 According to the World Health Organization (WHO), it is not a
    question of if, but when, another influenza pandemic will occur. During
    the peak weeks of an outbreak of a severe influenza pandemic, the Homeland
    Security Council estimates that 40 percent of the U.S. workforce might not
    be at work due to illness, the need to care for family members who are
    sick, or fear of becoming infected. DOD military and civilian personnel
    and contractors would not be immune and the department would face a
    similar absentee rate.

    Recent concerns about the possibility of an influenza pandemic have arisen
    due to an unprecedented outbreak of H5N1, a deadly strain of avian
    influenza which began in Hong Kong in 1997 and spread among bird
    populations in parts of Asia, the Middle East, Europe, and Africa, with
    limited infections in humans. According to WHO, 309 human cases of H5N1
    resulting in 187 human deaths had been reported worldwide as of May 31,
    2007. Scientists and public health officials agree that the rapid spread
    of the virus in birds and the occurrence of limited infections in humans
    have increased the risk that this disease may mutate into a form that is
    easily transmissible among humans. According to WHO, three conditions must
    be met before an influenza pandemic begins: (1) a new influenza virus
    subtype that has not previously circulated in humans must emerge, (2) the
    virus must be capable of causing disease in humans, and (3) the virus must
    be capable of being passed easily among humans. The H5N1 virus currently
    meets the first two of these three conditions.

    ^1The 1957 "Asian flu" pandemic and 1968 "Hong Kong flu" pandemic caused
    far fewer deaths--70,000 and 34,000, respectively, in the United
    States--partly because of antibiotic treatment of secondary infections and
    more aggressive support care.

    To address the potential threat of an influenza pandemic, the Homeland
    Security Council issued its National Strategy for Pandemic Influenza in
    November 2005.^2 The Implementation Plan for the National Strategy for
    Pandemic Influenza (national implementation plan),^3 which was released in
    May 2006, tasked each federal agency with developing its own
    implementation plan that addresses two issues: (1) how it would address
    the actions assigned to the agency and (2) its approach to employee
    safety, continuity of operations, and communications with stakeholders
    departmentwide. DOD finalized its implementation plan for pandemic
    influenza in August 2006 and released the plan publicly in May 2007.^4 Of
    the more than 300 actions in the national implementation plan, DOD is
    responsible for 114 actions--31 actions as a lead agency and 83 actions as
    a supporting agency.^5 Appendix I lists these actions, the implementation
    deadline, and the lead DOD organization responsible for implementing the
    action.

    DOD began its departmentwide planning and preparedness efforts in
    September 2004, when the Assistant Secretary of Defense (ASD) for Health
    Affairs issued guidance to the military departments on preparing for an
    influenza pandemic. The Deputy Secretary of Defense designated the ASD for
    Homeland Defense and Americas' Security Affairs (ASD[HD&ASA]), within the
    Office of the Under Secretary of Defense for Policy, as the lead for DOD's
    pandemic influenza planning efforts,^6 and DOD identified functional leads
    to oversee the 31 actions assigned to DOD as a lead agency in the national
    implementation plan. The ASD(HD&ASA) is the lead for those actions related
    to providing defense support of civil authorities, the ASD for Health
    Affairs is the functional lead for force health protection actions, and
    the Joint Staff oversees the combatant commands' (COCOM) planning and
    implementation efforts. In August 2006, the Secretary of Defense named the
    U.S. Northern Command (NORTHCOM) the lead COCOM for directing, planning,
    and synchronizing DOD's global response to pandemic influenza.

    ^2Homeland Security Council, National Strategy for Pandemic Influenza
    (Washington, D.C.: November 2005).

    ^3Homeland Security Council, Implementation Plan for the National Strategy
    for Pandemic Influenza (Washington, D.C.: May 2006).

    ^4DOD, Department of Defense Implementation Plan for Pandemic Influenza
    (Arlington, Va.: August 2006).

    ^5The national implementation plan generally identifies lead and support
    roles for the actions federal agencies are responsible for completing but
    it is not explicit in defining these roles or processes for coordination
    and collaboration.

    As operational commanders, DOD's unified COCOMs are an essential part of
    the department's pandemic influenza planning. There are currently nine
    COCOMs--five with geographic responsibilities and four with functional
    responsibilities.^7 The five COCOMs with geographic responsibilities are
    the U.S. Central Command (CENTCOM), U.S. European Command (EUCOM),
    NORTHCOM, U.S. Pacific Command (PACOM), and U.S. Southern Command
    (SOUTHCOM). Their geographic areas of responsibility are shown in figure
    1. The four functional COCOMs are the U.S. Joint Forces Command (JFCOM)
    which, among other things, engages in joint training and force provision;
    U.S. Special Operations Command (SOCOM), which trains, equips, and deploys
    special operations forces to other COCOMs and leads counterterrorist
    missions worldwide; U.S. Strategic Command (STRATCOM), whose missions
    include space and information operations; missile defense; global command
    and control; intelligence, surveillance, and reconnaissance; strategic
    deterrence; and integration and synchronization of DOD's departmentwide
    efforts in combating weapons of mass destruction; and U.S. Transportation
    Command (TRANSCOM), which provides air, land, and sea transportation for
    DOD.

    ^6The Office of the Under Secretary of Defense for Policy was reorganized
    in December 2006. This reorganization included, among other things, the
    Office of the Assistant Secretary of Defense for Homeland Defense being
    renamed the Office of the Assistant Secretary of Defense for Homeland
    Defense and Americas' Security Affairs. Throughout this report we refer to
    the office by its current name.

    ^7In February 2007, the Secretary of Defense announced that DOD will
    establish a sixth COCOM with geographic responsibilities--the U.S. Africa
    Command--which is expected to become operational by September 2008.
    Responsibility for African operations currently is divided among EUCOM,
    CENTCOM, and PACOM.

    Figure 1: Geographic COCOMs' Areas of Responsibility

    Notes: Areas of responsibility are as of October 1, 2006. In February
    2007, the Secretary of Defense announced that DOD will establish a sixth
    COCOM with geographic responsibilities--the U.S. Africa Command--which is
    expected to become operational by September 2008. Responsibility for
    African operations currently is divided among EUCOM, CENTCOM, and PACOM.

    aThe state of Alaska is assigned to NORTHCOM's area of responsibility.
    Forces based in Alaska, however, remain assigned to PACOM.

    You asked that we examine DOD's planning and preparedness efforts for an
    influenza pandemic. In September 2006, we issued a report on DOD's efforts
    to prepare its workforce for an influenza pandemic.^8 We reported that
    since September 2004, DOD had taken a number of actions to prepare for an
    influenza pandemic; however, DOD faced four management challenges for its
    ongoing pandemic influenza preparedness efforts. We found that DOD had not
    defined lead and supporting roles and responsibilities, oversight
    mechanisms, or goals and performance measures for its planning efforts;
    had not requested funding to support pandemic influenza preparedness; had
    not fully defined or communicated which types of personnel--military and
    civilian personnel, contractors, dependents, and beneficiaries--would be
    included in vaccine and antiviral distribution; and had not fully
    developed a communications strategy. We recommended that DOD take actions
    to address these issues. DOD generally concurred with our recommendations,
    but had not yet taken actions to address our recommendations. While our
    September 2006 report focused on DOD's planning and preparedness efforts
    departmentwide, this report focuses on the COCOMs' planning and
    preparedness efforts for an influenza pandemic. Specifically, this report
    addresses (1) the actions the COCOMs have taken to prepare for an
    influenza pandemic and (2) management challenges the COCOMs face as they
    continue their planning and preparedness efforts.

    To address these objectives, we reviewed drafts of the five geographic
    COCOMs' plans and one functional COCOM's plan that were available at the
    time of our review. We did not evaluate the plans; rather, we used the
    plans to determine the actions the COCOMs have taken and plan to take to
    prepare for an influenza pandemic. We also reviewed a November 2005 Joint
    Staff planning order, an April 2007 Joint Staff planning order, DOD's
    implementation plan for pandemic influenza, the Implementation Plan for
    the National Strategy for Pandemic Influenza, DOD budget requests and
    appropriations, and after-action reports for exercises. We met with more
    than 200 officials involved in pandemic influenza planning and
    preparedness efforts at the nine COCOMs, service and special operations
    subcomponents at two COCOMs (EUCOM and PACOM), and U.S. Forces Korea. We
    also met with officials from the Office of the ASD(HD&ASA), the Office of
    the ASD for Health Affairs, and the Joint Staff. Additionally, we met with
    officials at the Department of State to discuss their pandemic influenza
    planning and preparedness efforts in relation to the COCOMs' efforts
    abroad. Finally, we compared COCOMs' actions to date with best practices
    we have identified in prior work on risk management, influenza pandemics,
    emergency preparedness, and general management. We conducted our review
    from September 2006 through April 2007 in accordance with generally
    accepted government auditing standards. Further details on our scope and
    methodology are in appendix II.

    ^8GAO, Influenza Pandemic: DOD Has Taken Important Actions to Prepare, but
    Accountability, Funding, and Communications Need to be Clearer and Focused
    Departmentwide, [30]GAO-06-1042 (Washington, D.C.: Sept. 21, 2006).

    Results in Brief

    DOD's COCOMs have taken numerous actions to prepare for an influenza
    pandemic, including management actions, such as establishing working
    groups, and operational actions, such as coordinating with other nations.
    The COCOMs' pandemic influenza planning and preparedness efforts are
    evolving. At the time of our review, each of the COCOMs had established or
    intended to establish a working group to oversee plan development and work
    on other aspects of pandemic influenza preparation. Additionally, eight of
    the nine COCOMs had developed or were developing a pandemic influenza
    plan. Although SOCOM's headquarters is not developing a pandemic influenza
    plan, officials said they expect each of the geographically-based special
    operations commands will develop an annex for their geographic COCOMs'
    plans. To test their pandemic influenza plans, half of the COCOMs have
    conducted a pandemic or avian influenza-specific exercise or included a
    pandemic or avian influenza scenario within another exercise, and nearly
    all of the COCOMs plan to address pandemic influenza in future exercises.
    Several of the COCOMs are taking steps to address some lessons learned
    from the exercises. Five of the nine COCOMs have started to use various
    strategies, including using various media outlets, training programs, and
    outreach events, to inform their personnel--including military and
    civilian personnel, contractors, dependents, and beneficiaries--about
    pandemic influenza. For example, PACOM held an outreach event that
    combined providing seasonal flu vaccinations with distributing information
    about pandemic influenza. Each of the geographic COCOMs has worked or
    plans to work with nations in its area of responsibility to raise
    awareness about and assess capabilities for responding to avian and
    pandemic influenza. For example, CENTCOM has performed assessments and
    identified gaps for Afghanistan's pandemic influenza preparedness and
    response.

    Although COCOMs have taken numerous actions, we identified three
    management challenges that may prevent the COCOMs from being fully
    prepared to effectively protect personnel and perform their missions
    during an influenza pandemic. Two of these challenges--the lack of clearly
    defined roles and responsibilities and the lack of information on required
    resources--are related to departmentwide issues that we recommended DOD
    take actions to address in our September 2006 report, but DOD has not yet
    taken action to address them. The challenges are as follows:

               o The roles, responsibilities, and authorities of key
               organizations involved in DOD's pandemic influenza planning and
               preparedness efforts relative to other organizations leading and
               supporting the department's pandemic influenza planning
               efforts--including NORTHCOM as the lead for DOD's planning and the
               individual COCOMs--remained unclear because of the continued lack
               of sufficiently detailed guidance from the Secretary of Defense or
               his designee. We have previously reported that, as with preparing
               for and responding to any other type of disaster, leadership roles
               and responsibilities must be clearly defined, effectively
               communicated, and well understood to facilitate rapid and
               effective decision making.^9 As a result of not yet issuing
               guidance fully and clearly defining the roles, responsibilities,
               authorities, and relationships of key organizations, such as
               offices within the Office of the Secretary of Defense, the
               military services, and the COCOMs, the unity and cohesiveness of
               DOD's pandemic influenza preparation could be impaired.
               Furthermore, the potential remains for confusion and gaps or
               duplication in actions taken by the COCOMs relative to other DOD
               organizations, such as the military services. For example,
               officials from the Office of the ASD(HD&ASA) and the Joint Staff
               said the COCOMs were responsible for completing few actions
               assigned to DOD in the national implementation plan; however,
               COCOM officials reported that they were, in part, responsible for
               implementing between 12 and 18 of these actions.

               o Second, we identified a disconnect between the COCOMs' planning
               and preparedness activities and resources to complete these
               activities in part because DOD's guidance for the COCOMs' planning
               efforts does not identify the resources required to complete these
               activities. We have previously reported that information on
               required resources is critical for making sound analyses of how to
               pursue goals.^10 Without realistic information on required
               resources, decision makers cannot determine whether a strategy to
               achieve those goals is realistic and cost effective, or make
               trade-offs against other funding priorities. The continued lack of
               a link between planning and preparedness activities and resources
               may limit the COCOMs' ability to effectively prepare for and
               respond to an influenza pandemic. For example, EUCOM and PACOM
               officials said a lack of resources will limit their ability to
               exercise their pandemic influenza plans in the future.

               o Third, we identified factors that are beyond the COCOMs'
               control--such as limited detailed guidance from other federal
               agencies on the support expected from DOD, lack of control over
               DOD's stockpile of antivirals, limited information on decisions
               that other nations may make during an influenza pandemic, reliance
               on civilian medical providers for medical care, and reliance on
               military services for medical materiel--that they have not yet
               fully planned how to mitigate. We have recommended a comprehensive
               risk-management approach, including putting steps in place to
               reduce the effects of any outbreak that does occur, as a framework
               for decision making.^11 Some COCOMs have taken steps to mitigate
               the effects of these factors that are beyond their control;
               however, planning officials from at least one COCOM said they will
               not develop specific plans to address some of these factors until
               they receive more information. Planning officials from three
               COCOMs and two service subcomponents said that planning to provide
               support at the last minute could lead to a less effective and less
               efficient use of resources. While we recognize the difficulty of
               planning for an influenza pandemic, not yet developing options to
               mitigate the effects of factors that are beyond their control may
               place at risk the COCOM commanders' ability to protect their
               personnel, including military and civilian personnel, contractors,
               dependents, and beneficiaries, and perform their missions during
               an influenza pandemic. For example, if a nation decides to close
               its borders at the start of a pandemic, COCOMs and installations
               may not be able to obtain needed supplies, such as antivirals.

