Influenza Pandemic: Federal Agencies Should Continue to Assist	 
States to Address Gaps in Pandemic Planning (19-JUN-08, 	 
GAO-08-539).							 
                                                                 
The Implementation Plan for the National Strategy for Pandemic	 
Influenza states that in an influenza pandemic, the primary	 
response will come from states and localities. To assist them	 
with pandemic planning and exercising, Congress has provided $600
million to states and certain localities. The Department of	 
Homeland Security (DHS) established five federal influenza	 
pandemic regions to work with states to coordinate planning and  
response efforts. GAO was asked to (1) describe how selected	 
states and localities are planning for an influenza pandemic and 
who they involved, (2) describe the extent to which selected	 
states and localities conducted exercises to test their influenza
pandemic planning and incorporated lessons learned as a result,  
and (3) identify how the federal government can facilitate or	 
help improve state and local efforts to plan and exercise for an 
influenza pandemic. GAO conducted site visits to five states and 
10 localities.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-539 					        
    ACCNO:   A82901						        
  TITLE:     Influenza Pandemic: Federal Agencies Should Continue to  
Assist States to Address Gaps in Pandemic Planning		 
     DATE:   06/19/2008 
  SUBJECT:   Disease control					 
	     Disease surveillance				 
	     Emergency preparedness				 
	     Emergency preparedness programs			 
	     Emerging infectious diseases			 
	     Federal aid to localities				 
	     Federal/state relations				 
	     Grants to states					 
	     Homeland security					 
	     Infectious diseases				 
	     Influenza						 
	     Lessons learned					 
	     Local governments					 
	     Locally administered programs			 
	     Pandemic						 
	     Policy evaluation					 
	     Program management 				 
	     Public health					 
	     Regional planning					 
	     Risk management					 
	     Strategic planning 				 

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GAO-08-539

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Report to Congressional Requesters:

United States Government Accountability Office: 
GAO:

June 2008:

Influenza Pandemic:

Federal Agencies Should Continue to Assist States to Address Gaps in 
Pandemic Planning:

GAO-08-539: 

GAO Highlights:

Highlights of GAO-08-539, a report to congressional requesters. 

Why GAO Did This Study:

The Implementation Plan for the National Strategy for Pandemic 
Influenza states that in an influenza pandemic, the primary response 
will come from states and localities. To assist them with pandemic 
planning and exercising, Congress has provided $600 million to states 
and certain localities. The Department of Homeland Security (DHS) 
established five federal influenza pandemic regions to work with states 
to coordinate planning and response efforts.
 
GAO was asked to (1) describe how selected states and localities are 
planning for an influenza pandemic and who they involved, (2) describe 
the extent to which selected states and localities conducted exercises 
to test their influenza pandemic planning and incorporated lessons 
learned as a result, and (3) identify how the federal government can 
facilitate or help improve state and local efforts to plan and exercise 
for an influenza pandemic. GAO conducted site visits to five states and 
10 localities.

What GAO Found:

All of the five states and 10 localities reviewed by GAO had developed 
influenza pandemic plans. In fact, according to officials at the 
Centers for Disease Control and Prevention (CDC), which administers the 
federal pandemic funds, all 50 states have developed an influenza 
pandemic plan, in accordance with federal pandemic funding 
requirements. At the time of GAOï¿½s site visits, officials from the 
selected states and localities reviewed said that they involved the 
federal government, other state and local agencies, tribal nations, and 
nonprofit and private sector organizations in their influenza pandemic 
planning. Since GAOï¿½s site visits, the Department of Health and Human 
Services (HHS) has provided feedback to the states, territories, and 
the District of Columbia (hereafter referred to as states) on whether 
their plans addressed 22 priority areas, such as policy process for 
school closure and communication. On average the department found that 
statesï¿½ plans had ï¿½many major gapsï¿½ in 16 of the 22 priority areas. In 
March 2008, HHS, DHS, and other federal agencies issued guidance to 
states to help them update their pandemic plans, which are due by July 
2008, in preparation for another HHS-led review.

According to CDC officials, all states and localities that received the 
federal pandemic funds have met the requirement to conduct an exercise 
to test their plans. Officials from all of the states and localities 
reviewed by GAO reported that they had incorporated lessons learned 
from influenza pandemic exercises into their influenza pandemic 
planning, such as buying additional medical equipment, providing 
training, and modifying influenza pandemic plans. For example, as a 
result of an exercise, officials at the Dallas County Department of 
Health and Human Services (Texas) reported that they developed an 
appendix to their influenza pandemic plan on school closures during a 
pandemic.

The federal government has provided influenza pandemic guidance on a 
variety of topics including an influenza pandemic planning checklist 
for states and localities and draft guidance on allocating an influenza 
pandemic vaccine. However, officials of the states and localities 
reviewed by GAO told GAO that they would welcome additional guidance 
from the federal government in a number of areas to help them to better 
plan and exercise for an influenza pandemic, in areas such as community 
containment (community-level interventions designed to reduce the 
transmission of a pandemic virus). Three of these areas were also 
identified as having ï¿½many major gapsï¿½ in statesï¿½ plans nationally in 
the HHS-led review. In January 2008, HHS and DHS, in coordination with 
other federal agencies, hosted a series of meetings of states in the 
five federal influenza pandemic regions to discuss the draft guidance 
on updating their pandemic plans. Although a senior DHS official 
reported that there are no plans to conduct further workshops, 
additional regional meetings could provide a forum for state and 
federal officials to address gaps in statesï¿½ planning identified by the 
HHS-led review and to maintain the momentum of statesï¿½ pandemic 
preparedness through this next governmental transition.

What GAO Recommends: 

GAO recommends that the Secretaries of Health and Human Services and 
Homeland Security, in coordination with other federal agencies, convene 
additional meetings of the states in the five federal influenza 
pandemic regions to help them address identified gaps in their 
planning. HHS generally concurred with the recommendation and DHS 
concurred. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-539]. For more 
information, contact Bernice Steinhardt at (202) 512-6543 or 
[email protected]. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

States and Localities Have Planned for an Influenza Pandemic and Have 
Involved Others in Their Planning, but HHS Has Found Major Gaps in 
States' Plans: 

All States and Localities Reviewed Have Conducted or Participated in at 
Least One Exercise to Test Their Planning for an Influenza Pandemic and 
Have Incorporated Lessons Learned: 

HHS and DHS Could Further Assist States in Addressing Gaps Identified 
in Pandemic Planning: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Comments from the Department of Homeland Security: 

Related GAO Products: 

Table: 

Table 1: National Average of Status of States' Pandemic Plans by 
Priority Areas and Lead Federal Government Reviewer: 

Figures: 

Figure 1: Five Federal Influenza Pandemic Regions: 

Figure 2: HHS Influenza Pandemic Supplemental Appropriations, Fiscal 
Year 2006: 

Abbreviations: 

ASPR: Office of the Assistant Secretary for Preparedness and Response: 

CDC: Centers for Disease Control and Prevention: 

DHS: Department of Homeland Security: 

FCO: Federal Coordinating Officer: 

FEMA: Federal Emergency Management Agency: 

HHS: Department of Health and Human Services: 

HSEEP: Homeland Security Exercise and Evaluation Program: 

LLIS: Lessons Learned Information Sharing System: 

MOU: Memorandum of Understanding: 

National Pandemic Implementation Plan: Implementation Plan for the 
National Strategy for Pandemic Influenza: 

National Pandemic Strategy: National Strategy for Pandemic Influenza: 

NIMS: National Incident Management System: 

NIPP: National Infrastructure Protection Plan: 

NRF: National Response Framework: 

PAHPA: Pandemic and All-Hazards Preparedness Act: 

PFO: Principal Federal Official: 

PHEP: Public Health Emergency Preparedness Program: 

SFO: Senior Federal Official: 

Stafford Act: Robert T. Stafford Disaster Relief and Emergency 
Assistance Act: 

[End of section] 

United States Government Accountability Office:
Washington, DC 20548: 

June 19, 2008: 

Congressional Requesters: 

The Implementation Plan for the National Strategy for Pandemic 
Influenza (National Pandemic Implementation Plan) states that in the 
event of an influenza pandemic the distributed nature and sheer burden 
of disease across the nation would mean that the federal government's 
support to any particular community is likely to be limited, with the 
primary response to a pandemic coming from states and local 
communities. However, given the unique nature of an influenza pandemic, 
all sectors of society, including the federal government, states and 
local communities, the private sector, nonprofit organizations, tribal 
nations, individual citizens, and global partners will need to be 
involved in preparedness for and response to a pandemic. 

An influenza pandemic is a real and significant threat facing the 
United States and the world. There is widespread agreement that it is 
not a question of if, but when, such an influenza pandemic will occur. 
Some of the issues associated with the preparation for and responses to 
an influenza pandemic are similar to those for any other type of 
disaster or hazard. However, a pandemic poses some unique challenges. 
During the peak weeks of an outbreak of a severe influenza pandemic in 
the United States, an estimated 40 percent of the United States 
workforce might not be at work due to illness, the need to care for 
family members who are sick, or fear of becoming infected. Moreover, an 
influenza pandemic is likely to occur in several waves, each lasting up 
to 6 to 8 weeks, with outbreaks occurring simultaneously across the 
country. 

The National Strategy for Pandemic Influenza (National Pandemic 
Strategy), which was issued in November 2005 by the President and his 
Homeland Security Council, is intended to provide a high-level overview 
of the approach that the federal government will take to prepare for 
and respond to an influenza pandemic. The National Pandemic 
Implementation Plan, which was issued in May 2006 by the President and 
his Homeland Security Council, lays out the broad implementation 
requirements and responsibilities among the appropriate federal 
agencies and defines expectations of nonfederal entities for the 
National Pandemic Strategy. The National Pandemic Implementation Plan 
lays out the expectation that states and communities should have 
influenza pandemic preparedness plans and conduct pandemic exercises. 
Exercises are crucial in testing and planning. Our work has shown the 
importance of ensuring that lessons learned from exercises are 
incorporated into planning to address any gaps or challenges 
identified.[Footnote 1] To assist in planning and coordinating efforts 
to respond to an influenza pandemic, in December 2006, the Secretary of 
Homeland Security established five federal influenza pandemic regions 
across the United States to work with states to coordinate planning and 
response efforts. In addition, cooperative agreements and grants from 
the Department of Health and Human Services (HHS) and the Department of 
Homeland Security (DHS) provide funds that state and local governments 
can use to support planning and exercising for an influenza pandemic. 
During fiscal year 2006, Congress provided HHS $600 million in 
supplemental funding for state and local influenza pandemic planning 
and exercising, which has been administered by the Centers for Disease 
Control and Prevention (CDC), the last portion is to be distributed in 
2008. The federal government has communicated the importance of 
remaining vigilant and sustaining pandemic preparedness. Continuing and 
maintaining these efforts is particularly crucial now, given the 
upcoming federal governmental transition in January 2009. 

This report responds to your request that we (1) describe how selected 
states and localities are planning for an influenza pandemic and how 
their efforts are involving the federal government, other state and 
local agencies, tribal nations, nonprofit organizations, and the 
private sector, (2) describe the extent to which selected states and 
localities have conducted exercises to test their influenza pandemic 
planning and incorporated lessons learned into their planning, and (3) 
identify how the federal government can facilitate or help improve 
state and local efforts to plan and exercise for an influenza pandemic. 

To address these objectives, from June 2007 through September 2007, we 
conducted site visits to the five most populous states: California, 
Florida, Illinois, New York, and Texas. Recognizing that we would be 
limited in our ability to report on all states in detail, we selected 
these five states for a number of reasons, including that these states: 

* comprised over one-third of the United States population; 

* received over one-third of the total funding from HHS and DHS that 
could be used for planning or exercising for an influenza pandemic, 
[Footnote 2] and each state received the highest amount of total HHS 
and DHS funding that could be used for planning and exercising for an 
influenza pandemic respectively within each of the five regions 
established by DHS for influenza pandemic preparedness and emergency 
response, and; 

* were likely entry points for individuals coming from another country 
given that the states bordered either Mexico or Canada or contained 
major ports, or both, and accounted for over one-third of the total 
number of passengers traveling within the United States, and over half 
of both inbound and outbound international air passenger traffic to and 
from the United States. 

