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

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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][email protected] .
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. GAO staff who made
contributions to this report are listed in appendix IV.

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

Appendix I: 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][email protected]

Staff Acknowledgments

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

Related GAO Products

Homeland Security: Observations on DHS and FEMA Efforts to Prepare for and
Respond to Major and Catastrophic Disasters and Address Related
Recommendations and Legislation. [50]GAO-07-835T . Washington, D.C.: May
15, 2007.

Financial Market Preparedness: Significant Progress Has Been Made, but
Pandemic Planning and Other Challenges Remain. [51]GAO-07-399 .
Washington, D.C.: March 29, 2007.

Public Health and Hospital Emergency Preparedness Programs: Evolution of
Performance Measurement Systems to Measure Progress. [52]GAO-07-485R .
Washington, D.C.: March 23, 2007.

Homeland Security: Preparing for and Responding to Disasters.
[53]GAO-07-395T . Washington, D.C.: March 9, 2007.

Homeland Security: Applying Risk Management Principles to Guide Federal
Investments. [54]GAO-07-386T . Washington, D.C.: February 7, 2007.

Influenza Pandemic: DOD Has Taken Important Actions to Prepare, but
Accountability, Funding, and Communications Need to be Clearer and Focused
Departmentwide. [55]GAO-06-1042 . Washington, D.C.: September 21, 2006.

Hurricane Katrina: Better Plans and Exercises Need to Guide the Military's
Response to Catastrophic Natural Disasters.  [56]GAO-06-808T . Washington,
D.C.: May 25, 2006.

Hurricane Katrina: Better Plans and Exercises Needed to Guide the
Military's Response to Catastrophic Natural Disasters. [57]GAO-06-643 .
Washington, D.C.: May 15, 2006.

Continuity of Operations: Agencies Could Improve Planning for Telework
during Disruptions. [58]GAO-06-740T . Washington, D.C.: May 11, 2006.

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
[email protected].

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

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