    ^9GAO, Homeland Security: Preparing for and Responding to Disasters,
    [31]GAO-07-395T (Washington, D.C.: Mar. 9, 2007) and GAO, Emergency
    Preparedness and Response: Some Issues and Challenges Associated with
    Major Emergency Incidents, [32]GAO-06-467T (Washington, D.C.: Feb. 23,
    2006).

    ^10GAO, Agencies' Annual Performance Plans Under the Results Act: An
    Assessment Guide to Facilitate Congressional Decisionmaking,
    [33]GAO/GGD/AIMD-10.1.18 (Washington, D.C.: Feb. 1, 1998).

    We are making three recommendations to improve the COCOMs' ongoing
    pandemic influenza planning and preparedness efforts. Specifically, we
    recommend that DOD take steps to clarify the COCOMs' roles and
    responsibilities in DOD's pandemic influenza planning and preparedness
    efforts, identify the sources and types of resources needed for the COCOMs
    to accomplish their pandemic influenza-related efforts, and develop
    options to mitigate the effects of factors that are beyond their control.

    ^11GAO, Homeland Security: Applying Risk Management Principles to Guide
    Federal Investments, [34]GAO-07-386T (Washington, D.C.: Feb. 7, 2007) and
    GAO, Hurricane Katrina: GAO's Preliminary Observations Regarding
    Preparedness, Response, and Recovery, [35]GAO-06-442T (Washington, D.C.:
    Mar. 8, 2006).

    We provided a draft of this report to DOD and the Department of State in
    April 2007 for their review and comment. In written comments on a draft of
    this report, DOD concurred with all of our recommendations and noted that
    the department is confident that future plans will adequately address
    specific roles, resources, and risk mitigation. The Department of State
    had no comments. DOD also provided us with technical comments, which we
    incorporated in the report, as appropriate. DOD's comments can be found in
    appendix III.

    Background

    Planning for an influenza pandemic is a difficult and daunting task,
    particularly because so much is currently unknown about a potential
    pandemic. While some scientists and public health experts believe that the
    next influenza pandemic could be spawned by the H5N1 avian influenza
    strain, it is unknown when an influenza pandemic will occur, where it will
    begin, or whether a variant of H5N1 or some other strain would be the
    cause. Moreover, the severity of an influenza pandemic, as well as the
    groups of people most at risk for infection, cannot be accurately
    predicted. Past pandemics have spread worldwide within months and a future
    pandemic is expected to spread even more quickly given modern travel
    patterns. The implication of such a rapid spread is that many, if not
    most, countries will have minimal time to implement preparations and
    responses once a pandemic virus begins to spread. However, as we have
    previously reported, despite all of these uncertainties, sound planning
    and preparedness could lessen the impact of any influenza pandemic.^12

    Preparing for an influenza pandemic can be helpful not only to lessen a
    pandemic's impact, but also to help prepare for other disasters that may
    occur. As we have previously reported, the issues associated with
    preparation for and response to an influenza pandemic are similar to those
    for any other type of disaster: clear leadership roles and
    responsibilities, authority, and coordination; risk management; realistic
    planning, training, and exercises; assessing and building the capacity
    needed to effectively respond and recover; effective information sharing
    and communication; and accountability for the effective use of
    resources.^13 At the same time, a pandemic poses some unique challenges.
    Rather than being localized in particular areas and occurring within a
    short period of time, as do disasters such as earthquakes, explosions, or
    terrorist incidents, an influenza pandemic is likely to affect wide areas
    of the world and continue for weeks or months. Past pandemics have spread
    globally in two and sometimes three waves, according to WHO, and a
    pandemic is likely to come in waves lasting months, according to the
    national implementation plan. Additionally, responding to an influenza
    pandemic would be more challenging than dealing with annual influenza.
    Each year, annual influenza causes approximately 226,000 hospitalizations
    and 36,000 deaths in the United States. According to WHO, an influenza
    pandemic would spread throughout the world very quickly, usually in less
    than a year, and could sicken more than a quarter of the global
    population, including young, healthy individuals who are not normally as
    affected by the annual flu.

    ^12 [36]GAO-06-1042 .

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

    ^13 [37]GAO-07-395T .

    Figure 2: Comparison of WHO Pandemic Phases and Federal Government Stages

    COCOMs Have Taken Numerous Actions to Prepare for an Influenza Pandemic

    COCOMs have taken numerous management and operational actions to prepare
    for an influenza pandemic and the COCOMs' efforts are evolving. While the
    COCOMs are at different stages in their planning and preparedness efforts,
    each has taken actions to plan and prepare for an influenza pandemic.
    These actions include establishing working groups, developing plans,
    exercising plans, implementing strategies to inform personnel about
    pandemic influenza, and coordinating with other nations. Table 1
    summarizes the COCOMs' actions to prepare for an influenza pandemic.

    Table 1: Summary of COCOMs' Actions to Prepare for an Influenza Pandemic

    Combatant  Established   Developed Conducted Informed   Coordinated with
    command   working groups   plans   exercises personnel    other nations
    CENTCOM         X            X         X                        X
    EUCOM           X            X         X         X              X
    JFCOM                        X
    NORTHCOM        X            X         X         X              X
    PACOM           X            X         X         X              X
    SOCOM                       ^a
    SOUTHCOM        X            X                   X              X
    STRATCOM        X            X         X         X
    TRANSCOM        X            X

    Source: GAO analysis of DOD data.

    aSOCOM headquarters is not developing a pandemic influenza plan. However,
    SOCOM planning officials expect that the geographically-based special
    operations commands will develop an annex to their geographic COCOM's
    plan.

    COCOMs Have Established Working Groups to Address Pandemic Influenza

    Each of the geographic COCOMs has established a working group to address
    various aspects of pandemic influenza, and each of the functional COCOMs
    has either established a working group or is planning to do so. Medical
    and operational planning officials from the geographic COCOMs told us they
    viewed pandemic influenza planning as both an operational and force health
    protection issue and, accordingly, these groups are generally led by
    officials in the operations or plans and policy directorates, the office
    of the command surgeon, or a combination of these offices. Officials from
    across the command, and in some cases service subcomponents and other
    federal agencies, participate regularly or as needed. These working groups
    oversee pandemic influenza plan development and work on other aspects of
    pandemic influenza preparation. For example, PACOM's working group is
    headed by three officials, one each from the operations directorate, plans
    and policy directorate, and the Office of the Command Surgeon. According
    to a PACOM official, intelligence, logistics, and public affairs officials
    regularly attend meetings, and officials from other directorates and
    subcomponents attend as needed. The group was established to develop a
    pandemic influenza response plan covering PACOM's geographic area of
    responsibility based on the November 2005 Joint Staff order to plan for an
    influenza pandemic.

    In addition to its core pandemic influenza planning team, PACOM tasked two
    of its service subcomponents to lead operational groups with
    responsibilities for pandemic influenza preparation and response in
    PACOM's area of responsibility. PACOM designated its Marine subcomponent,
    Marine Forces Pacific, to lead PACOM's international support response
    during an influenza pandemic, which will be conducted through a
    multiservice task force formed to conduct relief operations during an
    influenza pandemic.^14 The task force may also conduct noncombatant
    evacuation operations of Americans living abroad. PACOM also tasked its
    Army subcomponent, U.S. Army Pacific, to assist partner governments and
    conduct defense support of civil authorities in PACOM's domestic area of
    responsibility through a standing task force that defends PACOM's domestic
    region from external military threats. PACOM's domestic area of
    responsibility, in contrast to the command's foreign area of
    responsibility, consists of the state of Hawaii, and various U.S.
    territories, possessions, and protectorates, including Guam, American
    Samoa, and the Marshall Islands.

    Normally in a supporting role, the functional COCOMs were not formally
    tasked to plan for pandemic influenza by the November 2005 Joint Staff
    planning order. However, each established or intends to establish a group
    to prepare for pandemic influenza. For example, JFCOM is in the process of
    establishing a pandemic influenza working group. Prior to establishing the
    group, JFCOM's operations directorate was leading its pandemic influenza
    planning efforts. Once established, JFCOM's working group will include
    representatives from select directorates, the installation where JFCOM's
    headquarters is located, and the regional public health emergency
    officer,^15 according to JFCOM officials.

    Additionally, in 2007 NORTHCOM established a working group, called the
    Global Pandemic Influenza Working Group, to develop DOD's global plan for
    pandemic influenza that applies to all of DOD's COCOMs, military services,
    and defense agencies. The working group has met three times in 2007 and
    included representatives from the Office of the Secretary of Defense; the
    Joint Staff; the geographic COCOMs; three of the four functional COCOMs;
    the four military services; two defense agencies--the Defense Intelligence
    Agency and the Defense Logistics Agency--and the Air Force Medical
    Intelligence Center; and other interagency partners, including the
    Departments of State, Health and Human Services, Homeland Security, and
    Agriculture.

    ^14While Marine Forces Pacific will lead PACOM's international support
    response in most of the command's area of responsibility, U.S. Forces
    Korea will lead PACOM's international support response on the Korean
    peninsula.

    ^15The Public Health Emergency Officer is the primary medical official
    designated to manage public health emergencies on installations.

    COCOMs Have Developed Pandemic Influenza Plans for Their Areas of Responsibility

    At the time of our review, eight of the nine COCOMs had developed or were
    developing a plan to prepare for and respond to a potential pandemic
    influenza outbreak. Figure 3 illustrates when the COCOMs started their
    pandemic influenza planning efforts.

    Figure 3: Timeline of COCOMs' Pandemic Influenza Planning Efforts

    Note: SOCOM headquarters is not developing a pandemic influenza plan.
    However, SOCOM planning officials expect that the geographically-based
    special operations commands will develop an annex to their geographic
    COCOMs' plan.

    In November 2005, the Joint Staff requested that the geographic COCOMs
    develop or adapt existing pandemic influenza plans to address force health
    protection, defense support of civil authorities, and humanitarian
    assistance. Two geographic COCOMs, EUCOM and PACOM, began developing plans
    before the November 2005 planning order. In August 2005, PACOM issued an
    instruction on pandemic influenza preparation and response. Similarly, in
    August 2005, EUCOM began developing its plan as a result of media reports
    of avian influenza cases. Although the Joint Staff did not request that
    the functional COCOMs develop plans, three of the four functional COCOMs
    are developing plans to preserve their ability to continue their own
    operations or to address their support role during an influenza pandemic.
    While SOCOM's headquarters was not developing a pandemic influenza plan,
    SOCOM planning officials said they expect each of the geographically-based
    special operations commands will develop an annex for their respective
    geographic COCOMs' plan; the tasking to develop these plans will come from
    the geographic COCOM, rather than SOCOM. For example, PACOM's special
    operations component is developing a plan for special operations forces in
    PACOM's area of responsibility.

    Each of the geographic COCOMs' plans contain phases that indicate various
    actions for the COCOMs to take prior to and during a potential pandemic.
    DOD generally uses phases in its plans when conducting complex joint,
    interagency, or multinational operations to integrate and synchronize
    interrelated activities. The Joint Staff required that the geographic
    COCOMs' plans take into account the WHO phases for an influenza pandemic;
    however, the COCOMs were not required to adopt the same phases. This
    allowed the COCOMs to develop their own phasing structures for their plans
    and, as a result, the COCOMs plans have different phasing structures. By
    definition, an influenza pandemic would simultaneously affect multiple
    geographic COCOMs' areas of responsibility and would, therefore, require
    unified and cohesive efforts to respond. According to officials from the
    Office of the ASD(HD&ASA), the Joint Staff, and two of the COCOMs,
    differing phasing structures may result in the COCOMs' plans having gaps
    and duplication of effort among the COCOMs. Using a uniform phasing
    structure may increase the likelihood that all COCOMs understand what
    actions to take and when to take those actions, resulting in a unified and
    cohesive effort. At the time of our review, NORTHCOM, as the lead COCOM
    for DOD's planning efforts, was drafting an overarching plan for the
    COCOMs' response to an influenza pandemic, which is to include a common
    phasing structure for the COCOMs' plans.

    The COCOMs' plans include not only actions to respond to an influenza
    pandemic, but also actions to prepare for an influenza pandemic. According
    to planning officials, each of the geographic COCOMs is implementing
    actions from the initial phases of their plans. Planning officials at four
    of the five geographic COCOMs told that us that advance preparation was
    essential for an effective pandemic response.