In each state, we interviewed officials responsible for health, 
emergency management, and homeland security. We also interviewed 
officials at 10 localities in these same states, which consisted of 
five urban areas and five rural counties. We interviewed officials 
responsible for health and emergency management at an urban area and a 
rural county in each of the five states. The urban areas included Los 
Angeles County (California), Miami (Florida), Chicago (Illinois), New 
York City (New York), and Dallas (Texas). These urban areas were 
selected based on having the highest population totals of all urban 
areas in the respective states and high levels of international airport 
passenger traffic. Three of these urban areas also received federal 
pandemic funds: Los Angeles County, Chicago, and New York City. The 
rural counties we selected--Stanislaus County (California), Taylor 
County (Florida), Peoria County (Illinois), Washington County (New 
York), and Angelina County (Texas)--were each nominated by state 
officials based on the following criteria: these counties had conducted 
some planning or exercising for an influenza pandemic and they were 
representative of challenges and needs that surrounding counties might 
also be facing. In total we interviewed officials with 34 different 
agencies. We also reviewed documentation from the selected state and 
local governments. 

While the states and localities selected provided a broad perspective, 
we cannot generalize or extrapolate the information gleaned from the 
site visits to the nation. In addition, since the states that we 
selected were large, the most populous states, and likely entry points 
for people coming into the United States, the information we collected 
may not be as relevant to smaller, less populated states that are not 
likely entry points for people coming into the United States. 

We also interviewed HHS, CDC, and DHS officials about how they are 
working with states and localities in planning and exercising for an 
influenza pandemic and reviewed documentation that they provided, 
including information on the HHS-led review of states', five 
territories',[Footnote 3] and the District of Columbia's[Footnote 4] 
influenza pandemic plans and the guidance to assist them in updating 
their influenza plans for the next assessment of their plans. In 
January 2008, we observed two of five influenza pandemic regional 
workshops led by HHS and DHS, in coordination with other federal 
agencies. The purpose of the workshops was to obtain state leaders' 
input on guidance to assist their governments in updating their 
pandemic plans in preparation for a second HHS-led review of these 
plans. In addition, we interviewed officials from the National 
Governors Association, Association of State and Territorial Health 
Officials, National Association of County and City Health Officials, 
and the National Emergency Management Association who are working on 
issues related to state and local influenza pandemic activities. We 
also reviewed relevant literature and prior GAO work. 

We conducted this performance audit from March 2007 to June 2008 in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. Detailed information on our 
scope and methodology appears in appendix I. In addition, a list of 
related GAO products is included at the end of this report. 

Results in Brief: 

All of the five states and 10 localities we reviewed, both urban and 
rural, had developed influenza pandemic plans. In addition, all 50 
states have developed an influenza pandemic plan in accordance with 
federal pandemic funding requirements according to CDC officials. At 
the time of our site visits, officials from three of the five states 
and two of the three localities that received direct federal pandemic 
funds reported conferring with HHS and CDC for technical assistance in 
planning for an influenza pandemic. Officials from the selected states 
and localities reviewed said that they involved other state and local 
agencies, tribal nations, and nonprofit and private sector 
organizations in their influenza pandemic planning in accordance with 
federal pandemic funding requirements. For example, state public health 
agencies in all the states reported assisting their local counterparts 
with their influenza pandemic plans. Since we visited these states and 
localities, HHS has provided feedback to the states on whether their 
plans addressed 22 priority areas, such as policy process for school 
closures and communication. On average, the department found that 
states had "many major gaps" in their influenza pandemic plans in 16 of 
the 22 priority areas. In March 2008, HHS, DHS, and other federal 
agencies issued guidance to states to help them to update their 
pandemic plans, which are due by July 2008. 

According to CDC officials, all states and localities that received 
federal pandemic funds have met the requirement to conduct an exercise 
to test their influenza pandemic plans. These states and localities 
could have met this requirement by conducting a discussions-based 
exercise or an operations-based exercise, which is used to validate the 
plans, policies, agreements, and procedures assessed in discussions- 
based exercises. One state and two localities conducted at least one 
discussions-based and an operations-based exercise, one state and one 
locality conducted at least one operations-based exercise, and the 
remaining three states and seven localities conducted or participated 
in at least one discussions-based influenza pandemic exercise. 
Officials from all of the states and localities we reviewed reported 
that they had incorporated lessons learned from influenza pandemic 
exercises into their influenza pandemic planning, such as buying 
additional medical equipment, providing training, and modifying 
policies or influenza pandemic plans. For example, as a result of an 
exercise, officials at the Dallas County Department of Health and Human 
Services (Texas) reported that they developed an appendix to their 
influenza pandemic plan on school closures during a pandemic that 
included factors for schools to consider in deciding when to close 
schools and for how long. 

The federal government has provided influenza pandemic information and 
guidance through Web sites and state and regional meetings on a variety 
of topics including an influenza pandemic planning checklist for states 
and localities, draft guidance on allocating and targeting an influenza 
pandemic vaccine, and discussions-based exercises for influenza 
pandemic preparedness for local public health agencies. However, 
officials of the states and localities we reviewed told us that they 
would welcome additional guidance from the federal government in a 
number of areas to help them to better plan and exercise for an 
influenza pandemic. Three of these areas--including community 
containment, which is community-level interventions, such as closing 
schools, designed to reduce the transmission of a pandemic virus--were 
also identified as having "many major gaps" in states' plans nationwide 
in the HHS-led review. In January 2008, HHS and DHS, in coordination 
with other federal agencies, hosted a series of meetings of states in 
the five federal influenza pandemic regions to discuss draft guidance 
on updating their pandemic plans. Although a senior DHS official in the 
Office of Health Affairs reported that there are no plans to conduct 
further regional state workshops on influenza pandemic, additional 
meetings could provide a forum for state and federal officials to 
address gaps in states' planning identified by the HHS-led review. The 
meetings could also help maintain the momentum that has already been 
started by HHS and DHS to continue to work with the states on pandemic 
preparedness through this next federal government transition. 

Although HHS completes distribution of the federal pandemic funds in 
2008, the federal government can continue to provide support to states 
in other ways. To help maintain a continuity of focus on state pandemic 
planning efforts and to further assist states in their pandemic 
planning, we recommend that the Secretaries of Health and Human 
Services and Homeland Security, in coordination with other federal 
agencies, convene additional meetings of the states in the five federal 
influenza pandemic regions to help them address identified gaps in 
their planning. 

We provided a draft of the report to the Secretaries of Health and 
Human Services and Homeland Security for their review and comment. HHS 
generally concurred with our recommendation in an e-mail. The 
department stated that although additional workshops would be 
impractical in the short-term in light of the ongoing update of the 
state pandemic plans, the workshops had been successful, and HHS was 
prepared to arrange for similar sessions in the future if states would 
find them useful. The department also provided us with technical 
comments, which we incorporated as appropriate. DHS generally agreed 
with the contents of the report and concurred with our recommendation. 
DHS's comments are reprinted in appendix II. We also provided draft 
portions of the report to the state and local officials from the five 
states and 10 localities we reviewed to ensure technical accuracy. We 
received no comments from these states and localities. 

Background: 

Federal Emergency Response Framework: 

In the event of a disaster, such as an influenza pandemic, states may 
request federal assistance to maintain essential services pursuant to 
the Robert T. Stafford Disaster Relief and Emergency Assistance Act 
(Stafford Act) of 1974.[Footnote 5] The Stafford Act primarily 
establishes the programs and processes for the federal government to 
provide disaster assistance to state and local governments and tribal 
nations, individuals, and qualified private nonprofit organizations. 
Federal assistance may include technical assistance, the provision of 
goods and services, and financial assistance. The Federal Emergency 
Management Agency (FEMA), which is part of DHS, is responsible for 
carrying out the functions and authorities of the Stafford Act. For 
Stafford Act incidents, upon the recommendation of the Secretary of 
Homeland Security and the FEMA Administrator, the President may appoint 
a Federal Coordinating Officer (FCO) to manage and coordinate federal 
resource support activities provided pursuant to the Stafford Act. 

DHS has recently updated the National Response Plan, now called the 
National Response Framework (NRF).[Footnote 6] To assist in planning 
and coordinating efforts to respond to an influenza pandemic, in 
December 2006, the Secretary of Homeland Security predesignated a 
national Principal Federal Official (PFO) and FCO for influenza 
pandemic, and established five federal influenza pandemic regions each 
with a regional PFO and FCO. This structure was formalized in the NRF. 
The PFO facilitates federal support to establish incident management 
and assistance activities for prevention, preparedness, response, and 
recovery efforts while the FCO manages and coordinates federal resource 
support activities provided pursuant to the Stafford Act. The PFO is to 
provide a primary point of contact and situational awareness for the 
Secretary of Homeland Security. In addition, according to an official 
in HHS' Office of the Assistant Secretary for Preparedness and Response 
(ASPR), HHS has also predesignated a national Senior Federal Official 
(SFO) and a regional SFO for influenza pandemic in each of the five 
federal influenza pandemic regions who serve as ambassadors for public 
health to states, territories, and the District of Columbia, which 
aligns with the PFO and FCO structure. The federal influenza pandemic 
regions, each of which consists of two standard federal regions, are 
shown below. 

Figure 1: Five Federal Influenza Pandemic Regions: 

[See PDF for image] 

This figure is a listing of the Five Federal Influenza Pandemic 
Regions, as follows: 

Region: A; 
Standard federal regions: 1 + 2 (Boston/New York); 
By state: 
* Connecticut; 
* Maine; 
* Massachusetts; 
* New Hampshire; 
* New Jersey; 
* New York; 
* Puerto Rico; 
* Rhode Island; 
* Vermont; 
* Virgin Islands. 

Region: B; 
Standard federal regions: 3 + 4 (Philadelphia/Atlanta); 
By state: 
* Alabama; 
* Delaware; 
* District of Columbia; 
* Florida;
* Georgia; 
* Kentucky; 
* Maryland; 
* Mississippi; 
* North Carolina; 
* Pennsylvania;
* South Carolina; 
* Tennessee; 
* Virginia; 
* West Virginia. 

Region: C; 
Standard federal regions: 5 + 8 (Chicago/Denver); 
By state: 
* Colorado; 
* Illinois; 
* Indiana; 
* Michigan; 
* Minnesota; 
* Montana; 
* North Dakota; 
* Ohio; 
* South Dakota; 
* Utah; 
* Wisconsin; 
* Wyoming. 

Region: D; 
Standard federal regions: 6 + 7 (Denton/Kansas City); 
By state: 
* Arkansas; 
* Iowa; 
* Kansas; 
* Louisiana; 
* Missouri; 
* Nebraska; 
* New Mexico; 
* Oklahoma; 
* Texas. 

Region: E; 
Standard federal regions: 9 + 10 (Oakland/Bothell); 
By state: 
* Alaska; 
* Arizona; 
* California; 
* Hawaii; 
* Idaho; 
* Nevada; 
* Oregon; 
* Washington. 

Source: DHS. 

[End of figure] 

In addition, under the Public Health Service Act, the Secretary of 
Health and Human Services has the authority to declare a public health 
emergency and to take actions necessary to respond to that emergency 
consistent with his/her authorities.[Footnote 7] These actions may 
include making grants, entering into contracts, and conducting and 
supporting investigations into the cause, treatment, or prevention of 
the disease or disorder that caused the emergency. According to the 
National Pandemic Implementation Plan, as the lead agency responsible 
for public health and medical care, HHS would lead efforts during an 
influenza pandemic while DHS would be responsible for overall 
nonmedical support such as domestic incident management and federal 
coordination. 