    COCOMs Have Conducted Exercises for Pandemic Influenza Plans

    To test their pandemic influenza plans, five of the nine COCOMs have
    conducted a pandemic influenza-related exercise. Three of the geographic
    COCOMs--CENTCOM, EUCOM, and PACOM--and one of the functional
    COCOMs--STRATCOM--conducted a pandemic or avian influenza-specific
    exercise. For example, EUCOM conducted its Avian Wind exercise in June
    2006, which included more than 100 participants representing partner
    nations, other federal agencies, and DOD and EUCOM components. The
    exercise was designed to identify and enhance the coordination of actions
    to plan for, respond to, contain, and mitigate the effects of avian or
    pandemic influenza within EUCOM's area of responsibility. The other three
    COCOMs held smaller tabletop exercises to familiarize participants with
    pandemic influenza in general and the COCOMs' plans more specifically.
    Additionally, two of the geographic COCOMs--NORTHCOM and PACOM--included a
    pandemic influenza scenario within another exercise. SOUTHCOM planning and
    medical officials said they have not yet conducted a pandemic influenza
    exercise because they are waiting for information from the countries in
    their area of responsibility to determine the status of pandemic influenza
    planning and preparedness of those countries which, in turn, will help
    SOUTHCOM recommend exercises to address gaps in those countries'
    preparedness. Until SOUTHCOM has a clearer assessment of its partner
    nations' capabilities, SOUTHCOM officials do not believe generic pandemic
    influenza-related exercises are cost-efficient. In the absence of pandemic
    influenza-related exercises, medical and operational planning officials
    from SOUTHCOM said the command is coordinating with interagency partners,
    such as the Pan American Health Organization and the U.S. Agency for
    International Development, to gather information on other countries'
    capabilities and planning efforts. Although SOUTHCOM plans to conduct its
    own regional tabletop exercise later in fiscal year 2007, SOUTHCOM
    officials said the command will not (and cannot) get ahead of the
    Department of State as the lead federal agent--and other interagency
    partners--in such activities. Each of the geographic COCOMs and three of
    the four functional COCOMs are planning to conduct pandemic
    influenza-specific exercises or include pandemic influenza scenarios in
    future exercises. For example, STRATCOM plans to conduct three tabletop
    exercises--an internal exercise for STRATCOM's staff; an exercise with the
    installation where STRATCOM's headquarters is located (Offutt Air Force
    Base, Nebraska); and an exercise with STRATCOM's staff, the installation,
    and the civilian community--to test STRATCOM's pandemic influenza plan to
    continue its own operations.

    Officials from the five COCOMs that have held exercises said they
    identified some lessons as a result of their exercises and are starting to
    take steps to address these lessons. Some of these lessons were general
    and related to overall planning efforts. For example, in March 2006,
    CENTCOM conducted a tabletop exercise to familiarize participants with the
    command's pandemic influenza plan. The results of the exercise facilitated
    establishing an operational planning team to continue to address pandemic
    influenza efforts, according to CENTCOM's lead planning official.
    Similarly, an official responsible for planning PACOM's exercises said the
    command included avian influenza in one scenario in its Cobra Gold
    exercise in May 2006, a regularly scheduled multinational exercise hosted
    by Thailand. In the exercise, PACOM, the Royal Thai Army, and the
    Singapore Army planned for implications and conducted operations
    supporting humanitarian assistance in an area where H5N1 avian influenza
    was a factor. According to a planning official, PACOM determined that the
    command needs to hold a separate pandemic influenza exercise to
    effectively test its pandemic influenza plan. However, an official
    responsible for planning PACOM's exercises said it has been a challenge to
    meet another exercise requirement without additional resources, including
    personnel and funding. Similarly, U.S. Forces Korea planning officials
    said the command has not held a pandemic influenza-specific exercise or
    included a pandemic influenza scenario in any war-planning exercises
    because of the time required and lack of funding for such a scenario.
    Influenza pandemic exercises have not been a priority because U.S. Forces
    Korea has been focused on events involving North Korea. According to a
    representative from one of the U.S. Army garrisons in South Korea, the key
    lesson learned from a tabletop exercise was that they are "very
    unprepared" for an influenza pandemic. Lessons learned from other
    exercises pertained to more specific aspects of plans. For example,
    officials involved in EUCOM's Avian Wind exercise identified the need to
    update the command's continuity of operations plan to increase the
    likelihood that critical missions, essential services, and functions could
    continue during an influenza pandemic. As a result, EUCOM planning
    officials report that the command plans to update its continuity of
    operations plan in spring 2007 to include pandemic influenza.

    COCOMs Have Started to Provide Information to Personnel about Pandemic Influenza

    Five of the nine COCOMs--EUCOM, NORTHCOM, PACOM, SOUTHCOM, and
    STRATCOM--have started to provide information to their personnel,
    including military and civilian personnel, contractors, dependents, and
    beneficiaries, about a potential influenza pandemic. COCOMs have used
    various strategies to inform personnel about pandemic influenza, including
    using various media outlets, training programs, and outreach events.

    Each of the COCOMs that have started to provide information to their
    personnel used radio or television commercials, news articles, briefings,
    or a combination of these means, to inform personnel about avian and
    pandemic influenza. Additionally, three of the COCOMs had a page on their
    publicly available Web sites that included some avian and pandemic
    influenza information and links to other Web sites, such as the federal
    government's pandemic influenza Web site, www.pandemicflu.gov.

    Three COCOMs--EUCOM, PACOM, and STRATCOM--offered training courses to
    inform personnel about pandemic influenza. Both EUCOM and PACOM offered
    training for public health emergency officers. In May 2006 and September
    2006, EUCOM's training for its public health emergency officers included
    general information about pandemic and avian influenza as well as
    strategies about how to communicate pandemic influenza-related information
    to beneficiaries. According to STRATCOM officials, in October 2006,
    STRATCOM required military and civilian personnel to complete a
    computer-based training module about pandemic and avian influenza that
    included information on force health protection measures, among other
    issues.

    Additionally, three COCOMs--PACOM, STRATCOM, and EUCOM--have used outreach
    programs to inform personnel, including military and civilian personnel,
    contractors, dependents, and beneficiaries, about pandemic influenza. A
    group of military medical professionals at PACOM conducted a series of
    public outreach events at military exchanges in Hawaii that combined
    providing seasonal flu vaccinations to military personnel, dependents, and
    beneficiaries with educating personnel by distributing information about
    general preventive health measures, as well as pandemic influenza. For
    example, the PACOM officials distributed pamphlets on cough etiquette, how
    to prepare for an influenza pandemic, and a list of items to keep on hand
    in an emergency kit. Figure 4 shows one of PACOM's military medical
    professionals sharing information with dependents and beneficiaries at a
    November 2006 event at the Navy Exchange in Honolulu, Hawaii. Similarly,
    STRATCOM held an outreach event, called "Pandemic Influenza Focus Day," in
    November 2006 for its military and civilian personnel and contractors.
    During the Focus Day, each directorate or office met to discuss the impact
    that a 40 percent absenteeism rate due to personnel being sick, caring for
    someone who was sick, or afraid to come to work, would have on the
    individual directorate or office.^16 Additionally, in March 2006, EUCOM
    directed service subcomponents that had not already done so to hold
    installation-level meetings to inform military and civilian personnel,
    contractors, dependents, and beneficiaries about the threat of avian
    influenza and related preventive measures.

    Figure 4: Official Provides Information about Pandemic Influenza at
    PACOM's Outreach Event

    ^16The assumption of 40 percent absenteeism is based on the planning
    assumptions for a severe pandemic in the national implementation plan.

    COCOMs Have Coordinated with Other Nations

    Each of the geographic COCOMs has started to work or plans to work with
    nations in its area of responsibility to raise awareness about and assess
    capabilities for responding to avian and pandemic influenza. COCOMs
    undertook some of these outreach efforts as a result of an action assigned
    to DOD as a lead agency in the national implementation plan to conduct
    assessments of avian and pandemic influenza preparedness and response
    plans of the militaries in partner nations (action 4.1.1.3). For example,
    CENTCOM's lead planning official reported that CENTCOM performed
    assessments and identified gaps for Afghanistan's pandemic influenza
    preparedness and response and has obtained funding for projects with the
    Afghanistan National Army and the Ministries of Public Health,
    Agriculture, and Higher Education. The CENTCOM official also noted, among
    other outreach efforts in the region, a meeting with a military medical
    delegation from Pakistan to discuss assessing the Pakistani military's
    pandemic influenza preparedness and response efforts. Officials involved
    in EUCOM's pandemic influenza planning and humanitarian assistance
    programs reported that EUCOM plans to complete the assessments through its
    regular coordination efforts with militaries in partner nations. While
    EUCOM obtained $1 million from the Combatant Commander Initiative Fund to
    complete actions assigned to DOD as a lead agency in the national
    implementation plan,^17 EUCOM officials cited resources, including
    funding, as a challenge to completing these assessments by the November
    2007 deadline.

    COCOMs also have started to take or plan to take other actions to work
    with other nations related to pandemic influenza. For example, SOUTHCOM
    plans to hold regional conferences focused on pandemic influenza to help
    educate partner nations, assess the preparedness of nations in the region,
    and identify appropriate contacts within the nations. SOUTHCOM planning
    and medical officials said they have two conferences tentatively planned,
    but noted that the number of conferences they can hold will be determined
    by the availability of funding. According to these officials, the
    conferences will address a variety of topics related to pandemic
    influenza, including developing plans and interagency collaboration.
    Moreover, officials from PACOM, Marine Forces Pacific, U.S. Forces Japan,
    and U.S. Forces Korea participated in a multilateral workshop with
    officials from Japan and South Korea to discuss the potential threat of a
    pandemic influenza in the Asia-Pacific region. Participants shared
    information about national strategies and military response plans and
    discussed ways to leverage existing partnerships, enhance
    interoperability, and integrate planning efforts to minimize the health
    and economic impact of an influenza pandemic.

    ^17The Combatant Commander Initiative Fund contains funds that may be
    requested by a COCOM commander and provided by the Chairman of the Joint
    Chiefs of Staff for various activities, including humanitarian and civil
    assistance, military training and education for military and related
    civilian personnel of foreign countries, and personnel expenses of defense
    personnel for bilateral or regional cooperation programs.

    COCOMs Face Three Management Challenges as They Continue to Prepare for an
    Influenza Pandemic

    While COCOMs have taken numerous actions to prepare for an influenza
    pandemic, we identified three management challenges that the COCOMs face
    as they continue their planning and preparedness efforts. First, the
    roles, responsibilities, and authorities of key organizations involved in
    the COCOMs' planning and preparedness efforts relative to other lead and
    supporting organizations remained unclear. As a result, the unity and
    cohesiveness of DOD's pandemic influenza preparation could be impaired and
    the potential remains for confusion among officials and gaps and
    duplication in actions taken by the COCOMs relative to the military
    services and other DOD organizations in implementing tasks, such as the
    actions assigned to DOD as a lead agency in the national implementation
    plan. Second, we identified a disconnect between the COCOMs' planning and
    preparedness activities and resources, including funding and personnel, to
    complete those activities. The continued disconnect between activities and
    resources may limit the COCOMs' ability to effectively prepare for and
    respond to an influenza pandemic. Third, we identified some factors that
    are beyond the COCOMs' control--such as limited detailed guidance from
    other federal agencies on the support expected from DOD, lack of control
    over DOD's antiviral stockpile, limited information on decisions that
    other nations may make during an influenza pandemic, reliance on civilian
    medical providers for medical care, and reliance on military services for
    medical materiel--that they have not yet fully planned how to mitigate.
    While we recognize the difficulty in planning for an influenza pandemic,
    not yet developing options to mitigate the effects of such factors may
    place at risk the COCOM commanders' ability to protect their
    personnel--including military and civilian personnel, contractors,
    dependents, and beneficiaries--or to perform their missions during an
    influenza pandemic.

    Roles, Responsibilities, and Authorities of Key Organizations Relative to Others
    Are Not Fully and Clearly Defined

    The roles, responsibilities, and authorities of key organizations involved
    in DOD's pandemic influenza planning and preparedness efforts relative to
    other organizations leading and supporting the department's pandemic
    influenza planning efforts--including NORTHCOM as the lead for DOD's
    planning and the individual COCOMs--remained unclear because of the
    continued lack of sufficiently detailed guidance from the Secretary of
    Defense or his designee. We have previously reported that in preparing for
    and responding to any type of disaster, leadership roles and
    responsibilities must be clearly defined, effectively communicated, and
    well understood to facilitate rapid and effective decision making.^18 As a
    result of not yet issuing guidance fully and clearly defining the roles,
    responsibilities, authorities, and relationships of key organizations, the
    unity and cohesiveness of DOD's pandemic influenza preparation could be
    impaired, and the potential remains for confusion among COCOM officials
    and gaps or duplication in actions taken by the COCOMs relative to the
    military services and other DOD organizations.

    In our September 2006 report, we identified the absence of clear and fully
    defined guidance on roles, responsibilities, and lines of authority for
    the organizations involved in DOD's pandemic influenza preparedness
    efforts as a potential hindrance to DOD's ability to effectively prepare
    for an influenza pandemic, and recommended that DOD take actions to
    address this issue,^19 but DOD had not yet done so. Officials from the
    Office of the ASD(HD&ASA), the Office of the ASD for Health Affairs, and
    the Joint Staff responded to the recommendations in our September 2006
    report by stating that DOD's implementation plan for pandemic influenza
    clearly establishes the roles and responsibilities for organizations
    throughout DOD. In its implementation plan, DOD established offices of
    primary responsibility for policy oversight of various tasks and outlined
    medical support tasks assigned to various organizations, but we found that
    the plan stopped short of fully and clearly identifying roles,
    responsibilities, and lines of authority for all key organizations,
    including the COCOMs. Since planning has occurred concurrently within DOD
    at various levels from the Office of the Secretary of Defense to
    installations, a more extensive delineation of roles, responsibilities,
    and lines of authority could lead to a more efficient and effective
    effort.