In December 2006, Congress passed the Pandemic and All-Hazards 
Preparedness Act (PAHPA)[Footnote 8] which codifies preparedness and 
response federal leadership roles and responsibilities for public 
health and medical emergencies by designating the Secretary of Health 
and Human Services as the lead federal official for public health and 
medical preparedness and response.[Footnote 9] The act also prescribes 
several new preparedness responsibilities for HHS. Among these, the 
Secretary must develop and disseminate criteria for an effective state 
plan for responding to an influenza pandemic. Additionally, the 
Secretary is required to develop and require the application of 
evidence-based benchmarks and objective standards that measure the 
levels of preparedness for public health emergencies in consultation 
with state, local, and tribal officials and private entities, as 
appropriate. Application of these benchmarks and standards is required 
of entities receiving funds under HHS public health emergency 
preparedness grant and cooperative agreement programs.[Footnote 10] 
Beginning in fiscal year 2009, the Secretary of Health and Human 
Services is to withhold certain amounts of funding under these grant 
and cooperative agreement programs where a state has failed to develop 
an influenza pandemic plan that is consistent with the criteria 
established by HHS or where an entity has failed to meet the benchmarks 
or standards established.[Footnote 11] 

Various Federal Funds Are Available to States and Localities for 
Influenza Pandemic Planning and Exercising: 

In addition to the federal pandemic funds provided for states and 
localities by Congress in fiscal year 2006, HHS and DHS receive funds 
for public health and emergency management grant programs that can be 
used by states and localities to continue to support influenza pandemic 
efforts. In fiscal year 2006, Congress appropriated $5.62 billion in 
supplemental funding to HHS for, among other things, (1) monitoring 
disease spread to support rapid response, (2) developing vaccines and 
vaccine production capacity, (3) stockpiling antivirals[Footnote 12] 
and other countermeasures, (4) upgrading state and local capacity, and 
(5) upgrading laboratories and research at CDC.[Footnote 13] 

As shown in figure 2, a total of $770 million, or about 14 percent, of 
this supplemental funding went to states and localities for 
preparedness activities. Of the $770 million, $600 million was 
specifically provided by Congress for state and local planning and 
exercising while the remaining $170 million was allocated for state 
antiviral purchases. According to HHS, as of May 2008, states had 
purchased $21.9 million of treatment courses of influenza antivirals 
for their state stockpiles. In addition to these state stockpiles of 
antivirals, HHS has also acquired antivirals that are in the HHS- 
managed Strategic National Stockpile, which is a national repository of 
medical supplies that is designed to supplement and resupply local 
public health agencies in the event of a public health emergency. 

Figure 2: HHS Influenza Pandemic Supplemental Appropriations, Fiscal 
Year 2006: 

[See PDF for image] 

This figure is a pie-chart depicting the following data: 

HHS Influenza Pandemic Supplemental Appropriations, Fiscal Year 2006 
(Dollars in million): 
Risk communications: $51 (1%); 
Medical supplies (personal protective equipment, ventilators, etc.); 
$170 (3%); 
International activities[A]: $179 (3%); 
Other domestic[B]: $276 (5%); 
State and local preparedness[C]: $770 (14%); 
Antivirals[C]: $911 (16%); 
Vaccine: $3,233 (58%); 

Total: $5,590[D]. 

Source: GAO, HHS. 

Notes: Data are from HHS, Pandemic Planning Update III: A Report from 
Secretary Michael O. Leavitt (Washington, D.C.: Nov. 13, 2006). 

[A] International activities includes: international preparedness, 
surveillance, response, and research. 

[B] Other domestic includes: surveillance, quarantine, lab capacity, 
rapid tests. 

[C] State and local preparedness includes funding for state subsidies 
of antiviral drugs. 

[D] This chart does not include $30 million in supplemental funding 
that was transferred to the United States Agency for International 
Development. 

[End of figure] 

In addition to the federal pandemic funds specifically provided by 
Congress, which are administered for HHS by CDC, HHS officials said 
that states and localities could use funds provided under two other HHS 
public health emergency preparedness cooperative agreement programs to 
continue to support their influenza pandemic activities.[Footnote 14] 

* The Public Health Emergency Preparedness Program (PHEP), which is a 
cooperative agreement administered by CDC, is intended to improve state 
and local public health security capabilities. Specifically, the Cities 
Readiness Initiative, a component of PHEP, is intended to ensure that 
major cities and metropolitan areas are prepared to distribute medicine 
and medical supplies during a large-scale public health emergency. 

* The Hospital Preparedness Program, which is administered by HHS ASPR, 
is intended to improve surge capacity and enhance community and 
hospital preparedness for public health emergencies. 

DHS officials also said that states and localities could use funds 
provided under three of the Homeland Security Grant Program grants, 
which are administered by DHS's Office of Grants and Training, to 
continue to support influenza pandemic activities. 

* The State Homeland Security Grant Program's purpose includes 
supporting, building, and sustaining capabilities at the state and 
local levels through planning, equipment, training, and exercise 
activities. 

* The Metropolitan Medical Response System Program is intended to 
support an integrated, systematic mass casualty incident preparedness 
program that enables an effective response during the first crucial 
hours of an incident such as an epidemic outbreak, natural disaster, 
and a large-scale hazardous materials incident. 

* The Urban Area Security Initiative Grant Program is intended to 
address the unique planning, equipment, training, and exercise needs of 
high-threat, high-density urban areas. 

States and Localities Have Planned for an Influenza Pandemic and Have 
Involved Others in Their Planning, but HHS Has Found Major Gaps in 
States' Plans: 

All of the five states and 10 localities we reviewed, both urban and 
rural, had developed influenza pandemic plans. As directed by the 
federal pandemic funding guidance, all 50 states and localities that 
received direct funding through the PHEP and Hospital Preparedness 
Program were required to plan and exercise for an influenza pandemic. 
According to CDC officials, all 50 states have developed an influenza 
pandemic plan. Of the $600 million designated by Congress for states 
and localities for planning and exercising, CDC divided the funding 
into three phases. Recipients included 50 states, five territories, 
[Footnote 15] three Freely Associated States of the Pacific,[Footnote 
16] three localities,[Footnote 17] and the District of Columbia. CDC 
awarded $100 million for Phase I in March 2006, $250 million for Phase 
II in two disbursements--July 2006 and March 2008 [Footnote 18]--and 
$250 million for Phase III in two disbursements--September 2007 and 
October 2007.[Footnote 19] Phase III is to be completed in 2008 and 
will be the final phase for dedicated federal pandemic funds to states 
and localities that received direct federal funding. 

For Phase I, recipients were expected to comply with the following 
requirements, among others: 

* establish a committee or consortium at the state and local levels 
with which the recipient is engaged that represents all relevant 
stakeholders in the jurisdiction, such as public health, emergency 
response, business, community-based, and faith-based sectors; 

* implement a planning framework for influenza pandemic preparedness 
and response activities to support public health and medical efforts; 

* collaborate among public health and medical preparedness, influenza, 
infectious disease, and immunization programs and state and local 
emergency management to maximize the effect of funds and efforts; 

* coordinate activities between state and local jurisdictions, tribes, 
and military installations; among local agencies; with hospitals and 
major health care facilities; and with adjacent states; 

* conduct exercises to test the plans of states or localities that 
receive the funding directly and prepare an after-action report, which 
is a summary of lessons learned highlighting necessary corrective 
actions; 

* assess gaps in pandemic preparedness using CDC's self-assessment tool 
to evaluate the jurisdiction's current state of preparedness; 

* submit a proposed approach to filling the identified gaps; and: 

* provide an associated budget for the critical tasks necessary to 
address those gaps. 

According to CDC officials, all entities that received direct federal 
funding have met the requirements for Phase I of the federal pandemic 
funds. 

For Phase II, recipients were expected to comply with the following 
four priority activities, among others: 

* development of a jurisdictional work plan to address gaps identified 
by the CDC self-assessment process in Phase I; 

* development of and exercise an antiviral drug distribution plan; 

* development of a pandemic exercise program that includes medical 
surge, mass prophylaxis,[Footnote 20] and nonpharmacological public 
health interventions[Footnote 21] and a community containment plan 
[Footnote 22] with emphasis on closing schools and discouragement of 
large public gatherings at a minimum; and: 

* submission of an influenza pandemic operational plan to CDC. 

According to HHS, CDC has reviewed whether recipients met the 
requirements identified in the Phase II guidance.[Footnote 23] 

In addition, recipients were asked to document the process used to 
engage Indian tribal governments in Phases I and II and to develop and 
implement an influenza pandemic preparedness exercise program involving 
community partners to exercise their capabilities and prepare an after- 
action report highlighting necessary corrective actions. Unlike Phase I 
in which there is no mention of DHS's Homeland Security Exercise and 
Evaluation Program (HSEEP),[Footnote 24] in Phase II CDC encouraged, 
but did not require, recipients to use HSEEP for disaster planning and 
exercising efforts. HSEEP guidance defines seven different types of 
exercises, each of which is either discussions-based or operations- 
based. Discussions-based exercises are a starting point in the building 
block approach of escalating exercise complexity. These types of 
exercises typically highlight existing plans, policies, interagency and 
interjurisdictional agreements, and procedures and focus on strategic, 
policy-oriented issues. An example of a discussions-based exercise is a 
tabletop exercise that can be used to assess plans, policies, and 
procedures or to assess the systems needed to guide the prevention of, 
response to, and recovery from a defined incident. Operations-based 
exercises are characterized by an actual reaction to simulated 
intelligence; response to emergency conditions; mobilization of 
apparatus, resources, and networks; and commitment of personnel, 
usually over an extended period. These exercises are used to validate 
the plans, policies, agreements, and procedures assessed in discussions-
based exercises. An example of an operations-based exercise is a full-
scale exercise, which is a multiagency, multijurisdictional, 
multiorganizational exercise that validates many facets of 
preparedness. CDC's federal pandemic funding guidance for Phase I and 
II did not explicitly specify the type of exercises to be conducted; 
the exception was the mass prophylaxis exercise for Phase II, which was 
required to be an operations-based exercise. In order to be compliant 
with HSEEP protocols, there are four distinct performance requirements. 
They include (1) conducting an annual training and exercise plan 
workshop and developing and maintaining a multiyear training and 
exercise plan, (2) planning and conducting exercises in accordance with 
the guidelines set forth by HSEEP, (3) developing and submitting an 
after-action report, and (4) tracking and implementing corrective 
actions identified in the after-action report. 

For Phase II, the National Governors Association conducted a series of 
nine influenza pandemic regional workshops for states between April 
2007 and January 2008 to enhance intergovernmental and interstate 
coordination. In a February 2008 issue brief, the National Governors 
Association reported its results from five regional influenza pandemic 
preparedness workshops involving 27 states and territories conducted 
between April and August 2007. The workshops were designed to identify 
gaps in state influenza pandemic preparedness--specifically in non- 
health-related areas such as continuity of government, maintenance of 
essential services, and coordination with the private sector, and to 
examine strengths and weaknesses of coordination activities among 
various levels of government. The workshops also included a discussions-
based exercise focused on regional issues.[Footnote 25] 

For Phase III, recipients were asked to describe ongoing influenza 
pandemic-related priority projects that would improve exercising and 
response capabilities specifically for an influenza pandemic. Phase III 
required recipients to fill planning gaps identified in Phase I and II. 
In addition, recipients were expected to comply with the following 
requirements, among others: 

* submit workplans that included specific influenza pandemic planning, 
implementation, and evaluation of activities; 

* update the existing influenza pandemic operational plan based on 
CDC's assessment on six priority thematic areas,[Footnote 26] by 
January 2008; 

* create an exercise strategy and schedule; and: 

* utilize the tools developed by DHS's HSEEP to create planning, 
training, and exercise evaluation programs, which includes an after- 
action report, improvement plan, and corrective action program for each 
seminar, tabletop, functional, or full-scale exercise conducted. 

States Have Made Progress in Developing Their Influenza Pandemic Plans: 

Over the past several years, states have made progress in developing 
pandemic plans. In 2006, CDC reported that most states did not have 
complete influenza pandemic plans addressing areas such as enhancing 
surveillance and laboratory capacity, managing vaccines and antivirals, 
and implementing community containment measures to reduce influenza 
transmission.[Footnote 27] However, all 50 states, territories, and the 
District of Columbia now have influenza pandemic plans according to CDC 
officials. Trust for America's Health, a health advocacy nonprofit 
organization, reported that the type of publicly available influenza 
pandemic plan varied from a comprehensive influenza pandemic plan to 
free-standing annexes to emergency management plans, to mere summaries 
of a state's influenza pandemic plan.[Footnote 28] 

At the time of our review, all five states we reviewed had influenza 
pandemic plans that focused on leadership, surveillance and laboratory 
testing, vaccine and antiviral distribution, and communications. Some 
state plans included sections on education and training, and infection 
control. Two of the three localities that received the federal pandemic 
funds in our study addressed similar types of topics, such as disease 
surveillance and laboratory testing, health care planning, vaccine and 
antiviral distribution, mental health response, and communications in 
their influenza pandemic plans. Most of the remaining urban and rural 
localities also primarily addressed similar topics. 

States and Localities We Reviewed That Received Federal Pandemic Funds 
Involved HHS and CDC in Planning: 

In planning for an influenza pandemic, officials from three of the five 
states and two of the three localities that received the federal 
pandemic funds told us that they interacted with HHS and CDC in 
planning for a pandemic. However, federal officials did not reach out 
to states and localities when the National Pandemic Implementation Plan 
was being developed and the PFOs for influenza pandemic had limited 
interaction with the selected states and localities. 