    ^18[38]GAO-07-395T and [39]GAO-06-467T .

    ^19 [40]GAO-06-1042 .

    DOD has outlined NORTHCOM's roles and responsibilities as the lead COCOM
    for the department's pandemic influenza planning efforts. In August 2006,
    the Secretary of Defense named NORTHCOM the lead COCOM for directing,
    planning, and synchronizing DOD's global response to pandemic influenza,
    or the "global synchronizer" for DOD's pandemic influenza planning. In
    April 2007, the Joint Staff issued a planning order that, among other
    things, outlined NORTHCOM's roles and responsibilities as global
    synchronizer, including

               o serving as a conduit between the Joint Staff or Office of the
               Secretary of Defense and the COCOMs, military services, and
               defense agencies on pandemic influenza-related issues;
               o assessing and advocating for resources for the COCOMs, military
               services, and defense agencies; and
               o leading planning efforts for the COCOMs, military services, and
               defense agencies, but not the execution of those plans in the
               other COCOMs' areas of responsibility.

    While DOD has outlined NORTHCOM's roles and responsibilities as the global
    synchronizer, the command's roles, responsibilities, and authorities
    relative to the lead offices for DOD's overall pandemic influenza planning
    efforts, as well as the relationships between the organizations, were not
    yet fully and clearly defined. The ASD(HD&ASA) is the lead, in
    coordination with the ASD for Health Affairs, for DOD's pandemic influenza
    planning and preparedness efforts departmentwide, and the Joint Staff also
    plays a key role in DOD's pandemic influenza planning. However, neither
    the Secretary of Defense nor his designee had yet issued guidance fully
    and clearly stating how NORTHCOM's roles and responsibilities as the lead
    for the COCOMs' planning efforts differed from the roles and
    responsibilities of the other lead offices for pandemic influenza
    preparedness efforts, including the Joint Staff, which led to varying
    expectations among some COCOM officials. For example, COCOM officials had
    different expectations about whether NORTHCOM would provide guidance to
    the COCOMs. Planning officials from two geographic COCOMs noted that the
    Joint Staff, not NORTHCOM, has the primary authority to provide guidance
    to the COCOMs. However, planning officials from at least three COCOMs were
    expecting NORTHCOM to provide guidance on key issues, such as quarantine,
    social distancing, treatment of DOD beneficiaries, and troop rotation.
    Additionally, there was confusion among the COCOMs on which organization
    was responsible for overseeing interagency coordination. Planning
    officials at one COCOM, as well as officials from the Office of the
    ASD(HD&ASA), the Office of the ASD for Health Affairs, and the Joint
    Staff, said offices within the Office of the Secretary of Defense and the
    Joint Staff would remain the points of contact for the actions assigned to
    DOD in the national implementation plan and would also remain the primary
    contacts for coordinating with other federal government agencies. However,
    a planning official from another geographic COCOM said that the global
    synchronizer role meant that NORTHCOM would coordinate with other federal
    government agencies for pandemic influenza planning. At the time of our
    review, officials leading NORTHCOM's planning and preparedness efforts
    acknowledged that the command's roles and responsibilities relative to the
    Joint Staff and offices within the Office of the Secretary of Defense were
    not well-defined, especially concerning direct coordination and sharing
    information with the other federal agencies, and that the command needed
    further guidance from the Office of the Secretary of Defense and the Joint
    Staff to more clearly establish its roles and responsibilities.

    Similarly, the roles, responsibilities, and authorities of the individual
    COCOMs for DOD's pandemic influenza planning and preparedness efforts were
    not yet fully and clearly defined. While there is guidance--such as the
    Unified Command Plan and 10 U.S.C. S 164--that describes the overall
    roles, responsibilities, and authorities of the COCOMs, we found that the
    COCOMs' roles, responsibilities, and authorities related to DOD's pandemic
    influenza planning and preparedness efforts were unclear. For example,
    medical and operational planning officials from three COCOMs said it was
    not clear to them which of the 31 actions assigned to DOD as a lead agency
    in the national implementation plan the COCOMs were to help complete.
    Officials from two of these COCOMs said that officials within the Office
    of the Secretary of Defense and the Joint Staff had not yet clearly stated
    which actions assigned to DOD in the national implementation plan should
    be implemented by COCOMs and which by the military services. Officials
    from the Office of the ASD(HD&ASA) and the Joint Staff said the COCOMs
    were responsible for implementing few of the actions assigned to DOD as a
    lead agency in the national implementation plan. However, in the absence
    of clear guidance, each of the COCOMs identified the actions they believed
    they are partly responsible for implementing. COCOM officials told us they
    determined they were partly responsible for between 12 and 18 of the 31
    actions for which DOD is a lead agency, as shown in table 2. We identified
    some inconsistency in which actions the geographic COCOMs saw as their
    responsibility to fulfill.

    Table 2: COCOM Perceptions of Responsibility for Actions Assigned to DOD

    Action
    number   Action assigned to DOD      CENTCOM EUCOM NORTHCOM PACOM SOUTHCOM
    4.1.1.3  Conduct                        X      X      X       X      X
                military-to-military
                assistance planning
    4.1.2.6  Priority country               X      X      X       X      X
                military-to-military
                infection control training
    4.1.8.4  Open source information               X
                sharing
    4.2.2.5  Inpatient and outpatient       X      X                     X
                disease surveillance
    4.2.2.6  Monitoring health of           X      X              X
                military forces worldwide
    4.2.2.7  Assist with influenza          X      X                     X
                surveillance in host
                nations
    4.2.3.8  Develop/enhance DOD network
                of overseas
                infrastructure^a
    4.2.3.9  Refinement of DOD                                    X      X
                laboratory methods
    4.2.3.10 Assess foreign country         X      X      X       X      X
                military laboratory
                capacity
    4.2.4.2  COCOM public health reports    X      X      X       X      X
                for area personnel
    4.3.2.2  Identify DOD facilities to     X      X      X              X
                serve as points of entry
                from outbreak countries
    5.1.1.5  Assessment of military                       X       X      X
                support for transportation
                and borders
    5.3.4.8  Strategic military             X      X      X              X
                deployment use of airports
                and seaports
    5.3.5.5  Monitor and report on                        X
                military assets requested
                for border protection
    6.1.6.3  Conduct medical materiel       X      X                     X
                requirements gap analysis
    6.1.6.4  Maintain antiviral and
                vaccine stockpiles^a
    6.1.7.4  Establish stockpiles of
                vaccine against H5N1^a
    6.1.9.3  Procure 2.4 million
                antiviral medications^a
    6.1.13.8 Supply military units/bases                                 X
                with influenza medication
    6.2.2.9  Enhance public health          X      X              X
                response capabilities
    6.2.3.4  Access to improved rapid       X      X
                diagnostic tests
    6.2.4.3  Provide health statistics             X
                on influenza-like illnesses
    6.3.2.4  DOD guidance to personnel      X      X      X       X      X
                on protective measures
    6.3.2.5  Implement infection control    X             X
                campaigns
    6.3.4.7  Enhance influenza              X      X
                surveillance reporting
                techniques
    6.3.7.2  Be prepared to augment                       X       X
                state/local government
                medical response
    6.3.7.5  Reserve medical personnel
                mobilization^a
    6.3.8.2  Update risk communication             X              X
                material
    8.1.2.5  National Guard training for
                state law enforcement^a
    8.1.2.6  Requests for assistance                              X
                from states/governors
    8.3.2.1  Plans for quarantine                  X      X       X
                enforcement
                Total                         15     18      12     13      13

    Source: GAO analysis of DOD data.

    aNone of the COCOMs indicated that they were responsible for implementing
    six of the actions assigned to DOD in the national implementation plan.
    Therefore, these rows are blank.

    COCOM officials' varying interpretations of which actions applied to them
    could lead to gaps in the completion of actions assigned to DOD or
    duplications in effort. For example, operational and medical planning
    officials from the Joint Staff, the Office of the ASD(HD&ASA), and the
    Office of the ASD for Health Affairs told us that there were no additional
    force health protection actions assigned to COCOMs, but COCOM medical and
    planning officials told us they shared responsibility for some of the
    force health actions, including actions relating to monitoring force
    health (action 4.2.2.6), analyzing medical materiel needs (action
    6.1.6.3), and implementing infection control campaigns (action 6.3.2.5).
    Officials from the Joint Staff and the Office of the ASD(HD&ASA) told us
    this confusion was evident in the collection of information on funding
    needs from COCOMs, as the COCOMs identified funding needs for actions
    these officials thought the COCOMs were not intended to fulfill.

    In addition, we identified that there was little guidance on what
    constituted fulfillment of the actions, some of which were open to
    interpretation and potentially were quite broad. For example, one action,
    which the Joint Staff issued to the geographic COCOMs, calls for DOD to
    assess the avian and pandemic influenza response plans of partner
    militaries, develop solutions for national and regional gaps, and develop
    and execute military-to-military influenza exercises to validate such
    plans (action 4.1.1.3), by November 2007. The wide scope for
    interpretation of the actions meant that COCOMs could expend unnecessary
    effort or fail to complete actions intended for them. Without fully and
    clearly identifying the roles, responsibilities, and authorities of the
    COCOMs, including a clear delineation of which actions apply to which
    organizations and what constitutes fulfillment of an action, DOD's
    preparation for an influenza pandemic risks gaps in efforts by failing to
    execute some actions by assuming that an action will be fulfilled by other
    organizations; duplicating efforts, as COCOMs may undertake actions that
    other DOD organizations are meant to complete; or both.

    Furthermore, the roles, responsibilities, and authorities of COCOMs
    relative to the military services for DOD's pandemic influenza planning
    and preparedness efforts were also not yet fully and clearly defined. The
    memorandum that names NORTHCOM the lead for directing, planning, and
    synchronizing DOD's global response to pandemic influenza is not limited
    to the efforts of the COCOMs; however, planning officials from one COCOM
    said it was unclear what authority NORTHCOM had over the military
    services. The April 2007 planning order directs the military services to
    coordinate with NORTHCOM to ensure that the services' pandemic influenza
    plans are synchronized with DOD's global pandemic influenza plan but does
    not define what this coordination entails. In addition to the need for
    more information on which actions the COCOMs were to complete compared to
    the military services discussed above, COCOM medical and planning
    officials sought clarification on the differences in the roles and
    responsibilities of the COCOMs and military services in implementing force
    health protection actions and moving medical assets within the area of
    responsibility. The November 2005 Joint Staff planning order tasked COCOMs
    to include force health protection in their plans for pandemic influenza.
    Planning officials from two of the geographic COCOMs said that, in
    general, COCOMs set the requirements for force health protection in their
    areas of responsibility and the military services are responsible for
    ensuring that their forces meet these requirements. However, medical and
    planning officials from one COCOM viewed the November 2005 Joint Staff
    planning order as assigning force health protection activities to the
    COCOMs and noted that pandemic influenza is the only area where the COCOMs
    are responsible for medical issues. Moreover, medical and planning
    officials from one of the COCOM's service subcomponents noted that because
    the COCOM's plan includes a "shaping" phase, which currently is being
    implemented, the COCOMs have a greater responsibility for force health
    protection than in other operations. A medical official from one COCOM
    noted that COCOMs can identify many of the things needed to prepare for
    and respond to an influenza pandemic, but the COCOMs lack the day-to-day
    authority over installations and resources to direct that these measures
    be taken during the initial phases of the COCOM's plan because force
    health protection typically is the responsibility of the military
    services. Similarly, planning officials at two geographic COCOMs reported
    concerns that they would not have the authority in a pandemic to move
    medical assets, such as antivirals, from one base in their area of
    responsibility controlled by one military service to another base
    controlled by a different service. An official from the Office of the ASD
    for Health Affairs confirmed that this is an issue, particularly within
    the United States, and noted that the military services and COCOMs will
    have to resolve this issue on their own because the Office of the ASD for
    Health Affairs is not part of the COCOMs' or military services'
    chains-of-command.

    The unity and cohesiveness of DOD's pandemic influenza planning,
    preparation, and response efforts could be hindered by the continued lack
    of fully and clearly defined roles, responsibilities, authorities, and
    relationships of organizations throughout DOD involved in these efforts.
    While the April 2007 planning order outlines NORTHCOM's roles and
    responsibilities, the lack of clarity of the roles, responsibilities, and
    authorities of key organizations involved in the COCOMs' planning and
    preparedness efforts relative to other lead and supporting organizations
    has created the potential for confusion, gaps, and overlaps in areas such
    as the actions assigned to DOD in the national implementation plan as well
    as force health protection measures for DOD's personnel. Without more
    fully and clearly defined roles and responsibilities, various
    organizations could fail to carry out certain actions or, alternatively,
    may perform actions that other organizations were to complete.
    Additionally, it may be difficult for DOD to accurately capture funding
    requirements without a clear delineation of which actions are to be
    executed by which organizations, as well as the scope of the actions.
    Finally, COCOM planning and response could be less effective if commanders
    do not have a clear sense of the assets under their control, such as
    medical materiel at service-controlled installations.

    DOD Has Not Identified Resources to Complete Planning and Preparedness
    Activities

    We identified a disconnect between the COCOMs' planning and preparedness
    activities and resources, including funding and personnel, to complete
    those activities. This disconnect is, in part, because DOD guidance,
    including DOD's implementation plan for pandemic influenza and the Joint
    Staff planning order that directed the COCOMs to plan, did not identify
    the resources required to complete these activities. We have previously
    reported that information on required resources is critical for making
    sound analyses of how to pursue goals.^20 Without realistic information on
    required resources, decision makers cannot determine whether a strategy to
    achieve those goals is realistic and cost-effective or make trade-offs
    against other funding priorities. In September 2006, we reported that DOD
    had not yet identified an appropriate funding mechanism or requested
    funding tied to its departmentwide goals, which could impair the
    department's overall ability to prepare for a potential pandemic, and
    recommended that DOD take actions to address this issue.^21 DOD generally
    concurred with our recommendation, but had not yet taken actions to
    address this recommendation. The continued lack of a link between the
    COCOMs' planning and preparedness activities and the resources required
    for them may limit the COCOMs' ability to effectively prepare for and
    respond to an influenza pandemic.

    ^20 [41]GAO/GGD/AIMD-10.1.18 .

    DOD did not request dedicated funding for its pandemic influenza
    preparedness activities in its fiscal year 2007 or fiscal year 2008 budget
    requests because, according to the Principal Deputy to the ASD(HD&ASA),
    several baseline plans, including the national implementation plan, DOD's
    implementation plan, and the geographic COCOMs' plans, needed to be
    drafted before DOD could assess its potential preparedness costs.
    Officials from the Office of the ASD(HD&ASA) and the Office of the ASD for
    Health Affairs were aware of the disconnect between the COCOMs' planning
    and preparedness activities and resources to accomplish these activities.
    The officials said that when the Homeland Security Council originally
    developed the national implementation plan, the officials expected to
    receive supplemental funding to complete the actions assigned to DOD.
    However, in the absence of sustained supplemental funding, the officials
    said they are struggling to find programs from which to divert resources
    to fund the department's planning and preparedness activities. In December
    2005, DOD received $130 million in supplemental appropriations for
    pandemic influenza; $120 million was for expenses, including
    health-related items for its own personnel, and $10 million was to provide
    equipment and assistance to partner nations.^22 However, as the
    Congressional Research Service reported, tracking federal funds for
    influenza preparedness is difficult because funds designated for pandemic
    influenza preparedness do not reflect the sum of all relevant activities,
    including developing the department's pandemic influenza plan.^23 The
    COCOMs have a certain amount of discretion over their operations and
    maintenance budgets to fund pandemic influenza-related activities.
    Although COCOM officials have started to identify funding requirements
    through multiple Joint Staff inquiries regarding COCOM funding needs,
    planning, medical, and budget officials from the geographic COCOMs said
    there is still not an accurate assessment of actual funding needs and DOD
    has not yet requested funding for the department's planning and
    preparedness activities. An official from the Office of the ASD(HD&ASA)
    said obtaining funding to fully establish NORTHCOM as the global
    synchronizer for the department's efforts is the office's top priority.
    After NORTHCOM establishes its global synchronizer role, the official said
    one of NORTHCOM's responsibilities will be to assist the Joint Staff in
    determining how much funding is required for DOD's pandemic influenza
    planning and preparedness activities.

    ^21 [42]GAO-06-1042 .

    ^22Department of Defense, Emergency Supplemental Appropriations to Address
    Hurricanes in the Gulf of Mexico, and Pandemic Influenza Act, 2006, Pub.
    L. No. 109-148 (2005). The act provided $120 million for necessary
    expenses related to vaccine purchases, storage, expanded avian influenza
    surveillance programs, equipment, essential information management
    systems, and laboratory diagnostic equipment. Additionally, $10 million
    was provided for surveillance, communication equipment, and assistance to
    military partner nations for procuring protective equipment.

    Without resources identified for planning and preparedness activities,
    COCOMs have reallocated resources from other sources to undertake these
    activities. For example, budget officials at EUCOM said, in the absence of
    dedicated funding for pandemic influenza-related activities, EUCOM spent
    about $145,000 of its Operations and Maintenance funding in fiscal year
    2006 for travel to pandemic influenza-related conferences and for its
    Avian Wind exercise. COCOMs have also diverted planners from other areas
    to develop pandemic influenza plans. Planning officials from four of the
    five geographic COCOMs and four of the subcomponents we met with said
    pandemic influenza planning was one of many responsibilities for the
    personnel involved in their pandemic influenza planning and preparedness
    efforts, and often their other responsibilities were a higher priority.
    For example, planning officials from U.S. Forces Korea stated that they
    cannot dedicate the level of effort that pandemic influenza planning
    requires because of other more immediate priorities on the Korean
    peninsula. Similarly, members of CENTCOM's pandemic influenza planning
    team said they were distracted by a variety of other tasks calling for
    immediate action, many of which are related to the wars in Iraq and
    Afghanistan, and devoted a small percentage of their time to pandemic
    influenza; only the lead planner in the team was able to devote a
    significant percentage of time to pandemic influenza planning.

    ^23Congressional Research Service, Pandemic Influenza: Appropriations for
    Public Health Preparedness and Response (Washington, D.C.: Mar. 23, 2007).

    As a result of the lack of identified resources for DOD's pandemic
    influenza planning and preparedness activities, planning officials from at
    least three COCOMs said that they will likely be unable to complete some
    important activities. For example, although the Joint Staff planning order
    tasked geographic COCOMs to exercise their pandemic influenza plans at
    least once a year, officials responsible for CENTCOM's planning and
    PACOM's planning and exercises told us they need additional resources to
    conduct these exercises. While EUCOM has conducted an exercise, planning
    officials told us that they have had to reconsider future exercises
    because of the lack of resources. Additionally, officials from each of the
    COCOMs said they lack resources to complete some of the actions in the
    national implementation plan. For example, while the Joint Staff tasked
    all of the geographic COCOMs to assess the avian and pandemic influenza
    response plans of partner militaries, develop solutions for national and
    regional gaps, and develop and execute military-to-military influenza
    exercises to validate such plans (action 4.1.1.3), planning and medical
    budget officials from each of the geographic COCOMs said that they may be
    unable to complete this action by the November 2007 deadline because of
    the lack of resources, including funding.

    COCOMs Have Not Yet Developed Options to Mitigate the Effects of Factors beyond
    Their Control

    We identified factors that are beyond the COCOMs' control--such as limited
    detailed guidance from other federal agencies on the support expected from
    DOD, lack of control over DOD's antiviral stockpile, limited information
    on decisions that other nations may make during an influenza pandemic,
    reliance on civilian medical providers for medical care, and reliance on
    military services for medical materiel--that they have not yet fully
    planned how to mitigate. While we recognize the difficulty of planning for
    an influenza pandemic, not yet developing options to mitigate the effects
    of such factors may limit the COCOM commanders' ability to protect their
    personnel--including military and civilian personnel, contractors,
    dependents, and beneficiaries--or to perform their missions during an
    influenza pandemic.

    We have recommended a comprehensive risk-management approach as a
    framework for decision making.^24 Risk involves three elements: (1)
    threat, which is the probability that a specific event will occur; (2) the
    vulnerability of people and specific assets to that particular event; and
    (3) the adverse effects that would result from the particular event should
    it occur. We define risk management as a continuous process of assessing
    risks; taking actions to reduce, where possible, the potential that an
    adverse event will occur; reducing vulnerabilities as appropriate; and
    putting steps in place to reduce the effects of any event that does occur.
    Since it is not possible for the COCOMs to reduce the potential for an
    influenza pandemic, it is important they reduce their vulnerabilities and
    put in place steps to mitigate the effects of a potential pandemic.

    ^24[43]GAO-07-386T and [44]GAO-06-442T .

      COCOMs Have Not Yet Developed Options to Mitigate the Effects of Limited
      Detailed Guidance from Other Federal Agencies

    Planning officials from four of the five COCOMs told us they had received
    limited detailed guidance from other federal agencies on what support they
    might be asked to provide during an influenza pandemic or information that
    could help the COCOMs estimate such potential support. This is one factor
    that has hindered their ability to plan to provide support to other
    federal agencies domestically and abroad during an influenza pandemic. DOD
    was designated as a supporting agency for pandemic influenza response in
    the national implementation plan. After Hurricane Katrina, we reported
    that the military has significant and sometimes unique capabilities, but
    additional actions are needed to ensure that its contributions are clearly
    understood and well planned and integrated.^25 Additionally, we reported
    that many challenges faced in the response to Hurricane Katrina point to
    the need for plans that, among other things, identify capabilities that
    could be available and provided by the military. Planning officials from
    each of the geographic COCOMs said they anticipate that, during an
    influenza pandemic, the COCOM will provide support domestically and abroad
    as requested by other federal agencies and approved by the Secretary of
    Defense. However, planning officials from four of the five geographic
    COCOMs said they had not yet received detailed information from the
    Department of State on what assistance other nations may request from the
    United States. Without this information, the officials said they cannot
    effectively plan to provide support. Department of State officials told us
    they would not know what specific kinds of support other nations may need
    until an influenza pandemic occurred, but they had developed a list of
    priority countries for the U.S. government's pandemic influenza response.
    Additionally, Department of State officials said they had started to
    assess what kinds of support may be needed for embassies and they have
    developed a request for information about the level of assistance DOD may
    be able to provide at a specific list of posts deemed most vulnerable from
    a medical and security standpoint should an influenza pandemic emerge.
    Department of State officials expected that the request for information
    would be sent to DOD by the end of June 2007. At least one COCOM has taken
    steps to mitigate the effects of limited information, pending further
    information from the Department of State. PACOM established multiservice
    teams to work with nations, territories, possessions, and protectorates in
    its area of responsibility to identify potential needs during an influenza
    pandemic. For example, in September 2006 about 15 PACOM officials went to
    Malaysia to provide an avian and pandemic influenza "train the trainer"
    workshop, obtain information on the country's pandemic influenza planning
    efforts, and identify areas of mutual collaboration to increase the
    likelihood of a coordinated response to the current threat of avian
    influenza and a potential influenza pandemic. Planning officials from
    three COCOMs and two service subcomponents that we met with said planning
    to provide support at the last minute could lead to a less effective and
    less efficient use of resources. While identifying what capabilities may
    be needed and available at an indefinite point in the future is difficult,
    taking these steps now could allow the COCOMs to be better prepared to
    provide support to other federal agencies domestically and abroad during
    an influenza pandemic.

    ^25GAO, Hurricane Katrina: Better Plans and Exercises Need to Guide the
    Military's Response to Catastrophic Natural Disasters, [45]GAO-06-808T
    (Washington, D.C.: May 25, 2006).

      COCOMs Have Not Yet Developed Options to Mitigate the Effects of a Lack of
      Control over DOD's Antiviral Stockpile

    COCOM medical and planning officials have expressed concern about how they
    would gain access to and use DOD's stockpile of antivirals. These
    officials reported that their lack of control over DOD's stockpile of
    antivirals has limited their ability to plan to use this resource. The ASD
    for Health Affairs procured antivirals and prepositioned DOD's antiviral
    stockpile in the continental United States, Europe, and the Far East. The
    ASD for Health Affairs retained the authority to release the antivirals to
    allow more flexibility to direct these limited resources where they are
    needed the most, according to an official in the Office of the ASD for
    Health Affairs. However, according to planning and medical officials at
    three of the COCOMs, the absence of information about these assets has
    made it more difficult to plan for their use because the COCOM officials
    did not know when they would receive the antivirals or how many doses they
    would receive. For example, EUCOM planning and medical officials said that
    during a NORTHCOM exercise in 2006, it took 96 hours for the ASD for
    Health Affairs to authorize the release of antivirals. The EUCOM officials
    expressed concern that a lengthy release process could impact the
    effectiveness of antivirals, as they are most effective if given within 48
    hours of showing influenza-like symptoms. According to the officials, the
    lack of information on when the COCOMs might receive antivirals and how
    many antivirals they may receive limits the COCOMs' ability to plan for
    how they will use these resources and what steps they may need to take to
    transport, store, and secure these resources after the ASD for Health
    Affairs releases the stockpile. To help address this issue, the Office of
    the ASD for Health Affairs distributed about 470,000 treatment courses of
    an antiviral to military treatment facilities, which can be administered
    as determined by the facility's commander. Additionally, at least two
    service subcomponents purchased their own supply of antivirals to be used
    for critical personnel during an influenza pandemic. However, by not yet
    taking steps to mitigate the effect of not having sufficient information
    to plan to use antivirals in their areas of responsibility, COCOMs may not
    be prepared to effectively and efficiently use these resources or protect
    their personnel.

      COCOMs Have Not Yet Developed Options to Mitigate the Effects of Limited
      Information on Other Nations' Decisions

    Planning officials at four of the geographic COCOMs and one of the
    functional COCOMs mentioned the need for information on decisions other
    nations may make during an influenza pandemic, such as closing borders or
    restricting transportation into and out of the country, as a factor that
    has hindered their ability to plan to continue ongoing missions during an
    influenza pandemic. For example, currently most servicemembers injured in
    Iraq and Afghanistan, in the CENTCOM area of responsibility, travel to
    Germany for essential medical care. EUCOM planning officials noted that
    Germany has reserved the right to close off access to Ramstein Air Base,
    Germany, which is a key European transit point for EUCOM and CENTCOM.
    Additionally, CENTCOM planning officials said that the borders of Kuwait
    and Qatar could be shut down in a pandemic, causing problems for
    transporting personnel and supplies into Iraq and Afghanistan. EUCOM
    planning officials said they discussed the need for information on
    decisions other nations may make with officials from the Department of
    State to help mitigate the effect of limited information from other
    countries. However, according to the EUCOM officials, most countries are
    not at a point in their planning to make decisions on border closures or
    transportation restrictions. The EUCOM officials said they will assume
    there will be movement restrictions for the purpose of developing their
    plan, but will not develop specific plans for addressing the movement
    restrictions until they receive more information. However, information on
    other nations' decisions may not be available before an influenza
    pandemic. Developing plans at the last minute to address other nations'
    decisions could limit the COCOMs' ability to obtain or use certain assets,
    placing at risk the COCOMs' ability to effectively protect personnel and
    continue missions due to potential restrictions by other nations on
    ground, sea, and air transportation during an influenza pandemic. For
    example, if a nation decides to close its borders at the start of a
    pandemic, COCOMs and installations may not be able to obtain needed
    supplies, such as antivirals. Identifying specific options to mitigate the
    effects of other nations' possible decisions in advance of an influenza
    pandemic may help the COCOMs more fully develop their pandemic influenza
    plans, provide more flexibility in the COCOMs' response to an influenza
    pandemic, and better allow the COCOMs to continue ongoing missions.