At the time of our site visits, officials from three of the five states 
and two of the three localities that received direct federal funding 
reported interacting with HHS and CDC in planning for an influenza 
pandemic to clarify funding requirements and expectations. CDC 
officials in the Coordinating Office for Terrorism Preparedness and 
Emergency Response also told us that they reviewed reports from the 
states and local government recipients on how they had met the federal 
pandemic funding requirements. CDC then provided feedback to the states 
and localities on how well they were meeting the requirements. In 
addition, CDC officials told us that they provided technical assistance 
when requested. 

While the federal government has provided some support to states in 
their planning efforts, states and localities have had little 
involvement in national planning for an influenza pandemic. The 
National Pandemic Implementation Plan lays out a series of actions and 
defines responsibilities for those actions. The National Pandemic 
Implementation Plan includes 324 action items, 17 of which call for 
states and local governments to lead national and subnational efforts, 
and 64 in which their involvement is needed. In our August 2007 report, 
we highlighted that key stakeholders such as state and local 
governments were not directly involved in developing the action items 
in the National Pandemic Implementation Plan and the performance 
measures that are to assess progress, even though the National Pandemic 
Implementation Plan relies on these stakeholders' efforts.[Footnote 29] 
Stakeholder involvement during the planning process is important to 
ensure that the federal government's and nonfederal entities' 
responsibilities and resource requirements are clearly understood and 
agreed upon. Moreover, HHS ASPR officials confirmed that the National 
Pandemic Implementation Plan was developed by the federal government 
without any state input. Officials from all of the states and 
localities reviewed told us that they were not directly involved in 
developing the National Pandemic Implementation Plan. Officials from 
all five of the states and seven of the localities were aware of the 
National Pandemic Implementation Plan. Officials from Taylor County 
(Florida), Peoria County (Illinois) and Washington County (New York) 
had not seen the National Pandemic Implementation Plan. State officials 
from Florida, New York, and Texas, and officials from two localities in 
California and one locality in New York reported that they used its 
action items for their own planning efforts. 

In addition, states and localities reported limited interaction with 
the predesignated federal PFOs and FCOs in coordinating influenza 
pandemic efforts. According to the national PFO for influenza pandemic, 
the PFOs for influenza pandemic had limited interaction with state 
governments for influenza pandemic efforts because it was unclear 
whether the PFO structure for an influenza pandemic would remain in the 
National Response Framework until it was issued in January 2008, and 
finalized in March 2008. The Secretary of Homeland Security sent 
letters in December 2006 and in March 2008 to state Governors on the 
PFO structure, and the PFO structure was discussed at the HHS-and DHS- 
led workshops in the five federal pandemic regions. At the time of our 
site visits, we found that only state officials in California and New 
York were aware of these federally predesignated officials. In 
addition, in its issue brief on the five state influenza pandemic 
workshops, the National Governors Association reported that the 
presence of the PFOs for influenza pandemic at two of their workshops 
was the first opportunity for most states to interact with these 
officials. 

States and Localities We Reviewed Involved Other State and Local 
Agencies, Tribal Nations, Nonprofit Organizations, and the Private 
Sector in Pandemic Planning: 

In every state and locality reviewed, officials told us that they 
involved other state and local agencies within their jurisdiction in 
accordance with federal pandemic funding requirements. Health and 
emergency management officials at some of the states and localities 
reviewed said they collaborated with each other to develop the 
influenza pandemic plan for public health response as required by the 
federal pandemic funds and the influenza pandemic annex for emergency 
response where applicable. For example, the Miami-Dade County Health 
Department (Florida) collaborated with the Miami-Dade County Pandemic 
Influenza Workgroup, which included stakeholders such as the Miami-Dade 
County Department of Emergency Management and Homeland Security, CDC 
Miami Quarantine Station, Medical Examiner Department, and the Miami- 
Dade Corrections and Rehabilitation Department to develop its influenza 
plan. This plan is also used as an annex to the Miami-Dade County 
Department of Emergency Management and Homeland Security's 
Comprehensive Emergency Management Plan. In some cases, both the health 
and emergency management departments at the state and local levels 
developed separate influenza pandemic plans to address health and 
emergency response efforts respectively, while in other cases the 
emergency management departments used the health department's influenza 
pandemic plan as an annex to their emergency operations plans. 

In addition to developing their own influenza pandemic plans, state 
public health agencies in all the states reviewed assisted their local 
counterparts with their influenza pandemic plans. For example, 
officials from the Florida Department of Health said they used a 
standardized assessment tool to assess county influenza pandemic plans 
on 36 elements such as surveillance, response and containment, and 
community-based control and mitigation interventions. The tool also 
included a section on strengths and areas for improvement for each 
element. Further, New York State Department of Health officials said 
that they reviewed all of the county-level influenza pandemic plans and 
provided feedback. We also found that in some cases, localities 
consulted other localities' influenza pandemic plans to help them to 
develop their own plans. For example, officials from Stanislaus County 
Health Services Agency (California), Miami-Dade County Health 
Department (Florida), and Dallas County Health and Human Services 
(Texas) said they reviewed King County's (Washington) influenza 
pandemic plan to help them develop their own plans. 

Officials at all 15 of the states and localities reviewed also said 
they assisted other state and local agencies within their jurisdiction 
in their influenza pandemic efforts by reviewing each other's plans or 
sharing information. For example, New York State Department of Health 
officials said that as the lead agency responsible for influenza 
pandemic planning efforts, they participated in and coordinated 
meetings with other state agencies such as the Unified Court System and 
Department of Correctional Services to discuss areas such as infection 
control and community containment, visitation policies during an 
influenza pandemic, management of sick inmates, emergency staffing 
plans, and employee education and training. 

Officials from 6 of the 15 states and localities we reviewed reported 
that they had tribal nations within their jurisdictions. Of these 6, 
only officials from California, Florida, New York state, and Miami told 
us that they had included tribal nations in their influenza planning 
efforts, as required by the federal pandemic funds. For example, 
officials from the New York State Department of Health said they 
provided guidance to the Mohawk and Seneca tribes in developing 
influenza pandemic plans. Tribal nation representatives also had access 
to the state's health provider network and were invited to influenza 
pandemic training sessions and monthly influenza pandemic conference 
calls. Officials from Texas and Taylor County (Florida) reported that 
they did not include tribal nations in their influenza planning 
efforts. Texas Department of State Health Services officials reported 
that there are three tribes within the state with which the respective 
counties are coordinating. In Taylor County (Florida), officials 
reported that they had not yet involved their local tribe, the 
Miccosukee tribe, in their influenza pandemic planning efforts. 

Officials from all five states and four localities also reported that 
they provided guidance or technical assistance for continuity planning 
efforts to nonprofit organizations, and officials from all five states 
and seven localities told us that they provided the same assistance to 
the private sector. States and localities that received direct federal 
pandemic funding are required to involve nonprofit organizations and 
the private sector in planning for an influenza pandemic. For example, 
Peoria City/County Health Department (Illinois) officials told us that 
in addition to contracting with the Red Cross in providing bulk food 
distribution services during an influenza pandemic, they had initial 
discussions on how to implement isolation and quarantine. Officials 
from the New York City Department of Health and Mental Hygiene (New 
York) stated that they partnered with the New York City Department of 
Small Business Services and conducted six focus groups with 
approximately 60 participants from nonprofit and for-profit 
organizations to provide general information related to influenza 
pandemic, and to discuss the continuity strategies from CDC's Business 
Pandemic Influenza Planning Checklist and feasibility in adopting them. 

While all five selected states and seven localities have coordinated 
with the private sector for influenza pandemic planning, several 
officials from state agencies in Florida and Illinois, and local 
agencies in Los Angeles County (California), Chicago (Illinois), and 
Dallas County (Texas) have focused specifically on critical 
infrastructure sectors, such as transportation (highway and motor 
carriers), food and agriculture, water, energy (electricity), and 
telecommunications (communications). Officials from the Dallas County 
Department of Health and Human Services (Texas) said that they assisted 
a local power company and a grocery chain on continuity of operations 
planning for an influenza pandemic. The National Governors Association 
reported in its February 2008 issue brief that few states from its five 
regional workshops had defined the roles and responsibilities of 
private sector entities.[Footnote 30] Moreover, potential shortages of 
critical goods and services--specifically, food, electricity, and 
transportation capacity--were cited as key areas of concern across all 
five National Governors Association-led workshops. While Idaho, 
Minnesota, Montana, North Dakota, South Dakota, and Utah were less 
concerned about the food supply due to longstanding practices of 
stockpiling against severe weather and other threats, other 
participating states were concerned that they did not have agreements 
in place with the private sector food distribution and retail systems. 

HHS Has Found Major Gaps in States' Influenza Pandemic Plans: 

Since we visited these states and localities, HHS provided feedback to 
the states in November 2007 on whether their influenza pandemic plans 
addressed certain priority areas, such as fatality management, and 
found that there were major gaps nationally in the plans in these 
priority areas. In response to an action item in the National Pandemic 
Implementation Plan, HHS led a multidepartment effort to review 
pertinent parts of states' influenza pandemic plans in 22 priority 
areas[Footnote 31] along with other federal agencies such as the 
Departments of Agriculture, Commerce, Education, Homeland Security, 
Justice, Labor, and State under the auspices of the Homeland Security 
Council.[Footnote 32] For example, DHS was responsible for reviewing 
the priority area of how states worked with the private sector to 
ensure critical essential services. States were required to submit 
parts of their plans that addressed the priority areas to CDC by March 
2007. The participating departments reviewed the pertinent parts of the 
plans and HHS compiled the results into individual draft interim 
assessments, which included the status of planning for each entity and 
how they measured against the national average for the priority areas, 
and provided this feedback to the states.[Footnote 33] 

As shown in table 1, on average, states had major gaps in all areas, 
with a ranking of "many major gaps" in 16 of the 22 priority areas and 
"a few major gaps" in the remaining 6 priority areas, as defined by 
HHS.[Footnote 34] An official in HHS ASPR told us that generally, the 
states fared better in the public health priority areas such as mass 
vaccination and antiviral drug distribution plans than in other areas 
such as school closures and sustaining critical infrastructure. As we 
will discuss in more detail later in the report, we found that the 
areas in which state and local officials were looking for additional 
federal guidance were often the same areas that were rated by HHS as 
having "many major gaps" in planning. 

Table 1: National Average of Status of States' Pandemic Plans by 
Priority Areas and Lead Federal Government Reviewer: 

Priority areas: Mass Vaccination; 
National average: on status of planning: A Few Major Gaps; 
Lead reviewer for the federal government: HHS/CDC. 

Priority areas: Public Health Continuity of Operation Plan; 
National average: on status of planning: A Few Major Gaps; 
Lead reviewer for the federal government: HHS/CDC. 

Priority areas: Surveillance and Laboratory; 
National average: on status of planning: A Few Major Gaps; 
Lead reviewer for the federal government: HHS/CDC. 

Priority areas: Communication; 
National average: on status of planning: A Few Major Gaps; 
Lead reviewer for the federal government: HHS/CDC. 

Priority areas: Community-Wide Healthcare Coalitions; 
National average: on status of planning: A Few Major Gaps; 
Lead reviewer for the federal government: HHS/ASPR/Health Resources and 
Services Administration. 

Priority areas: Facilitating Medical Surge; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: HHS/ASPR/Health Resources and 
Services Administration. 

Priority areas: Fatality Management; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: HHS/ASPR/Health Resources and 
Services Administration. 

Priority areas: Antiviral Drug Distribution Plan; 
National average: on status of planning: A Few Major Gaps; 
Lead reviewer for the federal government: HHS/CDC. 

Priority areas: Community Containment Plan; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: HHS/CDC. 

Priority areas: Policy Process for School Closure and Communication; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: Department of Education. 

Priority areas: Education and Social Services in the Face of School 
Closures; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: Department of Education. 

Priority areas: Sustain/Support 17 Critical Infrastructure Sectors and 
Key Assets[A]; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: DHS. 

Priority areas: Working with the Private Sector to Ensure Critical 
Essential Services; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: DHS. 

Priority areas: State Plans Must Conform to All National Response Plan/ 
National Incident Management System Requirements; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: DHS. 