      COCOMs Have Not Yet Develped Options to Mitigate the Effects of Reliance on
      Civilian Medical Care

    Officials at each of the geographic COCOMs expressed concern that the
    COCOMs are reliant on civilian medical providers in the United States and
    abroad to provide medical care for military personnel, dependents, and
    beneficiaries. This is a factor that has hindered the COCOMs' ability to
    plan for how personnel will access medical care during an influenza
    pandemic. In fiscal year 2006, DOD provided health care to more than 9
    million active duty personnel, retirees, and their dependents through the
    department's TRICARE program. TRICARE beneficiaries can obtain health care
    through DOD's direct care system of military hospitals and clinics or
    through DOD's purchased care system of civilian providers. We reported
    that, in fiscal year 2005, an estimated 75 percent of inpatient care and
    65 percent of outpatient care for TRICARE beneficiaries was delivered by
    civilian providers.^26 Medical and planning officials at each of the five
    geographic COCOMs expressed concern that civilian medical facilities would
    not be able to meet the medical needs of their military personnel,
    dependents, and beneficiaries during an influenza pandemic, either because
    there may not be sufficient capacity in the civilian medical facilities or
    civilian medical facilities may choose to treat their own citizens ahead
    of these personnel. While COCOMs realistically cannot reduce their
    reliance on civilian medical capabilities, at least one COCOM has taken
    actions to mitigate the effect of the military's reliance on civilian
    medical care. EUCOM planning officials said they have invited host nation
    officials to planning conferences and met with at least two medical
    providers in Germany to coordinate efforts. However, the COCOMs do not
    control the civilian medical system and, therefore, cannot allocate
    resources or guarantee treatment for personnel in the civilian medical
    system during an influenza pandemic. Without options to mitigate the
    effects of DOD's reliance on the civilian medical system, COCOMs' risk
    being unable to protect personnel and carry out their missions during an
    influenza pandemic.

    ^26GAO, Defense Health Care: Access to Care for Beneficiaries Who Have Not
    Enrolled in TRICARE's Managed Care Option, [46]GAO-07-48 (Washington,
    D.C.: Dec. 22, 2006).

      COCOMs Have Not Yet Developed Options to Mitigate the Effects of Reliance on
      Military Services for Medical Materiel

    Planning officials from eight of the nine COCOMs expressed concern that
    their headquarters are tenants on military services' installations and,
    therefore, are reliant on the military services to distribute medical
    materiel and other supplies. This is a factor that has hindered the
    COCOMs' ability to fully address how their headquarters will receive
    medical materiel and other supplies during an influenza pandemic. Medical
    and planning officials at two COCOMs expressed concern with the variance
    among the military services' health-related policies and priorities. For
    example, the officials said that each military service has a different
    doctrine or policy on pandemic influenza-related health issues, such as
    the distribution of vaccines, antivirals, and other drugs.^27 Although
    guidance from the ASD for Health Affairs is the same for all of the
    military services, it could be applied differently among the military
    services. For example, medical and planning officials from four of the
    COCOMs noted that the military services would determine how vaccines and
    antivirals would be used because these supplies would be provided through
    the military services. This variance in policy implementation could lead
    to different preparedness levels and limit the operational control COCOM
    commanders have during a pandemic, which could impair the COCOMs' ability
    to carry out their missions. At least two of the COCOMs--JFCOM and
    STRATCOM--have taken steps to mitigate the impact of this issue by
    participating in pandemic influenza planning efforts with the installation
    where their headquarters are located, according to planning officials. The
    reliance of COCOMs' headquarters on the military services for plans,
    decisions, and supplies and the COCOMs' lack of plans to mitigate the
    impact of that dependence could impact the COCOMs' ability to maintain
    their own operations and missions during an influenza pandemic.

    Conclusions

    The COCOMs have taken numerous actions to plan and prepare for an
    influenza pandemic, and their efforts continue. However, the COCOMs have
    faced some management challenges that have and will continue to impair
    their ability to plan and prepare for an influenza pandemic in a unified
    and cohesive manner. Planning in an environment of tremendous uncertainty
    is an extremely difficult and daunting task, but the potential impact of
    an influenza pandemic on DOD's personnel and operations makes sound
    planning all the more crucial. Additionally, preparing for a pandemic can
    be helpful for preparing for and responding to other disasters that may
    occur. While we recognize that DOD's planning and preparedness efforts
    departmentwide continue to evolve, failure to address these challenges
    could affect DOD's ability to protect its personnel, maintain the
    military's readiness, conduct ongoing operations abroad, carry out
    day-to-day functions of the department, and provide civil support at home
    and humanitarian assistance abroad during an influenza pandemic.
    Clarifying what is expected of COCOMs and other organizations within DOD
    in planning and preparing for an influenza pandemic, what constitutes
    fulfillment of planning tasks, and the roles and responsibilities of key
    organizations involved in DOD's pandemic influenza planning and
    preparedness efforts could help lessen the potential for confusion among
    COCOM officials, limit gaps or duplication in DOD's efforts, and increase
    the likelihood that DOD will be prepared to efficiently and effectively
    respond to an influenza pandemic. Additionally, linking expectations to
    resources should help the COCOMs establish appropriate priorities and
    accomplish the actions assigned to them from the national implementation
    plan, as well as other planning and preparedness activities. Finally,
    while the COCOMs cannot control certain factors that have hindered their
    preparedness efforts, they can take various steps to mitigate their
    effects on certain aspects of the COCOMs' plans, including developing
    options to address these factors. Without taking steps to address these
    challenges, DOD risks being insufficiently prepared to respond in a
    unified manner to protect its personnel and conduct its missions during an
    influenza pandemic.

    ^27Because a pandemic strain has not emerged and an effective vaccine
    needs to be a match to the actual pandemic virus, vaccine production for
    the pandemic strain cannot begin until a pandemic virus emerges. Vaccine
    production generally takes at least 6 to 8 months after a virus strain has
    been identified and will, therefore, likely be in short supply during a
    pandemic influenza outbreak. Antiviral drugs can also contribute to the
    prevention and treatment of influenza. However, while antiviral drugs may
    help prevent or mitigate influenza-related illness or death until an
    effective vaccine becomes available, these drugs are expected to be in
    short supply during a pandemic influenza outbreak.

    Recommendations for Executive Action

    To reduce the potential for confusion, gaps, and duplications in the
    COCOMs' pandemic influenza planning and preparedness efforts and enhance
    the unity and cohesiveness of DOD's efforts, we recommend that the
    Secretary of Defense instruct the ASD(HD&ASA) to issue guidance that
    specifies the following:

               o Which of the actions assigned to DOD in the Implementation Plan
               for the National Strategy for Pandemic Influenza and other
               pandemic influenza-related planning tasks apply to the individual
               COCOMs, military services, and other organizations within DOD, as
               well as what constitutes fulfillment of these actions.
               o NORTHCOM's roles and responsibilities as global synchronizer
               relative to the roles and responsibilities of the various
               organizations leading and supporting the department's pandemic
               influenza planning.

    To increase the likelihood that the COCOMs can effectively continue their
    pandemic influenza planning and preparedness activities, including
    accomplishing actions assigned to DOD in the national implementation plan
    within established time frames, we recommend that the Secretary of Defense
    instruct the ASD(HD&ASA) to work with the Under Secretary of Defense
    (Comptroller) to identify the sources and types of resources that COCOMs
    need to accomplish their pandemic influenza planning and preparedness
    activities.

    To increase the likelihood that COCOMs are more fully prepared to protect
    personnel and perform ongoing missions during an influenza pandemic, we
    recommend that the Secretary of Defense instruct the Joint Staff to work
    with the COCOMs to develop options to mitigate the effects of factors that
    are beyond the COCOMs' control, such as limited detailed information from
    other federal agencies on the support expected from DOD, lack of control
    over DOD's antiviral stockpile, limited information on decisions that
    other nations may make during an influenza pandemic, reliance on civilian
    medical providers for medical care, and reliance on military services for
    medical materiel.

    Agency Comments and Our Evaluation

    In written comments on a draft of this report, DOD concurred with all of
    our recommendations and noted that the department is confident that future
    plans will adequately address specific roles, resources, and risk
    mitigation. DOD also provided us with technical comments, which we
    incorporated in the report, as appropriate. DOD's comments are included in
    appendix III. We also provided the Department of State an opportunity to
    comment on a draft of the report, but the department had no comments.

    As agreed with your offices, unless you publicly announce the contents of
    this report earlier, we plan no further distribution of it until 30 days
    from the date of this letter. We will then send copies of this report to
    the Chairman and Ranking Member of the Senate and House Committees on
    Appropriations, Subcommittees on Defense; Senate and House Committees on
    Armed Services; Senate Committee on Homeland Security and Governmental
    Affairs; House Committee on Homeland Security; and other interested
    congressional parties. We are also sending copies of this report to the
    Secretary of Defense; Secretary of State; Director, Office of Management
    and Budget; Chairman of the Joint Chiefs of Staff; Commanders of CENTCOM,
    EUCOM, JFCOM, NORTHCOM, PACOM, SOCOM, SOUTHCOM, STRATCOM, and TRANSCOM;
    and the Commander, U.S. Forces Korea. We will also provide copies to
    others upon request. In addition, this report will be available at no
    charge on GAO's Web site at [47]http://www.gao.gov .

    If you or your staff have any questions concerning this report, please
    contact me at (202) 512-5431 or by e-mail at [48]dagostinod@gao.gov .
    Contact points for our Offices of Congressional Relations and Public
    Affairs may be found on the last page of this report. GAO staff who made
    contributions to this report are listed in appendix IV.

    Davi M. D'Agostino
    Director, Defense Capabilities and Management

    Appendix I: Actions Assigned to DOD as a Lead Agency in the National
    Implementation Plan

                                                                  Lead Department
                                                                  of Defense
                                                                  (DOD)
                                                                  organization
                                                  Deadline to     responsible for
    Action                                     complete        implementing
    number   Action                            action^a        action
    4.1.1.3  DOD, in coordination with the     Within 18       Joint Staff
                Department of State and other     months
                appropriate federal agencies,
                host nations, and regional
                alliance military partners,
                shall, within 18 months: (1)
                conduct bilateral and
                multilateral assessments of the
                avian and pandemic preparedness
                and response plans of the
                militaries in partner nations or
                regional alliances, such as NATO,
                focused on preparing for and
                mitigating the effects of an
                outbreak on assigned mission
                accomplishment; (2) develop
                solutions for identified national
                and regional military gaps; and
                (3) develop and execute bilateral
                and multilateral
                military-to-military influenza
                exercises to validate
                preparedness and response plans.

                Measure of performance: all
                countries with endemic avian
                influenza engaged by U.S.
                efforts; initial assessment and
                identification of exercise
                timeline for the military of each
                key partner nation completed.
    4.1.2.6  DOD, in coordination with the     Within 18       Joint Staff
                Department of State, host         months
                nations, and regional alliance
                military partners, shall assist
                in developing priority country
                military infection control and
                case management capability
                through training programs, within
                18 months.

                Measure of performance: training
                programs carried out in all
                priority countries with increased
                military infection control and
                case management capability.
    4.1.8.4  The Department of Health and      Within 12       Assistant
                Human Services and DOD, in        months          Secretary of
                coordination with the Department                  Defense (ASD)
                of State, shall enhance open                      for Health
                source information sharing                        Affairs
                efforts with international
                organizations and agencies to
                facilitate the characterization
                of genetic sequences of
                circulating strains of novel
                influenza viruses within 12
                months.

                Measure of performance:
                publication of all reported novel
                influenza viruses which are
                sequenced.
    4.2.2.5  DOD shall develop active and      Within 18       ASD for Health
                passive systems for inpatient and months          Affairs
                outpatient disease surveillance
                at its institutions worldwide,
                with an emphasis on index case
                and cluster identification, and
                develop mechanisms for utilizing
                DOD epidemiological investigation
                experts in international support
                efforts, to include validation of
                systems/tools and improved
                outpatient/inpatient surveillance
                capabilities, within 18 months.

                Measure of performance:
                monitoring system and program to
                utilize epidemiological
                investigation experts
                internationally are in place.
    4.2.2.6  DOD shall monitor the health of   Within 18       ASD for Health
                military forces worldwide (bases  months          Affairs
                in the continental United States
                and outside of the continental
                United States, deployed
                operational forces, exercises,
                units, etc.), and in coordination
                with the Department of State,
                coordinate with allied,
                coalition, and host nation public
                health communities to investigate
                and respond to confirmed
                infectious disease outbreaks on
                DOD installations, within 18
                months.

                Measure of performance: medical
                surveillance "watchboard" reports
                show results of routine
                monitoring, number of validated
                outbreaks, and results of
                interventions.
    4.2.2.7  DOD, in coordination with the     Within 24       ASD for Health
                Department of State and with the  months          Affairs
                cooperation of the host nation,
                shall assist with influenza
                surveillance of host nation
                populations in accordance with
                existing treaties and
                international agreements, within
                24 months.

                Measure of performance: medical
                surveillance "watchboard"
                expanded to include host nations.
    4.2.3.8  DOD, in coordination with the     Within 18       ASD for Health
                Department of Health and Human    months          Affairs
                Services, shall develop and
                refine its overseas virologic and
                bacteriologic surveillance
                infrastructure through Global
                Emerging Infections Surveillance
                and Response System and the DOD
                network of overseas labs,
                including fully developing and
                implementing seasonal influenza
                laboratory surveillance and an
                animal/vector surveillance plan
                linked with World Health
                Organization (WHO) pandemic
                phases, within 18 months.

                Measure of performance:
                animal/vector surveillance plan
                and DOD overseas virologic
                surveillance network developed
                and functional.
    4.2.3.9  DOD, in coordination with the     Within 18       Joint Staff
                Department of Health and Human    months
                Services, shall prioritize
                international DOD laboratory
                research efforts to develop,
                refine, and validate diagnostic
                methods to rapidly identify
                pathogens, within 18 months.

                Measure of performance:
                completion of prioritized
                research plan, resources
                identified, and tasks assigned
                across DOD medical research
                facilities.
    4.2.3.10 DOD shall work with priority      Within 18       Joint Staff
                nations' military forces to       months
                assess existing laboratory
                capacity, rapid response teams,
                and portable field assay testing
                equipment, and fund essential
                commodities and training
                necessary to achieve an effective
                national military diagnostic
                capability, within 18 months.

                Measure of performance:
                assessments completed, proposals
                accepted, and funding made
                available to priority countries.
    4.2.4.2  DOD shall incorporate             Within 18       ASD for Health
                international public health       months          Affairs
                reporting requirements for
                exposed or ill military
                international travelers into the
                geographic combatant commanders'
                pandemic influenza plans within
                18 months.

                Measure of performance: reporting
                requirements incorporated into
                geographic combatant commanders'
                pandemic influenza plans.
    4.3.2.2  DOD, in coordination with the     Within 6 months Joint Staff
                Department of State, the
                Department of Health and Human
                Services, the Department of
                Transportation, and the
                Department of Homeland Security,
                shall limit official DOD military
                travel between affected areas and
                the United States.

                Measure of performance: DOD
                identifies military facilities in
                the United States and outside of
                the continental United States
                that will serve as the points of
                entry for all official travelers
                from affected areas, within 6
                months.
    5.1.1.5  DOD, in coordination with the     Within 18       Joint Staff
                Department of Homeland Security,  months
                the Department of Transportation,
                the Department of Justice, and
                the Department of State, shall
                conduct an assessment of military
                support related to transportation
                and borders that may be requested
                during a pandemic and develop a
                comprehensive contingency plan
                for Defense Support of Civil
                Authorities, within 18 months.

                Measure of performance: Defense
                Support of Civil Authorities plan
                in place that addresses emergency
                transportation and border
                support.
    5.3.4.8  DOD, in coordination with the     Within 18       Joint Staff
                Department of Homeland Security   months
                and the Department of State,
                shall identify those domestic and
                foreign airports and seaports
                that are considered strategic
                junctures for major military
                deployments and evaluate whether
                additional risk-based protective
                measures are needed, within 18
                months.

                Measure of performance:
                identification of critical air
                and seaports and evaluation of
                additional risk-based procedures,
                completed.
    5.3.5.5  DOD, when directed by the         In response to  Joint Staff
                Secretary of Defense and in       an influenza
                accordance with law, shall        pandemic
                monitor and report the status of
                the military transportation
                system and those military assets
                that may be requested to protect
                the borders, assess impacts (to
                include operational impacts), and
                coordinate military services in
                support of federal agencies and
                state, local, and tribal
                entities.

                Measure of performance: when DOD
                activated, regular reports
                provided, impacts assessed, and
                services coordinated as needed.
    6.1.6.3  DOD, as part of its departmental  Within 18       ASD for Health
                implementation plan, shall        months          Affairs
                conduct a medical materiel
                requirements gap analysis and
                procure necessary materiel to
                enhance Military Health System
                surge capacity, within 18 months.

                Measure of performance: gap
                analysis completed and necessary
                materiel procured.
    6.1.6.4  The Department of Health and      Within 6 months ASD for Health
                Human Services, DOD, the                          Affairs
                Department of Veterans Affairs,
                and the states shall maintain
                antiviral and vaccine stockpiles
                in a manner consistent with the
                requirements of the Food and Drug
                Administration's Shelf Life
                Extension Program and explore the
                possibility of broadening the
                Shelf Life Extension Program to
                include equivalently maintained
                state stockpiles, within 6
                months.

                Measure of performance:
                compliance with the Shelf Life
                Extension Program requirements
                documented; decision made on
                broadening the Shelf Life
                Extension Program to state
                stockpiles.
    6.1.7.4  DOD shall establish stockpiles of Within 18       ASD for Health
                vaccine against H5N1 and other    months of       Affairs
                influenza subtypes determined to  availability
                represent a pandemic threat
                adequate to immunize
                approximately 1.35 million
                persons for military use within
                18 months of availability.

                Measure of performance:
                sufficient vaccine against each
                influenza virus determined to
                represent a pandemic threat in
                DOD stockpile to vaccinate 1.35
                million persons.
    6.1.9.3  DOD shall procure 2.4 million     Within 18       ASD for Health
                treatment courses of antiviral    months          Affairs
                medications and position them at
                locations worldwide within 18
                months. Measure of performance:
                aggregate 2.4 million treatment
                courses of antiviral medications
                in DOD stockpiles.
    6.1.13.8 DOD shall supply military units   Within 18       Joint Staff
                and posts, installations, bases,  months
                and stations with vaccine and
                antiviral medications according
                to the schedule of priorities
                listed in the DOD pandemic
                influenza policy and planning
                guidance, within 18 months.

                Measure of performance: vaccine
                and antiviral medications
                procured; DOD policy guidance
                developed on use and release of
                vaccine and antiviral
                medications; and worldwide
                distribution drill completed.
    6.2.2.9  DOD shall enhance influenza       Within 18       ASD for Health
                surveillance efforts within 6     months          Affairs
                months by: (1) ensuring that
                medical treatment facilities
                monitor the Electronic
                Surveillance System for Early
                Notification of Community-based
                Epidemics and provide additional
                information on suspected or
                confirmed cases of pandemic
                influenza through their service
                surveillance activities; (2)
                ensuring that Public Health
                Emergency Officers report all
                suspected or actual cases through
                appropriate DOD reporting
                channels, as well as to the
                Centers for Disease Control and
                Prevention, state public health
                authorities, and host nations;
                and (3) posting results of
                aggregated surveillance on the
                DOD Pandemic Influenza
                Watchboard; all within 18 months.

                Measure of performance: number of
                medical treatment facilities
                performing Electronic
                Surveillance System for Early
                Notification of Community-based
                Epidemics surveillance greater
                than 80 percent; DOD reporting
                policy for public health
                emergencies, including pandemic
                influenza, completed.
    6.2.3.4  Department of Health and Human    Within 6 months ASD for Health
                Services-, DOD-, and Department   of when tests   Affairs
                of Veterans Affairs-funded        become
                hospitals and health facilities   available
                shall have access to improved
                rapid diagnostic tests for
                influenza A, including influenza
                with pandemic potential, within 6
                months of when tests become
                available.
    6.2.4.3  DOD and the Department of         Within 12       ASD for Health
                Veterans Affairs shall be         months          Affairs
                prepared to track and provide
                personnel and beneficiary health
                statistics and develop enhanced
                methods to aggregate and analyze
                data documenting influenza-like
                illness from their surveillance
                systems within 12 months.

                Measure of performance: influenza
                tracking systems in place and
                capturing beneficiary clinical
                encounters.
    6.3.2.4  As appropriate, DOD, in           Within 18       Joint Staff
                consultation with its combatant   months
                commanders, shall implement
                movement restrictions and
                individual protection and social
                distancing strategies (including
                unit shielding, ship sortie,
                cancellation of public
                gatherings, drill, training,
                etc.) within its posts,
                installations, bases, and
                stations. DOD personnel and
                beneficiaries living off-base
                should comply with local
                community containment guidance
                with respect to activities not
                directly related to the
                installation. DOD shall be
                prepared to initiate within 18
                months.

                Measure of performance: the
                policies/procedures are in place
                for at-risk DOD posts,
                installations, bases, stations,
                and for units to conduct an
                annual training evaluation that
                includes restriction of movement,
                shielding, personnel protection
                measures, health unit isolation,
                and other measures necessary to
                prevent influenza transmission.
    6.3.2.5  All Department of Health and      Within 3 months ASD for Health
                Human Services-, DOD-, and                        Affairs
                Department of Veterans
                Affairs-funded hospitals and
                health facilities shall develop,
                test, and be prepared to
                implement infection control
                campaigns for pandemic influenza,
                within 3 months.

                Measure of performance: guidance
                materials on infection control
                developed and disseminated on
                www.pandemicflu.gov and through
                other channels.
    6.3.4.7  DOD shall enhance its public      Within 18       Joint Staff
                health response capabilities by:  months
                (1) continuing to assign
                epidemiologists and preventive
                medicine physicians within key
                operational settings; (2)
                expanding ongoing DOD
                participation in the Centers for
                Disease Control and Prevention's
                Epidemic Intelligence Service
                program; and (3) within 18
                months, fielding specific
                training programs for Public
                Health Emergency Officers that
                address their roles and
                responsibilities during a public
                health emergency.

                Measure of performance: all
                military Public Health Emergency
                Officers fully trained within 18
                months; increase military
                trainees in the Centers for
                Disease Control and Prevention's
                Epidemic Intelligence Service
                program by 100 percent within 5
                years.
    6.3.7.2  DOD and Department of Veterans    Within 3 months Joint Staff
                Affairs assets and capabilities
                shall be postured to provide care
                for military personnel and
                eligible civilians, contractors,
                dependants, other beneficiaries,
                and veterans and shall be
                prepared to augment the medical
                response of state, territorial,
                tribal, or local governments and
                other federal agencies consistent
                with their Emergency Support
                Function #8--Public Health and
                Medical Services support roles,
                within 3 months.

                Measure of performance: DOD and
                Department of Veterans Affairs'
                pandemic preparedness plans
                developed; in a pandemic,
                adequate health response provided
                to military and associated
                personnel.
    6.3.7.5  DOD shall develop and implement   Within 18       ASD for Health
                guidelines defining conditions    months          Affairs
                under which Reserve Component
                medical personnel providing
                health care in nonmilitary health
                care facilities should be
                mobilized and deployed, within 18
                months.

                Measure of performance:
                guidelines developed and
                implemented.
    6.3.8.2  DOD and the Department of         Within 6 months ASD for Health
                Veterans Affairs, in coordination                 Affairs
                with the Department of Health and
                Human Services, shall develop and
                disseminate educational
                materials, coordinated with and
                complementary to messages
                developed by the Department of
                Health and Human Services but
                tailored for their respective
                departments, within 6 months.

                Measure of performance:
                up-to-date risk communication
                material published on DOD and

                Department of Veterans Affairs
                pandemic influenza Web sites,
                Department of Health and Human
                Services Web site
                www.pandemicflu.gov, and in other
                venues.
    8.1.2.5  DOD, in consultation with the     Within 18       Joint Staff
                Department of Justice and the     months
                National Guard Bureau, and in
                coordination with the states as
                such training applies to support
                state law enforcement, shall
                assess the training needs for
                National Guard forces in
                providing operational assistance
                to state law enforcement under
                either federal (Title 10) or
                state (Title 32 or State Active
                Duty) in a pandemic influenza
                outbreak and provide appropriate
                training guidance to the states
                and territories for units and
                personnel who will be tasked to
                provide this support, within 18
                months.

                Measure of performance: guidance
                provided to all states.
    8.1.2.6  DOD, in consultation with the     Within 6 months Joint Staff
                Department of Justice, shall
                advise state governors of the
                procedures for requesting
                military equipment and
                facilities, training, and
                maintenance support as authorized
                by 10 U.S.C. SS 372-74, within 6
                months.

                Measure of performance: all state
                governors advised.
    8.3.2.1  The Department of Justice, the    Within 6 months Joint Staff
                Department of Homeland Security,
                and DOD shall engage in
                contingency planning and related
                exercises to ensure they are
                prepared to maintain essential
                operations and conduct missions,
                as permitted by law, in support
                of quarantine enforcement and/or
                assist state, local, and tribal
                entities in law enforcement
                emergencies that may arise in the
                course of an outbreak, within 6
                months.

                Measure of performance: completed
                plans (validated by exercise[s])
                for supporting quarantine
                enforcement and/or law
                enforcement emergencies.

    Source: Homeland Security Council and DOD.

    aThe deadline to complete these actions is based on the May 2006 issuance
    date of the national implementation plan. Therefore, actions that were to
    be completed within 6 months were due in November 2006. The Homeland
    Security Council issued a report on the federal government's progress on
    the actions to be completed within 6 months of the issuance of the
    national implementation plan. For more information, see Homeland Security
    Council, National Strategy for Pandemic Influenza Implementation Plan
    Summary of Progress (Washington, D.C.: December 2006). Six of the seven
    actions assigned to DOD as a lead agency were reported to be complete; one
    action was not included in the report. We did not assess whether DOD met
    the performance measures listed in the plan for these actions since it was
    not part of this review.