Priority areas: Mitigate the Impact of an Influenza Pandemic on Workers 
in the State; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: Department of Commerce. 

Priority areas: Assisting Employers in the State; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: Department of Commerce. 

Priority areas: Employment Policies during an Influenza Pandemic; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: Department of Labor. 

Priority areas: Human Resource Policies for State Employees; 
National average: on status of planning: Combined with Previous 
Priority; 
Lead reviewer for the federal government: Department of Labor. 

Priority areas: Coordination of Law Enforcement; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: Department of Justice. 

Priority areas: Critical Essential Function for Food Safety[B]; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: Department of Agriculture, 
HHS/Food and Drug Administration. 

Priority areas: Operational Status of State-Inspected Slaughter and 
Food Processing Establishments; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: Department of Agriculture, 
HHS/Food and Drug Administration. 

Priority areas: Communication Strategy for USDA FSIS and FDA's Federal 
State Relationships; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: Department of Agriculture, 
HHS/Food and Drug Administration. 

Priority areas: Ensure Adequate Reporting System Regarding Food Safety; 
National average: on status of planning: Many Major Gaps; 
Lead reviewer for the federal government: Department of Agriculture, 
HHS/Food and Drug Administration. 

Priority areas: State Advisories Regarding Diplomatic Missions; 
National average: on status of planning: Not Reviewed; 
Lead reviewer for the federal government: Department of State. 

Source: GAO analysis of HHS data. 

Notes: The analysis is based on data from HHS Guidance to States on 
Pandemic Plans, January 2007, and HHS Feedback to States on Pandemic 
Plans, November 2007. 

[A] Since the HHS-led review of the first round of state influenza 
pandemic plans, on April 30, 2008, DHS designated critical 
manufacturing as an additional critical infrastructure sector under the 
National Infrastructure Protection Plan (NIPP), which brings the 
current number of critical infrastructure and key resources sectors 
from 17 to 18. 

[B] Only 28 states were required to address this priority area. 

[End of table] 

Every state received individual comments from CDC on the strengths and 
weaknesses of their influenza pandemic plans in six priority areas. 
[Footnote 35] According to HHS officials in ASPR, states also received 
feedback in some of the remaining priority areas. In addition, states 
received general comments from the Departments of Agriculture, 
Commerce, Labor, Homeland Security, and Justice. The Departments of 
Commerce, Labor, and Homeland Security noted that many state influenza 
pandemic plans did not address the effect of social distancing in 
private workplaces or state agencies. Nor did they address issues 
related to loss of jobs and income for workers, particularly for those 
needing to stay home to care for children dismissed from school or to 
care for themselves or ill relatives. Further, they concluded that many 
states needed to develop occupational safety and health plans that 
dealt with infection control and other influenza pandemic issues such 
as worker behavioral and mental health concerns. 

HHS, DHS, and other federal agencies issued guidance to states in March 
2008 to assist them in updating their current influenza pandemic plans. 
These updated plans are due in July 2008. HHS will provide feedback to 
them on the strengths and weaknesses of their plans as they did for the 
previous review of plans. 

All States and Localities Reviewed Have Conducted or Participated in at 
Least One Exercise to Test Their Planning for an Influenza Pandemic and 
Have Incorporated Lessons Learned: 

Disaster planning, including for an influenza pandemic, needs to be 
tested and refined with a rigorous and robust exercise program to 
expose weaknesses in planning and allow planners to address the 
weaknesses. Exercises--particularly for the type and magnitude of 
emergency incidents such as a severe influenza pandemic for which there 
is little actual experience--are essential for developing skills and 
identifying what works well and what needs further improvement. 

The first phase of the federal pandemic funds required states and 
localities that received this funding to test their influenza pandemic 
plan. CDC officials stated that their expectation was that the 
recipients would conduct a gap analysis using CDC's self-assessment 
tool to identify objectives to exercise to improve their plans and then 
exercise the identified vulnerabilities of their plans, rather than 
testing their entire plan. According to CDC officials, all states and 
localities that received this funding have met the requirement to 
conduct a discussions-based or operations-based exercise to test their 
influenza pandemic plans and to prepare an after-action report. The 
second phase of funding required states and localities that receive the 
funding directly to conduct an exercise that would test an antiviral 
drug distribution plan and to develop an influenza pandemic exercise 
schedule that included medical surge, mass prophylaxis, and 
nonpharmaceutical public health interventions such as closing schools 
and discouragement of large public gatherings. As noted earlier, HHS 
stated that CDC has reviewed whether recipients met the requirements 
identified in the Phase II guidance. 

All of the states and localities except for two of the localities in 
our review had conducted at least one influenza pandemic exercise to 
test their influenza pandemic planning. The two localities that had not 
conducted their own exercise had participated in discussions-based 
exercises in other jurisdictions. Among the states and localities that 
had conducted an exercise, one state and two localities conducted at 
least one discussions-based and an operations-based exercise, one state 
and one locality conducted at least one operations-based exercise, and 
the remaining three states and five localities conducted at least one 
discussions-based influenza pandemic exercise. For example, the 
Stanislaus County Health Services Agency (California) conducted an 
influenza pandemic discussions-based exercise and the New York City 
Department of Health and Mental Hygiene (New York) conducted both 
influenza pandemic discussions-based exercises and operations-based 
exercises. In addition, state agencies in New York, Texas, and Illinois 
conducted or funded regional influenza pandemic exercises that included 
multiple jurisdictions within each state. For example, the Peoria City/ 
County Health Department (Illinois) participated in an influenza 
pandemic discussions-based exercise with nine other counties. According 
to the National Governors Association, the states' influenza pandemic 
exercises have been almost exclusively discussions-based exercises and 
few have held regional or multistate exercises. In addition, health 
departments conducted influenza pandemic exercises at all but one of 
the states and localities that had conducted at least one influenza 
pandemic exercise. In all but one of the states and localities 
reviewed, emergency management officials had either conducted or 
participated in an influenza pandemic exercise. 

Officials from All States and Localities Reviewed Reported That Lessons 
Learned from Exercises Were Incorporated into Influenza Pandemic 
Planning: 

Officials of all states and localities reviewed reported they had 
incorporated lessons learned from exercises into their influenza 
pandemic planning. Officials told us that the changes made as a result 
of an exercise included buying additional medical equipment and 
providing training. For example, officials at the New York City 
Department of Health and Mental Hygiene (New York) informed us that an 
influenza pandemic exercise resulted in identifying a potential 
shortage of ventilators. In response, they purchased 70 ventilators 
that were relatively easy to train staff to use, which were being used 
by selected hospitals. Other influenza pandemic exercises resulted in 
providing additional training. For example, Stanislaus County Health 
Services Agency (California) officials identified the need for their 
staff to be trained in the National Incident Management System (NIMS), 
which is a consistent nationwide approach to enable all government, 
private-sector, and nongovernmental organizations to work together to 
prepare for, respond to, and recover from domestic incidents. All 
county staff have been subsequently trained in NIMS. 

Furthermore, state and local officials stated that influenza pandemic 
exercises led to modifying policies or influenza pandemic plans. 
Officials at the Illinois Department of Public Health realized during 
an exercise that a judge's ruling would be needed to quarantine an 
individual with a suspected contagious disease. As a result, the 
department sought and obtained amendments to its department's authority 
that if voluntary compliance cannot be obtained, then the department 
can quarantine an individual with a suspected contagious disease for 2 
days before a judge's ruling is necessary. In addition, officials at 
the Dallas County Department of Health and Human Services (Texas) 
reported that they identified the need for, and subsequently developed, 
an appendix to their influenza pandemic plan on school closures during 
a pandemic that included factors for schools to consider in deciding 
when to close schools and for how long. 

HHS and DHS Could Further Assist States in Addressing Gaps Identified 
in Pandemic Planning: 

HHS (including CDC), DHS and other federal agencies have provided a 
variety of influenza pandemic information and guidance for states and 
local governments through Web sites and state and regional meetings. 
HHS and CDC have disseminated pandemic preparedness checklists for 
workplaces, individuals and families, schools, health care, and 
community organizations, with one geared for state and local 
governments.[Footnote 36] HHS and CDC have also provided additional 
influenza pandemic guidance including Interim Pre-pandemic Planning 
Guidance: Community Strategy for Pandemic Influenza Mitigation in the 
United States (February 2007). CDC and other federal agencies are 
currently considering the Interim Guidance for the Use of Intervals, 
Triggers, and Actions in Pandemic Influenza Planning that was developed 
by HHS and CDC and provides a framework and thresholds for implementing 
student dismissal and school closure. HHS also issued Interim Public 
Health Guidance for the Use of Facemasks and Respirators in Non- 
Occupational Community Settings during an Influenza Pandemic, and 
funded Providing Mass Medical Care with Scarce Resources: A Community 
Planning Guide (November 2006). CDC officials stated that the journal 
CHEST published four papers on providing mass critical care with scarce 
resources for all-hazards in May 2008. In addition, HHS funded guidance 
on exercising for an influenza pandemic, including discussions-based 
exercises for influenza pandemic preparedness for local public health 
agencies.[Footnote 37] Furthermore, the federal planning guidance for 
states to update their influenza pandemic plans provided by HHS, DHS, 
and other federal agencies includes references to federal guidance that 
pertains to the topics on which the states' plans will be assessed. The 
guidance includes preparedness and planning advice and information on 
specific tasks and capabilities that the states' plans should contain 
for each of the priority areas for which the states will be assessed. 
The guidance contains information on several of the priority areas that 
state and local officials were looking for additional guidance on and 
that were rated as having "many major gaps" in planning in the first 
assessment, such as fatality management and community containment. 
However, while the guidance document states what the states' plans 
should contain for each of the topics, it does not include how to 
implement these tasks and capabilities. 

HHS and DHS, in coordination with other federal agencies, have also 
developed draft guidance on how to allocate limited supplies of 
vaccines, including target groups for individuals, and are working on 
similar guidance for antivirals. They are also working on guidance on 
the prophylactic use of antivirals (administering antivirals to 
individuals who had not shown symptoms).[Footnote 38] However, HHS and 
DHS officials acknowledged that the federal government has not provided 
guidance on some of the influenza pandemic-specific topics that state 
and local officials had told us that they would like guidance on from 
the federal government, such as ethical decision making and liability 
and legal issues. 

There are also two federal Web sites that contain influenza pandemic 
information. The purpose of the Web site [hyperlink, 
http://www.pandemicflu.gov] is to be one-stop access to U.S. government 
avian and pandemic flu information. The site includes guidance and 
information on state and local planning and response activities, such 
as all state influenza pandemic plans. The Web site [hyperlink, 
http://www.llis.dhs.gov] is a national network of lessons learned and 
best practices for emergency response providers and homeland security 
officials and contains information on many different topic areas, such 
as cyber security and wildland fires. Lessons Learned Information 
Sharing System (LLIS) officials stated that the best practices are 
vetted by working groups of subject matter experts. LLIS has an 
influenza pandemic topic area that includes news, upcoming events, 
plans and guidance, after-action reports, and best practices. An LLIS 
representative also informed us that there is an influenza pandemic 
forum that acts as a message board for LLIS users to discuss topics, 
which have included how to implement teleworking during an influenza 
pandemic. In addition, there is an influenza pandemic channel on the 
Web site that has a document and resource library and a message board, 
including topics such as antiviral and vaccine planning. HHS officials 
stated that CDC and LLIS have created a secure channel for state and 
local health departments to post and share influenza pandemic exercise 
information. According to an LLIS representative, the secure channel 
contains the influenza pandemic exercise schedules for states and 
localities that receive the funding directly and there are plans to 
include after-action reports from the exercises on the Web site. 

There are also several nonfederal Web sites that contain influenza 
pandemic practices on particular topics. The Center for Infectious 
Disease Research and Policy at the University of Minnesota has 
collected and peer-reviewed influenza pandemic "promising practices" 
that can be adapted or adopted by public health stakeholders. Their Web 
site [hyperlink, 
http://www.pandemicpractices.org/practices/list.do?topic-id=13] has 
practices on three themes: models for care (surge capacity, standards 
of care, triage strategies, out-of-hospital care, collaborations), 
communications (risk communications, community engagement, and 
resiliency), and mitigation (nonpharmaceutical interventions). In 
addition, National Public Health Information Coalition officials said 
that they are planning to post influenza pandemic communications on 
their Web site. CDC officials also stated that CDC has a cooperative 
agreement with the Association of State and Territorial Health 
Officials and the National Association of County and City Health 
Officials to provide influenza pandemic best practices and tools that 
states and localities can download from their respective Web sites. 