    Appendix II: Scope and Methodology

    To determine the actions the combatant commands (COCOM) have taken to date
    to prepare for an influenza pandemic, we reviewed drafts of the five
    geographic COCOMs' plans and one functional COCOM's plan that were
    available at the time of our review. We did not evaluate these plans;
    rather we used the plans to determine what actions the COCOMs have taken
    and plan to take to prepare for an influenza pandemic. Additionally we
    reviewed planning orders issued by the Joint Staff to the COCOMs in
    November 2005 and April 2007, DOD's implementation plan for pandemic
    influenza issued in August 2006, the Implementation Plan for the National
    Strategy for Pandemic Influenza issued by the Homeland Security Council in
    May 2006, DOD's budget requests for fiscal years 2007 and 2008 and
    appropriations for fiscal year 2007, and after-action reports from
    exercises related to pandemic influenza. Furthermore, we met with more
    than 200 officials involved in pandemic influenza planning and
    preparedness efforts at the nine COCOMs, including operational, medical,
    logistics, and continuity of operations planners; budget analysts;
    intelligence analysts and planners; public affairs professionals;
    humanitarian assistance liaisons; and representatives from the office of
    the command surgeon, including officials involved in force health
    protection activities. To better understand the extent of the COCOMs'
    efforts to plan and prepare for an influenza pandemic, we met with
    officials or, in one case, received written responses to our questions
    from the following COCOMs and their subcomponents:

               o Headquarters, U.S. Central Command, MacDill Air Force Base,
               Florida;
               o Headquarters, U.S. European Command, Patch Barracks, Germany;

                            o Marine Forces Europe, Patch Barracks, Germany;
                            o Naval Forces Europe, Patch Barracks, Germany;
                            o Special Operations Command Europe, Patch Barracks,
                            Germany;
                            o U.S. Air Forces Europe, Ramstein Air Base, Germany;
                            o U.S. Army Europe, Campbell Barracks, Germany;
                            o Installation Management Command Europe, Campbell
                            Barracks, Germany;
                            o European Regional Medical Command, Campbell
                            Barracks, Germany;
                            o U.S. Army Medical Materiel Command Europe,
                            Pirmasens, Germany;

               o Headquarters, U.S. Joint Forces Command, Norfolk, Virginia;
               o Headquarters, U.S. Northern Command, Peterson Air Force Base,
               Colorado;
               o Headquarters, U.S. Pacific Command, Camp H.M. Smith, Hawaii;

                            o Marine Forces Pacific, Camp H.M. Smith, Hawaii;
                            o Pacific Air Force, Hickam Air Force Base, Hawaii;
                            o Pacific Fleet, Naval Station Pearl Harbor, Hawaii;
                            o Special Operations Command Pacific, Camp H.M.
                            Smith, Hawaii;
                            o U.S. Army Pacific, Fort Shafter, Hawaii;
                            o U.S. Forces Korea, Yongsan Army Garrison, South
                            Korea;

                                         o U.S. Naval Forces Korea, Yongsan Army
                                         Garrison, South Korea;
                                         o 7th Air Force, Osan Air Base, South
                                         Korea;
                                         o 18th Medical Command, Yongsan Army
                                         Garrison, South Korea;
                                         o Installation Management Command Korea
                                         Regional Office, Yongsan Army Garrison,
                                         South Korea;

                            o Installation Management Command Pacific, Fort
                            Shafter, Hawaii;
                            o Tripler Army Medical Center, Hawaii;

               o Headquarters, U.S. Southern Command, Miami, Florida;
               o Headquarters, U.S. Special Operations Command, MacDill Air Force
               Base, Florida;
               o Headquarters, U.S. Strategic Command, Offutt Air Force Base,
               Nebraska; and
               o Headquarters, U.S. Transportation Command, Scott Air Force Base,
               Illinois;

    We elected to meet with officials from the military service and special
    operations subcomponents at the U.S. European Command and U.S. Pacific
    Command because these two commands have had to address outbreaks of H5N1
    avian influenza in their areas of responsibility. We selected U.S. Forces
    Korea because of the number of cases of H5N1 avian influenza in South
    Korea and the large number of U.S. military personnel stationed in U.S.
    Forces Korea's area of responsibility. Furthermore, to better understand
    how the COCOMs' planning and preparedness efforts relate to DOD's
    departmentwide planning efforts, we met in the Washington, D.C., area with
    officials from the Office of the Assistant Secretary of Defense for
    Homeland Defense and Americas' Security Affairs, Office of the Assistant
    Secretary of Defense for Health Affairs, and Joint Staff. We also met with
    officials from the Department of State to better understand their pandemic
    influenza planning and preparedness efforts, as they relate to the COCOMs'
    efforts. We did not assess the efforts of the individual installations to
    prepare for an influenza pandemic or whether installations' implementation
    plans supported the COCOM or military services' plans because many
    installations had not yet completed their implementation plans and because
    our focus for this report was on the COCOM-level planning and preparedness
    efforts.

    To determine management challenges that COCOMs face as they continue their
    planning efforts, we compared the COCOMs' actions to date to best
    practices that we have identified in our prior work. Specifically, we
    reviewed our previous work on risk management, influenza pandemics,
    emergency preparedness, and overall management to determine whether other
    issues or lessons learned addressed in these reports were applicable to
    the COCOMs' pandemic influenza planning and preparedness efforts. This
    work is referenced in the list of Related GAO Products at the end of this
    report.

    We conducted our review from September 2006 through April 2007 in
    accordance with generally accepted government auditing standards.

    Appendix III: Comments from the Department of Defense

    Appendix IV: GAO Contact and Staff Acknowledgments

    GAO Contact

    Davi M. D'Agostino, 202-512-5431, [49]dagostinod@gao.gov

    Staff Acknowledgments

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

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    Hurricane Katrina: GAO's Preliminary Observations Regarding Preparedness,
    Response, and Recovery. [59]GAO-06-442T . Washington, D.C.: March 8, 2006.

    Emergency Preparedness and Response: Some Issues and Challenges Associated
    with Major Emergency Incidents. [60]GAO-06-467T . Washington, D.C.:
    February 23, 2006.

    Statement by Comptroller General David M. Walker on GAO's Preliminary
    Observations Regarding Preparedness and Response to Hurricanes Katrina and
    Rita. [61]GAO-06-365R . Washington, D.C.: February 1, 2006.

    Influenza Pandemic: Applying Lessons Learned from the 2004-05 Influenza
    Vaccine Shortage. [62]GAO-06-221T . Washington, D.C.: November 4, 2005.

    Influenza Vaccine: Shortages in 2004-05 Season Underscore Need for Better
    Preparation. [63]GAO-05-984 . Washington, D.C.: September 30, 2005.

    Influenza Pandemic: Challenges in Preparedness and Response.
    [64]GAO-05-863T . Washington, D.C.: June 30, 2005.

    Influenza Pandemic: Challenges Remain in Preparedness. [65]GAO-05-760T .
    Washington, D.C.: May 26, 2005.

    Flu Vaccine: Recent Supply Shortages Underscore Ongoing Challenges.
    [66]GAO-05-177T . Washington, D.C.: November 18, 2004.

    Emerging Infectious Diseases: Review of State and Federal Disease
    Surveillance Efforts. [67]GAO-04-877 . Washington, D.C.: September 30,
    2004.

    Infectious Disease Preparedness: Federal Challenges in Responding to
    Influenza Outbreaks. [68]GAO-04-1100T . Washington, D.C.: September 28,
    2004.

    Emerging Infectious Diseases: Asian SARS Outbreak Challenged International
    and National Responses. [69]GAO-04-564 . Washington, D.C.: April 28, 2004.

    Public Health Preparedness: Response Capacity Improving but Much Remains
    to Be Accomplished. [70]GAO-04-458T . Washington, D.C.: February 12, 2004.

    HHS Bioterrorism Preparedness Programs: States Reported Progress but Fell
    Short of Program Goals for 2002. [71]GAO-04-360R . Washington, D.C.:
    February 10, 2004.

    Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack
    Certain Capacities for Bioterrorism Response. [72]GAO-03-924 . Washington,
    D.C.: August 6, 2003.

    Severe Acute Respiratory Syndrome: Established Infectious Disease Control
    Measures Helped Contain Spread, But a Large-Scale Resurgence May Pose
    Challenges. [73]GAO-03-1058T . Washington, D.C.: July 30, 2003.

    SARS Outbreak: Improvements to Public Health Capacity Are Needed for
    Responding to Bioterrorism and Emerging Infectious Diseases.
    [74]GAO-03-769T . Washington, D.C.: May 7, 2003.

    Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have
    Improved Public Health Response Capacity, but Gaps Remain. [75]GAO-03-654T
    . Washington, D.C.: April 9, 2003.

    Flu Vaccine: Steps Are Needed to Better Prepare for Possible Future
    Shortages. [76]GAO-01-786T . Washington, D.C.: May 30, 2001.

    Flu Vaccine: Supply Problems Heighten Need to Ensure Access for High-Risk
    People. [77]GAO-01-624 . Washington, D.C.: May 15, 2001.

    Influenza Pandemic: Plan Needed for Federal and State Response.
    [78]GAO-01-4 . Washington, D.C.: October 27, 2000.

    Global Health: Framework for Infectious Disease Surveillance.
    [79]GAO/NSIAD-00-205R . Washington, D.C.: July 20, 2000.

    (350786)

    [80]www.gao.gov/cgi-bin/getrpt?GAO-07-696 .

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

    For more information, contact Davi M. D'Agostino at (202) 512-5431 or
    dagostinod@gao.gov.

    Highlights of [81]GAO-07-696 , a report to the Committee on Oversight and
    Government Reform, House of Representatives

    June 2007

    INFLUENZA PANDEMIC

    DOD Combatant Commands' Preparedness Efforts Could Benefit from More
    Clearly Defined Roles, Resources, and Risk Mitigation

    An influenza pandemic could impair the military's readiness, jeopardize
    ongoing military operations abroad, and threaten the day-to-day
    functioning of the Department of Defense (DOD) due to a large percentage
    of sick or absent personnel.

    GAO was asked to examine DOD's pandemic influenza planning and
    preparedness efforts. GAO previously reported that DOD had taken numerous
    actions to prepare departmentwide, but faced four management challenges as
    it continued its efforts. GAO made recommendations to address these
    challenges and DOD generally concurred with them. This report focuses on
    DOD's combatant commands (COCOM) and addresses (1) actions the COCOMs have
    taken to prepare and

    (2) management challenges COCOMs face going forward. GAO reviewed
    guidance, plans, and after-action reports and interviewed DOD officials
    and more than 200 officials at the 9 COCOMs.

    [82]What GAO Recommends

    GAO recommends that DOD take steps to clarify the COCOMs' roles and
    responsibilities for pandemic influenza-related efforts, identify the
    sources and types of resources needed for the COCOMs to accomplish these
    efforts, and develop options to mitigate the effects of factors that are
    outside of their control. DOD concurred with each of these
    recommendations.

    COCOMs have taken numerous management and operational actions to prepare
    for an influenza pandemic, and the COCOMs' efforts are evolving. Each of
    DOD's nine COCOMs has established or intends to establish a working group
    to prepare for an influenza pandemic. Additionally, eight of the nine
    COCOMs have developed or are developing a pandemic influenza plan. Half of
    the COCOMs have conducted exercises to test their pandemic influenza plans
    and several are taking steps to address lessons learned. Five of the nine
    COCOMs have started to use various media, training programs, and outreach
    events to inform their personnel about pandemic influenza. Each of the
    geographic COCOMs has worked or plans to work with nations in its area of
    responsibility to raise awareness about and assess capabilities for
    responding to avian and pandemic influenza.

    Although COCOMs have taken numerous actions, GAO identified three
    management challenges that may prevent the COCOMs from being fully
    prepared to effectively protect personnel and perform missions during an
    influenza pandemic, two of which are related to issues GAO previously
    recommended that DOD address. First, the roles, responsibilities, and
    authorities of key organizations relative to others involved in DOD's
    planning efforts remained unclear in part due to the continued lack of
    sufficiently detailed guidance from the Secretary of Defense or his
    designee. As a result, the unity and cohesiveness of DOD's efforts could
    be impaired and the potential remains for confusion and gaps or
    duplication in actions taken by the COCOMs relative to the military
    services and other DOD organizations, such as in completing actions
    assigned to DOD in the Implementation Plan for the National Strategy for
    Pandemic Influenza. Second, GAO identified a disconnect between the
    COCOMs' planning and preparedness activities and resources, including
    funding and personnel, to complete these activities, in part, because
    DOD's guidance does not identify the resources required to complete these
    activities. The continued lack of a link between planning and preparedness
    activities and resources may limit the COCOMs' ability to effectively
    prepare for and respond to an influenza pandemic, including COCOMs'
    ability to exercise pandemic influenza plans in the future. Third, GAO
    identified factors that are beyond the COCOMs' control--such as limited
    detailed guidance from other federal agencies on support expected from
    DOD, lack of control over DOD's stockpile of antivirals, limited
    information on decisions that other nations may make during an influenza
    pandemic, reliance on civilian medical providers for medical care, and
    reliance on military services for medical materiel--that they have not yet
    fully planned how to mitigate. While GAO recognizes the challenge of
    pandemic influenza planning, not yet developing options to mitigate the
    effects of factors that are beyond their control may place at risk the
    COCOM commanders' ability to protect their personnel and perform missions
    during an influenza pandemic. For example, if a nation decides to close
    its borders at the start of a pandemic, COCOMs and installations may not
    be able to obtain needed supplies, such as antivirals.

    GAO's Mission

    The Government Accountability Office, the audit, evaluation and
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