In addition to providing guidance, HHS has also convened state 
influenza pandemic planning summits and funded regional state influenza 
pandemic workshops. To help coordinate influenza pandemic planning, HHS 
and other federal agencies, including DHS, held "State Pandemic 
Planning Summits" with the public health and emergency response 
community in all states in 2005 and 2006. As part of the summits, the 
Secretary of Health and Human Services signed memorandums of 
understanding (MOU) with each state that identified shared common goals 
and shared and independent responsibilities between HHS and the 
individual state for influenza pandemic planning and preparedness. For 
example, the MOU between HHS and the state of California noted that 
states and local communities are responsible under their own 
authorities for responding to an influenza pandemic outbreak within 
their jurisdictions and having comprehensive influenza pandemic 
preparedness plans and measures in place to protect their citizens. In 
addition, to further assist states and localities with their influenza 
pandemic preparedness efforts, HHS funded the National Governors 
Association to conduct a series of influenza pandemic regional 
workshops for states, the first five of which are discussed earlier. A 
National Governors Association official stated the association held 
nine workshops between April 2007 and January 2008 and that it is not 
planning to conduct additional influenza pandemic workshops for states. 

In addition, in May 2008, FEMA hosted an influenza pandemic exercise 
and seminar for senior executives. The purpose of the exercise, which 
involved FEMA officials, the Pandemic Region A PFO team, and a number 
of states in Pandemic Region A, was to determine best practices for 
communication and coordination during an influenza pandemic response. 
The senior executive seminar, which included officials from CDC, HHS, 
DHS, and a number of states in Pandemic Region C, was intended to 
address pandemic risk, challenges, and issues, both regionally and 
nationally. FEMA is also planning to host another influenza pandemic 
seminar in May 2008 for the other states in Pandemic Region C that did 
not participate in the previous seminar. 

State and Local Officials Reported That They Wanted Additional Federal 
Influenza Pandemic Guidance: 

Despite these efforts, state and local officials from all of the states 
and localities we interviewed told us that they would like additional 
federal influenza pandemic guidance from the federal government on 
specific topics to help them to better plan and exercise for an 
influenza pandemic. Although, as discussed earlier, there is federal 
guidance for some of these topics, the existing guidance may not have 
reached state and local officials or may not address the particular 
concerns or circumstances of the state and local officials we 
interviewed. 

Three of the areas on which state and local officials reported that 
they wanted federal influenza pandemic guidance were rated as having 
"many major gaps" nationally among states' influenza pandemic plans in 
the first HHS-led review of their influenza pandemic plans. These areas 
were (1) implementing the community interventions, such as closing 
schools, discussed in the Interim Pre-pandemic Planning Guidance: 
Community Strategy for Pandemic Influenza Mitigation in the United 
States (which is called community containment in the federal priority 
topics), (2) fatality management, and (3) facilitating medical surge. 
[Footnote 39] Two other areas that state and local officials told us 
that they would like additional federal influenza pandemic guidance on, 
mass vaccination and antiviral drug distribution, were also rated as 
having "a few major gaps" nationally. State and local officials also 
told us that they would like the federal government to provide guidance 
on additional topics: ethical decision making, prophylactic use of 
antivirals, Strategic National Stockpile utilization, liability and 
legal issues, and personal protective equipment. 

While officials from some state and local governments were looking for 
guidance from the federal government, others were developing the 
information on their own. For example, while California Department of 
Health officials stated that they were developing standards and 
guidelines for health care professionals to use in any medical surge 
(including an influenza pandemic), which has since been released, 
Peoria City/County Health Department (Illinois) officials told us that 
they wanted guidance on how to deal with medical surge. In addition, 
the Texas Department of State Health Services developed an antiviral 
prioritization plan, while Illinois Department of Public Health 
officials said they would like the federal government to provide 
guidance on antiviral prioritization. 

Two recent reports found similar concerns among state and local 
officials. In its February 2008 issue brief, the National Governors 
Association reported that states were grappling with many of the same 
issues that we found: community containment (school closures), 
antiviral prioritization, prophylactic use of antivirals, and legal 
issues.[Footnote 40] Similarly, an October 2007 Kansas City Auditor's 
Office report on influenza pandemic preparedness in the city noted that 
Kansas City Health Department officials would like the federal 
government to provide additional guidance on some of the same issues we 
found: clarifying community interventions such as school closings and 
the criteria that will trigger these measures, antiviral and vaccine 
prioritization, and the type of personal protective equipment to use 
(e.g., type of face mask).[Footnote 41] 

Additional HHS and DHS State Influenza Pandemic Meetings Could Be Held 
to Assist States in Addressing Gaps in States' Influenza Pandemic 
Plans: 

According to the National Pandemic Implementation Plan, it is essential 
for states and localities to have plans in place that support the full 
spectrum of societal needs over the course of an influenza pandemic and 
for the federal government to provide clear guidance on the manner in 
which these needs can be met. As discussed earlier, the HHS-led 
assessment of the states' pandemic plans was in response to an action 
item in the National Pandemic Implementation Plan that states that HHS, 
in coordination with DHS, shall review and approve states' influenza 
pandemic plans. The assessment found "many major gaps" in 16 of the 22 
priority areas in the states' pandemic plans. 

HHS and DHS, in coordination with the Homeland Security Council, Office 
of Personnel Management, and the Departments of Agriculture, Commerce, 
Defense, Education, Homeland Security, Justice, Labor, State, 
Transportation, the Treasury, and Veteran Affairs, led a series of five 
workshops for states in the five influenza pandemic regions shown in 
figure 1 in January 2008. Prior to the meetings, HHS ASPR officials 
told us that the workshops would be an opportunity for states to 
request additional influenza pandemic guidance from the federal 
government. We observed two of the five workshops, and received 
summaries from HHS of all five workshops. The discussions at the 
workshops mainly focused on the draft guidance and evaluation criteria 
for the second round of assessing the state pandemic plans, but the 
participants also raised concerns and requested guidance.[Footnote 42] 
Some of the common high-level themes discussed at some of these 
workshops included a need for more involvement from federal agencies in 
communicating with state counterparts. The March 2008 planning guidance 
included a list of contacts and phone numbers in federal agencies for 
the state officials to help them to communicate with their federal 
counterparts as they update their pandemic plans. Participants also 
requested guidance on various topics. Among the five workshops 
conducted, state officials in three of the workshops sought guidance on 
how to handle school closures and ports of entry issues while state 
officials in two of the workshops wanted to know how to plan with CDC 
quarantine stations. In addition, in three of the workshops, state 
officials discussed wanting more critical infrastructure information or 
guidance. For example, state officials discussed that there are 
challenges for state health departments to work with the critical 
infrastructure sectors because they have no authority to influence 
their participation in influenza pandemic planning. However, there was 
not an opportunity to explore these issues in greater depth during the 
meetings. A senior DHS official in the Office of Health Affairs 
reported that there are no plans to conduct further regional state 
workshops on influenza pandemic. 

HHS, DHS, and the Department of Labor hosted three Web seminars that 
provided an overview of the March 2008 planning guidance and included 
time for discussion. In addition, according to HHS, state-specific 
assistance has been provided through conference calls. 

Additional meetings of states by federal influenza pandemic region, led 
by HHS and DHS, and in coordination with other relevant federal 
agencies, could be held and their purpose broadened to provide a forum 
for state and federal officials to address the identified gaps in 
states' planning. The federal agencies that were the lead departments 
for rating priority areas in the states' influenza pandemic plans could 
provide additional corresponding information and guidance on their 
respective priority areas to the states on their common challenges. 
Federal agencies could provide assistance to the states on the priority 
areas that they rated as having "many major gaps" in planning 
nationally. For example, the Department of Justice could provide 
assistance on the coordination of law enforcement, the Department of 
Agriculture could provide assistance on the operational status of state-
inspected slaughter and food processing establishments, and the 
Department of Education on the policy process for school closures and 
communication. With plans due in July 2008 for a second round of 
review, states' plans may still have major gaps that could be addressed 
by federal and state governments working together to address these 
challenges. 

The meetings could also provide a forum for states to build networks 
with one another and federal officials. In our October 2007 report 
related to critical infrastructure protection challenges that require 
federal and private sector coordination for an influenza pandemic, we 
found that for influenza pandemic efforts, DHS has used critical 
infrastructure coordinating councils primarily to share influenza 
pandemic information across sectors and government levels rather than 
to address many of the identified challenges. Thus, we recommended that 
DHS lead efforts to encourage the councils to consider and address the 
range of identified challenges, such as clarifying roles and 
responsibilities between federal and state governments, for a potential 
influenza pandemic.[Footnote 43] DHS concurred with our recommendation 
and is planning initiatives--with some underway--to address our 
recommendation, such as the development of pandemic contingency plan 
guidance tailored to each critical infrastructure sector. Similarly, 
during the National Governors Association's workshops, state officials 
reported that they would be interested in the influenza pandemic 
response activities initiated in neighboring states, but few, if any 
mechanisms, exist for states to gain regional situational awareness. 
According to the National Governors Association's report, the networks 
that do exist are informal communications among peers, which are built 
on personal relationships and are not integrated into any formal 
communications capacity or system. The National Governors Association 
also reported that states must coordinate their plans among state, 
local, and federal agencies and that this coordination should be tested 
through exercises with neighboring states and with relevant federal 
officials. In addition, the March 2008 planning guidance to help states 
update their plans notes that among the keys for successful preparation 
for an influenza pandemic are collaborating with other states to share 
promising practices and lessons learned and to collaborate with 
regional PFOs. Both of these collaborative relationships with other 
states and with the federal government could be facilitated by 
additional meetings and discussions within the framework of the federal 
pandemic regional structure. 

Conclusions: 

HHS is to complete distribution in 2008 of all the federal pandemic 
funds provided by Congress for states and localities, but HHS, DHS, and 
other federal agencies can continue to provide other types of support 
to states. Although all states have developed influenza pandemic plans, 
the HHS-led review of states' influenza pandemic plans in coordination 
with other federal agencies found "many major gaps" in planning 
nationally in 16 out of 22 priority areas. While the federal government 
has provided influenza pandemic guidance on a variety of topics, state 
and local officials told us they would welcome additional guidance. 
These requests highlight some of the areas where federal guidance does 
not exist and other areas where guidance may exist, but may not have 
reached state and local officials or may not have addressed their 
particular concerns. In addition, three of the topics that state and 
local officials told us that they wanted federal influenza pandemic 
guidance on--community containment, fatality management, and 
facilitating medical surge--were rated as having "many major gaps" 
nationally among states' influenza pandemic plans in the first HHS-led 
review of states' influenza pandemic plans. Moreover, the National 
Governors Association's workshops and the March 2008 planning guidance 
underscore the value of states collaborating with each other and the 
federal government for pandemic planning. With plans due in July 2008 
for a second round of review, states' plans may still have major gaps 
that can only be addressed by federal and state governments working 
together to address these challenges. 

Although a senior DHS official in the Office of Health Affairs reported 
that there are no plans to hold additional workshops in the five 
pandemic regions, these workshops could be a useful model both for 
sharing information across states and building relationships within 
regions and to address the identified gaps in states' planning, and to 
maintain the momentum that has already been started by HHS and DHS to 
continue to work with the states on pandemic preparedness given the 
upcoming governmental transition. 

Recommendation for Executive Action: 

To help maintain a continuity of focus on state pandemic planning 
efforts and to further assist states in their pandemic planning, we 
recommend that the Secretaries of Health and Human Services and 
Homeland Security, in coordination with other federal agencies, convene 
additional meetings of the states in the five federal influenza 
pandemic regions to help them address identified gaps in their 
planning. 

Agency Comments: 

We provided a draft of the report of the Secretaries of Health and 
Human Services and Homeland Security for their review and comment. HHS 
generally concurred with our recommendation in an e-mail. The 
department stated that additional regional workshops would be 
impractical in the short-term because of HHS' current involvement in 
the update of the states' pandemic plans. However, the department 
believes that the regional workshops already held were uniformly 
successful and is prepared to arrange for similar sessions in the 
future if states would find such sessions useful. HHS also provided us 
with technical comments, which we incorporated as appropriate. DHS 
generally agreed with the contents of the report and concurred with our 
recommendation. DHS's comments are reprinted in appendix II. We also 
provided draft portions of the report to the state and local officials 
from the five states and 10 localities we reviewed to ensure technical 
accuracy. We received no comments from these states and localities. 

As agreed with your offices, we plan no further distribution of this 
report until 30 days from its date, unless you publicly announce its 
contents earlier. At that time, we will send copies of this report to 
the Secretary of Health and Human Services and the Secretary of 
Homeland Security; and other interested parties. We will also make 
copies available to others upon request. In addition, this report is 
available at no charge on the GAO Web site at [hyperlink, 
http://www.gao.gov]. 

If you or your staff have any further questions about this report, 
please contact me at (202) 512-6543 or [email protected]. Contact 
points for our Offices of Congressional Relations and Public Affairs 
may be found on the last page of this report. Major contributors to 
this report include Sarah Veale, Assistant Director; Maya Chakko, 
Analyst-in-Charge; Susan Sato; Susan Ragland; Karin Fangman; David 
Dornisch; and members of GAO's Pandemic Working Group. 

Signed by: 

Bernice Steinhardt: 
Director, Strategic Issues: 

List of Requesters: 

The Honorable Judd Gregg: 
Ranking Member: 
Committee on the Budget: 
United States Senate: 

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

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

The Honorable Bennie G. Thompson: 
Chairman: 
Committee on Homeland Security: 
House of Representatives: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

The objectives of this study were to (1) describe how selected states 
and localities are planning for an influenza pandemic and how their 
efforts are involving the federal government, other state and local 
agencies, tribal nations, nonprofit organizations, and the private 
sector, (2) describe the extent to which selected states and localities 
have conducted exercises to test their influenza pandemic planning and 
incorporated lessons learned into their planning, and (3) identify how 
the federal government can facilitate or help improve state and local 
efforts to plan and exercise for an influenza pandemic. 

To identify how selected states and localities are planning and 
exercising for an influenza pandemic and how the federal government can 
assist their efforts, from June 2007 to September 2007, we conducted 
site visits to the five most populous states: California, Florida, 
Illinois, New York, and Texas. Recognizing that we would be limited in 
our ability to report on all states in detail, we selected these five 
states for a number of reasons, including that these states: 

* comprised over one-third of the United States population; 

* received over one-third of the total funding from the Department of 
Health and Human Services (HHS) and the Department of Homeland Security 
(DHS) that could be used for planning or exercising for an influenza 
pandemic, and each state received the highest amount of total HHS and 
DHS funding that could be used for planning and exercising for an 
influenza pandemic respectively within each of the five regions 
established by DHS for influenza pandemic preparedness and emergency 
response; and: 

* were likely entry points for individuals coming from another country 
given that the states bordered either Mexico or Canada or contained 
major ports, or both, and accounted for over one-third of the total 
number of passengers traveling within the United States, and over half 
of both inbound and outbound international air passenger traffic to and 
from the United States. 

At each state, we interviewed officials responsible for health, 
emergency management, and homeland security. We also interviewed 
officials at 10 localities in these same states, which consisted of 
five urban areas and five rural counties. We interviewed officials 
responsible for health and emergency management at an urban area in 
each of the five states, which included Los Angeles County 
(California), Miami (Florida), Chicago (Illinois), New York City (New 
York), and Dallas (Texas). These urban areas were selected based on 
having the highest population totals of all urban areas in the 
respective states as of July 2006 and high levels of international 
airport passenger traffic as of 2005. Three of these urban areas, Los 
Angeles County, Chicago, and New York City, also received federal 
pandemic funds. 

In addition, we asked the state officials to nominate a rural county 
for us to interview in their states based on the following criteria: 
(1) has conducted some planning or exercising for an influenza 
pandemic; and (2) is representative of challenges and needs that other 
surrounding rural counties might also be facing. The state officials in 
each state nominated only one rural county. We interviewed officials 
responsible for health and emergency management in the nominated 
counties of Stanislaus County (California), Taylor County (Florida), 
Peoria County (Illinois), Washington County (New York), and Angelina 
County (Texas). In total we interviewed officials with 34 different 
agencies, which included for each state the health, emergency 
management, and homeland security agencies, except for Texas which had 
a combined emergency management and homeland security agency, and 
officials responsible for health and emergency management for each 
urban area and rural county in the five states. In both states and 
localities we also typically interviewed several officials from each of 
the agencies. In addition, in four states and four localities reviewed, 
we interviewed the state or local government agencies individually, and 
for the remainder we interviewed the state or local government agencies 
together. We interviewed both urban and rural counties in order to 
obtain the perspectives of officials at both densely populated urban 
areas and rural areas. We report the results of our interviewing as 
counts at the level of the 15 states and localities. In general, if any 
one of the officials we interviewed in a particular state or locality 
stated a factor or issue, such as lessons learned from exercises being 
applied to pandemic planning, then we considered that statement to 
apply to the state or locality as a whole. However, a limitation of our 
interview methodology is that we did not comprehensively or 
systematically survey all interviewees across the range of interview 
questions. 

We did not interview tribal nations, and except in two cases when urban 
areas included private and nonprofit officials in our interviews with 
their agency, we did not interview private sector entities or nonprofit 
organizations. We focused on state and local government officials and 
asked these officials about their interaction with tribal nations, 
private sector entities, and nonprofit organizations. Finally, we 
interviewed the selected state and urban area's auditors on any current 
or planned related audits. While the states and localities selected 
provided a broad perspective, we cannot generalize or extrapolate the 
information gleaned from the site visits to the nation. In addition, 
since the states that we selected were large, the most populous states, 
and likely entry points for people coming into the United States, the 
information we collected may not be as relevant to smaller, less 
populated states that are not likely entry points for people coming 
into the United States. 

We also reviewed the influenza pandemic planning and exercise documents 
from the selected states and localities. We reviewed the state and 
local influenza pandemic plans for common topics, however we did not 
analyze the quality of the documents systematically amongst those 
states and localities. Instead, we relied on the HHS-led assessment of 
whether state's influenza pandemic plans contained 22 priority areas. 
We reviewed the reliability of the data reported from that assessment 
and determined that the data were sufficiently reliable for the 
purposes of this engagement. We also reviewed the states' and 
localities' exercise documents for commonalities across jurisdictions. 

We also interviewed HHS, Centers for Disease Control and Prevention 
(CDC), and DHS officials about how they are working with states and 
localities in planning and exercising for an influenza pandemic and 
reviewed documentation that they provided, including the HHS-led 
feedback to states on their influenza pandemic plans and the March 2008 
planning guidance to assist them in updating their influenza pandemic 
plans. Within HHS, we met with or received information from the Deputy 
Director of the Office of Policy and Strategic Planning within the 
Office of Assistant Secretary for Preparedness and Response; the Senior 
Advisor to the Director, Coordinating Office for Terrorism Preparedness 
and Emergency Response at CDC; the Regional Inspector General, Office 
of Inspector General; and their staff. Within DHS, we met with and or 
received information from the Director and Associate Chief Medical 
Officer for Medical Readiness, Office of Health Affairs; the Branch 
Chief, National Integration Center, Federal Emergency Management 
Agency; the National Principal Federal Official for influenza pandemic, 
United States Coast Guard; the Program Director, Lessons Learned 
Information System; and the Deputy Inspector General, the Office of the 
Inspector General; and their staff. In January 2008, we observed two of 
the five influenza pandemic regional workshops led by HHS and DHS, in 
coordination with other federal agencies. The purpose of the workshops 
was to obtain state leaders' input on guidance to assist their 
governments in updating their pandemic plans in preparation for a 
second HHS-led review of these plans. 

In addition, we reviewed prior GAO work and other relevant literature. 
We also interviewed officials from the National Governors Association, 
Association of State and Territorial Health Officials, National 
Association of County and City Health Officials, and the National 
Emergency Management Association who are working on issues related to 
state and local influenza pandemic activities. We obtained information 
on state and local activities from the state and local auditors in 
Kansas City, Missouri; Portland, Oregon; and New York state, who as 
members of the GAO Comptroller General's Domestic Working Group, all 
participated in a collaborative effort to assess influenza pandemic 
planning in their jurisdictions.[Footnote 44] 

We conducted this performance audit from March 2007 to June 2008, in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. 

[End of section] 

Appendix II: Comments from the Department of Homeland Security: 

U.S. Department of Homeland Security: 
Washington, DC 20528: 

May 27, 2008: 

Ms. Bernice Steinhardt: 
Director, Strategic Issues: 
U.S. Government Accountability Office: 
441 G St. NW: 
Washington, D.C. 20548: 

Dear Ms. Steinhardt: 

Thank you for the opportunity to review and provide comments on the 
Government Accountability Office's (GAO) draft report entitled, 
Influenza Pandemic: Federal Agencies Should Continue to Assist States 
to Address Gaps in Pandemic Planning (GAO-08-539). 

The Department of Homeland Security (DHS) has reviewed the referenced 
GAO report, and we concur with the recommendation that "the Secretaries 
of Health and Human Services and Homeland Security, in coordination 
with other federal agencies, convene additional meetings of the states 
in the five federal influenza pandemic regions to help them address 
identified gaps in their planning." 

We would like to emphasize that DHS, as part of its efforts to continue 
to help states and localities in the five federal influenza pandemic 
regions, is currently seeking input from its security partners on 
issues in the National Infrastructure Protection Plan (NIPP) that need 
to be updated as part of the NIPP triennial review process. DHS is also 
developing guidance to states and localities on developing their 
critical infrastructure and key resources protection plans and ensuring 
that they are in line with the NIPP. 

We would also like to highlight a recently completed study, "National 
Population Economic and Infrastructure Impacts of Pandemic Influenza 
with Strategic Recommendations," developed by the National 
Infrastructure Simulation and Analysis Center (NISAC) that could 
further inform all ongoing discussions or workshops between federal, 
state, and local health officials. 

This study was tasked to the NISAC by the 2006 National Strategy for 
Pandemic Implementation Plan, and will soon be releasable to private 
sector entities as well as to all governmental levels. The report 
contains specific recommendations addressing areas of concern 
identified by the aforementioned GAO draft report, such as when to 
close schools, disease containment strategies applicable to specific 
infrastructure sectors, and other perceived gaps in existing Federal 
guidance. The NISAC study has been briefed and provided to the 
appointed federal Pandemic Influenza Principal Officials and regional 
Senior Federal Officials as For Official Use Only (FOUO). Because of 
the wide applicability of the recommendations contained in the NISAC 
report, it is in the final stages of being made available for 
unrestricted release. 

DHS is dedicated to assisting our state and local partners in 
maintaining the health and resiliency of the homeland. Thank you for 
the opportunity to review and provide comments on this draft report. 

Sincerely, 

Signed by: 

Penelope G. McCormack: 
Acting Director: 
Departmental GAO/OIG Liaison Office: 

[End of section] 

Related GAO Products: 

Emergency Preparedness: States Are Planning for Medical Surge, but 
Could Benefit from Shared Guidance for Allocating Scarce Medical 
Resources. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-668]. 
Washington, D.C.: June 13, 2008. 

Influenza Pandemic: Efforts Under Way to Address Constraints on Using 
Antivirals and Vaccines to Forestall a Pandemic. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-08-92]. Washington, D.C.: 
December 21, 2007. 

Influenza Pandemic: Opportunities Exist to Address Critical 
Infrastructure Protection Challenges That Require Federal and Private 
Sector Coordination. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
08-36]. Washington, D.C.: October 31, 2007. 

Influenza Vaccine: Issues Related to Production, Distribution, and 
Public Health Messages. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-08-27]. Washington, D.C.: October 31, 2007. 

Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer 
Federal Leadership Roles and an Effective National Strategy. 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-781]. Washington, 
D.C.: August 14, 2007. 

Homeland Security: Observations on DHS and FEMA Efforts to Prepare for 
and Respond to Major and Catastrophic Disasters and Address Related 
Recommendations and Legislation. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-1142T]. Washington, D.C.: July 31, 2007. 

The Federal Workforce: Additional Steps Needed to Take Advantage of 
Federal Executive Boards' Ability to Contribute to Emergency 
Operations. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-515]. 
Washington, D.C.: May 4, 2007. 

Financial Market Preparedness: Significant Progress Has Been Made, but 
Pandemic Planning and Other Challenges Remain. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-07-399]. Washington, D.C.: March 
29, 2007. 

Public Health and Hospital Emergency Preparedness Programs: Evolution 
of Performance Measurement Systems to Measure Progress. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-07-485R]. Washington, D.C.: March 
23, 2007. 

Homeland Security: Preparing for and Responding to Disasters. 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-395T]. Washington, 
D.C.: March 9, 2007. 

Catastrophic Disasters: Enhanced Leadership, Capabilities, and 
Accountability Controls Will Improve the Effectiveness of the Nation's 
Preparedness, Response, and Recovery System. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-06-618]. Washington, D.C.: 
September 6, 2006. 

Hurricane Katrina: GAO's Preliminary Observations Regarding 
Preparedness, Response, and Recovery. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-06-442T]. Washington, D.C.: March 
8, 2006. 

Emergency Preparedness and Response: Some Issues and Challenges 
Associated with Major Emergency Incidents. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?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. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-365R]. 
Washington, D.C.: February 1, 2006. 

Influenza Pandemic: Applying Lessons Learned from the 2004-05 Influenza 
Vaccine Shortage. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-
221T]. Washington, D.C.: November 4, 2005. 

Influenza Vaccine: Shortages in 2004-05 Season Underscore Need for 
Better Preparation. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
05-984]. Washington, D.C.: September 30, 2005. 

Influenza Pandemic: Challenges in Preparedness and Response. 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-863T]. Washington, 
D.C.: June 30, 2005. 

Flu Vaccine: Recent Supply Shortages Underscore Ongoing Challenges. 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-177T]. Washington, 
D.C.: November 18, 2004. 

Emerging Infectious Diseases: Review of State and Federal Disease 
Surveillance Efforts. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
04-877]. Washington, D.C.: September 30, 2004. 

Infectious Disease Preparedness: Federal Challenges in Responding to 
Influenza Outbreaks. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
04-1100T]. Washington, D.C.: September 28, 2004. 

Public Health Preparedness: Response Capacity Improving, but Much 
Remains to Be Accomplished. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-04-458T]. Washington, D.C.: February 12, 2004. 

Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but 
Lack Certain Capacities for Bioterrorism Response. [hyperlink, 
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Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have 
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9, 2003. 

[End of section] 

Footnotes: 

[1] GAO, Influenza Pandemic: Further Efforts Are Needed to Ensure 
Clearer Federal Leadership Roles and an Effective National Strategy, 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-781] (Washington, 
D.C.: Aug. 14, 2007). 

[2] We discuss the various HHS and DHS funding that could be used for 
influenza pandemic planning and exercising later in the report. 

[3] The five territories are American Samoa, Guam, Northern Mariana 
Islands, Puerto Rico, and the United States Virgin Islands. 

[4] Hereafter, we will refer to these entities collectively as states 
for both the five influenza pandemic regional workshops and guidance 
documents to assist them in updating their pandemic plans. 

[5] The Robert T. Stafford Disaster Relief and Emergency Assistance Act 
of 1974 is codified, as amended, at 42 U.S.C. ï¿½ 5121-5207. 

[6] Issued in January 2008 and effective in March 2008, the NRF is a 
guide to how the nation conducts all-hazards incident response. It 
focuses on how the federal government is organized to support 
communities and states in catastrophic incidents. The NRF builds upon 
the National Incident Management System, which provides a national 
template for managing incidents. 

[7] See 42 U.S.C. ï¿½ 247d. 

[8] Pub. L. No. 109-417, 120 Stat. 2831, December 19, 2006. 

[9] Section 101 of Pub. L. No. 109-417. See 42 U.S.C. ï¿½ 300hh. 

[10] See programs authorized under 42 U.S.C. ï¿½ 247d-3a and ï¿½ 247d-3b. 

[11] Section 201 and 305 of Pub. L. No. 109-417, amending 42 U.S.C. ï¿½ 
247d-3a and ï¿½247d-3b, respectively. 

[12] Antivirals are drugs that are used to prevent or cure a disease 
caused by a virus, such as influenza, by interfering with the ability 
of the virus to multiply in number or spread from cell to cell. 

[13] See Department of Defense Emergency Supplemental Appropriations to 
Address Hurricanes in the Gulf of Mexico, and Pandemic Influenza Act, 
2006, Pub. L. No. 109-148, 119 Stat. 2680, 2783, 2786 and Emergency 
Supplemental Appropriations Act for Defense, the Global War on Terror 
and Hurricane Recovery, 2006, Pub. L. No. 109-234, 120 Stat. 418, 479- 
80 (includes $30 million to be transferred to the U.S. Agency for 
International Development). 

[14] According to 31 U.S.C. ï¿½ 6304 and ï¿½ 6305, unlike federal grants, 
where there is no substantial involvement between a federal agency and 
the recipient, cooperative agreements are used in cases where 
substantial involvement is expected between a federal agency and the 
recipient. 

[15] The five territories included Puerto Rico, the U.S. Virgin 
Islands, American Samoa, Northern Mariana Islands, and Guam. 

[16] The three Freely Associated States of the Pacific included the 
Republic of the Marshall Islands, the Republic of Palau, and the 
Federated States of Micronesia. 

[17] The three localities included Chicago, Los Angeles County, and New 
York City. 

[18] Of the $250 million awarded for Phase II, CDC awarded $225 million 
in July 2006. States and localities could apply for $24 million by 
March 2008 on a competitive basis to develop plans to develop, 
implement, and evaluate influenza pandemic interventions, and $990,000 
was awarded to the National Governors Association in September 2006 to 
conduct a series of influenza pandemic regional workshops for states in 
2007 and 2008 to enhance intergovernmental and interstate coordination. 

[19] Of the $250 million awarded for Phase III, $175 million was 
awarded to recipients. Recipients of the Hospital Preparedness Program 
cooperative agreement had the opportunity to apply for an additional 
$75 million in October 2007. These Phase III funds were awarded to 
assist states and localities in upgrading their influenza pandemic 
preparedness capacities. For example, they will allow states and 
localities to establish stockpiles of critical medical equipment and 
supplies, support the planning and development of alternate care sites, 
and conduct medical surge exercises for an influenza pandemic. 

[20] Prophylactic use of medications is providing the medicine before 
an individual is diagnosed. 

[21] Nonpharmaceutical interventions are used to reduce the spread of 
an infectious disease without use of pharmaceutical products such as 
vaccines. Examples of nonpharmaceutical interventions include isolation 
and treatment with influenza antiviral medications, voluntary home 
quarantine, dismissal of students from school and school-based 
activities, and use of social distance measures to reduce contact 
between adults in the community and workplace. 

[22] A community containment plan includes community-level 
interventions designed to limit the transmission of a pandemic virus. 

[23] According to HHS, for example, CDC reviewed whether recipients 
developed and exercised the antiviral drug distribution plan and 
submitted state operational pandemic plans. 

[24] HSEEP is a capabilities-and performance-based exercise program 
that provides a standardized policy, methodology, and terminology for 
exercise design, development, conduct, evaluation, and improvement 
planning. 

[25] National Governors Association Center for Best Practices, Issue 
Brief: Pandemic Preparedness in the States: An Interim Assessment from 
Five Regional Workshops (Washington, D.C.: February 2008). 

[26] CDC conducted an assessment of six priority thematic areas, which 
included mass vaccination, continuity of operations plan, 
communications, surveillance and laboratory, antiviral distribution, 
and community containment. 

[27] CDC analyzed data taken from its Pandemic Influenza State Self- 
Assessments conducted in April 2006 using 49 states where progress was 
reported in a number of key activities as either being completed, in 
progress, or not started. 

[28] Trust for America's Health, Ready or Not? Protecting the Public's 
Health from Diseases, Disasters, and Bioterrorism (Washington, D.C.: 
December 2007). 

[29] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-781]. 

[30] National Governors Association Center for Best Practices, Issue 
Brief: Pandemic Preparedness. 

[31] Initially, there were 24 priority areas that states had to 
address. However, HHS officials in ASPR stated that the interagency 
reviewers combined two priority areas into one priority area related to 
human resources and did not review one priority area related to state 
advisories regarding diplomatic missions. So, in total, states were 
assessed on 22 priority areas. 

[32] Action item 6.1.1.2. of the National Pandemic Implementation Plan 
states that HHS, in coordination with DHS, shall review and approve 
State Pandemic Influenza plans to supplement and support DHS state 
Homeland Security Strategies to ensure that federal homeland security 
grants, training, exercises, technical assistance, and other forms of 
assistance are applied to a common set of priorities, capabilities, and 
performance benchmarks. 

[33] HHS Assistant Secretary for Preparedness and Response, Pandemic 
and All-Hazards Preparedness Act Progress Report, Public Law 109-417 
(Washington, D.C.: November 2007). 

[34] The national average for each of the 22 priority areas was 
computed as follows. Each of the 50 states, five territories, and the 
District of Columbia were given a score ranging from 0 to 7 on each of 
the 22 priority areas. For each priority area, this score was 
determined by adding the number of points received by the state or 
territory on three key factors: (1) preparedness planning (a maximum of 
3 points could be given)--assessing whether the 56 entities addressed 
major preparedness objectives in guidance documents and other 
publications for each priority area, (2) operations orientation (a 
maximum of 3 points could be given)--assessing whether roles and 
responsibilities are assigned for each priority area, and (3) self- 
assessment of operations plan (a maximum of 1 point could be given)-- 
assessing whether states provided evidence that an exercise was 
conducted for at least one of the priority areas. The national average 
for each priority was then calculated by adding up all 56 scores and 
dividing by 56. HHS ASPR officials explained that a total score of 0-1 
equated to no or inadequate information provided, 2-3 equated to many 
major gaps, 4-5 equated to a few major gaps, and 6-7 equated to 
adequate or no major gaps. 

[35] These six priority areas were mass vaccination, public health 
continuity of operations plan, surveillance and laboratory, 
communication, antiviral drug distribution plan, and community 
containment plan. 

[36] HHS and CDC, State and Local Pandemic Influenza Checklist (Dec. 2, 
2005). 

[37] RAND Corporation, Facilitated Look Backs: A New Quality 
Improvement Tool for Management of Routine Annual and Pandemic 
Influenza (Santa Monica, Calif.: 2006) and Tabletop Exercises for 
Pandemic Influenza Preparedness in Local Public Health Agencies (Santa 
Monica, Calif.: 2006). 

[38] Draft Guidance on Allocating and Targeting Pandemic Influenza 
Vaccine (Oct. 17, 2007), and Proposed Considerations for Antiviral Drug 
Stockpiling by Employers In Preparation for an Influenza Pandemic and 
Proposed Guidance on Antiviral Drug Use during an Influenza Pandemic. 

[39] Medical surge is the capability to rapidly expand the capacity of 
the existing health care system. In an influenza pandemic, however, 
communities will not be able to count on receiving personnel or medical 
equipment from elsewhere, as they might in other types of emergencies. 
In our report on medical surge in a mass casualty event, we reviewed 
four key components of preparing for medical surge: increasing hospital 
capacity, identifying alternate care sites when hospitals are full, 
registering medical volunteers, and planning for altering established 
standards of care. The term "altered standards" generally means a shift 
to providing care and allocating scarce equipment, supplies, and 
personnel in a way that saves the largest number of lives, in contrast 
to the traditional focus of treating the sickest or most injured 
patients first. GAO, Emergency Preparedness: States Are Planning for 
Medical Surge, but Could Benefit from Shared Guidance for Allocating 
Scarce Medical Resources, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-08-668] (Washington, D.C.: June 13, 2008). 

[40] National Governors Association Center for Best Practices, Issue 
Brief: Pandemic Preparedness. 

[41] City Auditor's Office, City of Kansas City, Missouri, Performance 
Audit: Pandemic Flu Preparedness (October 2007). 

[42] HHS conducted these workshops with states to fulfill the 
requirement under PAHPA of 2006 for the Secretary of Health and Human 
Services to develop and disseminate criteria for an effective plan for 
responding to a pandemic. See Section 201 of the act, amending 42 
U.S.C. ï¿½ 247d-3a. 

[43] GAO, Influenza Pandemic: Opportunities Exist to Address Critical 
Infrastructure Protection Challenges That Require Federal and Private 
Sector Coordination, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
08-36] (Washington, D.C.: Oct. 31, 2007). 

[44] City Auditor's Office, City of Kansas City, Missouri, Performance 
Audit: Pandemic Flu Preparedness (October 2007); Office of City 
Auditor, Portland, Oregon, Pandemic Flu Planning: City bureaus aware of 
national plans, A Report from the City Auditor (March 2007). 

[End of section] 

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